Case of the Week COW #9

CC: “Post Surgical Pain” ; Abdominal pain

HPI: 8 year old Male with PMH of Sickle Cell Disease (HbSC), Post-opt Day 10 for laparoscopic splenectomy for recurrent sequestration crises presents to the Emergency Department (ED) complaining of abdominal pain x 2 days. The pain is described as diffuse and worse in the RUQ. Denies exacerbating or relieving factors. Pain is associated with constipation; last Bowel movement was 7 days prior. Mother states he did have one small BM shortly after surgery. He is tolerating PO without difficulty and does report flatus. She has been giving him Oxycodone 2mg every 6 hours for pain with minimal relief. Upon review of systems, patient reports feeling hot for the past 2 days but without a recorded temperature at home. Additionally, patient complained of a non-productive cough for 2 days and has been “breathing fast” for the same duration of time.

Physical Exam:

BP 112/74    HR 129     RR 24   SpO2 93% on RA   Temp 99.9F      26.3 kg

Constitutional: Well developed, well-nourished child who is awake, alert and in moderate distress due to pain and feeling hot; making tears

HEENT: NCAT, pupils PERRLA, neck supple

Respiratory: CTA B/L, no wheezing, rales or rhonchi

Chest/Axilla: Normal symmetrical motion, no tenderness

Cardiac: +S1/S2, RRR, no MRG,

Abdomen: Scars noted over splenectomy site which are clean dry and intact, healing well without discharge; Diminished Bowel Sounds in all quadrants; soft, non-distended with mild tenderness in all 4 quadrants. No rebound or guarding.

Neuro exam: AAO x 3. No deficits

Extremities: no edema, no tenderness or swelling

Pertinent Labs:

CBC: 42.1

HBG: 12.5

HCT: 36.9

Platelets: 721

Seg: 79

Lymphs: 9

Mono: 12

Reticulocyte count: reported as normal

Pertinent Imaging and other tests:

Working Diagnosis:

Generalized abdominal pains

Elevated WBC

Abscess of spleen

ED/Hospital course:

Surgery was consulted in the ED and they believed the pain was not related to the surgery. Abdominal U/S performed at their request showed “s/p splenectomy with gallbladder sludge.” Patient had moderate improvement in his pain after Toradol 15mg IV and Morphine 2mg IV were given in the ED. Patient also received Rocephin 75mg/kg and NS 500mL IV Fluid bolus for presumed infection with the leukocytosis of 42.1.

The patient was admitted to Pediatric Step down for further evaluation and management. Overnight, he remained comfortable with stable vital signs, afebrile and saturating 94-96% on 2L NC. On Hospital day #1, patient became febrile to 103F and continued to deny chest pain, SOB or difficulty breathing. The cough remained unchanged since admission. A repeat Chest X-Ray was obtained and the patient was diagnosed with Acute Chest Syndrome and received exchange transfusion the same day (Refer to Image below) Additionally, he received Ceftriaxone, Azithromycin, Nitric oxide and IVF at ¾ maintenance ate throughout hospitalization. On Hospital Day #4 he was discharged home.

Pearls:

Acute Chest Syndrome

  • It is the leading cause of death in patients with SCD in the United States
  • Most often occurs as a single episode, but patients may have multiple attacks resulting in chronic lung disease
  • Multiple Etiologies
    • Pulmonary infections
    • Iatrogenic cause including aggressive hydration for sickle cell painful crisis ——à causing Pulmonary Edema
    • Opioid use —–à Decreased inspiratory effort——à Atelectasis
  • New infiltrate identified on Chest X-Ray with at least one of the following: Fever, cough, wheezing, tachypnea, chest pain, hypoxemia.
  • Radiographic changes often lag behind clinical features so initially the Chest X-Ray may actually be normal (as in our case)
  • Treatment
    • Supportive: Early Supplemental Oxygen, analgesics and IV Hydration up to 1.5x maintenance rate
    • Antibiotic irrespective of cultures
    • Transfusion is believed to be lifesaving; recommendations based on empirical observations and not on firm evidence
    • Exchange transfusion seems to be more advantageous, especially in patients with a hemoglobin of > 9.0
      • It decreases the concentration of sickled hemoglobin with little iron gain
    • Inhaled Nitrous Oxide is beneficial
      • Due to its vasodilatory effects –à improved ventilation/perfusion in damaged lung tissue
      • Reduced RBC and leukocyte adhesion to endothelial cells, therefore affecting disease progression
    • Hydroxyurea reduces occurrence of acute chest syndrome

Case Presented by Greg Cassidy, MD

 

References:

  1. Stapczynski, J. S., & Tintinalli, J. E. (2016). Tintinalli’s emergency medicine: A comprehensive study guide (8th ed.). New York, N.Y.: McGraw-Hill Education LLC..

 

EM Conference Pearls (9/20)

Pediatric congenital heart disease

  • Congenital HD: Two types: Neonates with ductal dependent lesions and infants (2-6months) presents with CHF
  • Cyanosis presentation: When ductal-dependent lesion is required for pulmonary blood flow (Will not respond to oxygen)
  • Shock presentation: When ductal-dependent lesion is required for systemic blood flow (appear septic and not response to fluids, may get worse with fluids)
  • Hypoxic/cyanotic or shocky/acidotic baby treatment = Prostaglandin E1 (PGE1) and transfer to facility with pediatric cardiovascular surgeon.
  • PGE1 treatment may cause apnea (monitor closely and consider intubation)
  • CHF in infants = wheezing, retractions, tachypnea, sweating/crying, difficulty feeding

EBM in the ED

  • EBM = What the evidence shows in the literature + What the physician wants for the patient + what the patient wants for themselves
  • Just like we need to practice intubation, central lines –> Learning to read and interpret literature is a skill that needs to be practiced.

Aortic Dissection

  • AD: Chest pain plus disease (ex: CP + Neurodeficit)
  • If you find your self giving large amounts of strong pain meds (narcotics) while treating what is seemingly ACS…STOP..think about AD or alternative diagnosis of chest pain
  • The 3 important questions, aortic dissection is the subarachnoid hemorrhage of the torso, migrating pain, colicky pain + opioids = badness and pain that comes and goes can still be a dissection.
  • Treatment: Treat pain, HR, BP
  • Pain: Fentanyl 25 – 50 mcg bolus
  • HR: Goal of 60 bbpm
  • Esmolol 0.5 mg/kg bolus then 50 – 300 mcg/kg/min or
  • Labetalol 10 – 20 mg bolus then 0.5-2 mg/minor
  • BP control: Goal SBP =110
  • Nitroprusside 0.25 – 0.5 mcg/kg/min then titrate (CN toxicity)
  • Nicardipine 5 mg/hr
  • Warning: Giving a vasodilator without concomitant reduction in ionotropy may cause progression of dissection. Start BB first before vasodilation meds.

Case of the Week COW #8

CC: Altered Mental Status

HPI: 50 -year-old Male with PMH of HIV, CVA and Meningitis presents to the Emergency Department (ED) for altered mental status. As per the patient’s girlfriend at bedside, the patient woke up confused and was not making any sense when he spoke. He even urinated on the floor but does not remember doing so. Patient had been complaining of back pain, testicular pain and leg pain for the past couple of weeks and had been evaluated for it in the ED. Patient also states he is currently taking “something for his HIV” but is unclear what his last CD4+ count was. Denies sick contacts. The rest of the review of systems was limited by confusion, but denied vomiting, diarrhea, abdominal pain, or any other complaints.

Physical Exam:

BP 128/78   HR 129     RR 14   SpO2 96% on RA   Temp 102.4F

Constitutional: Diaphoretic, confused and intermittently following commands.

HEENT: NCAT, pupils PERRLA, neck supple

Respiratory: CTA B/L, no wheezing, rales or rhonchi

Cardiac: +S1/S2, tachycardia, no MRG, regular rhythm

Abdomen: soft, mildly distended with mild tenderness in RUQ and LUQ.  Was not able to appreciate any focal masses . No rebound or guarding

Neuro exam: Not oriented to time or situation, No focal deficits, moving all four extremities. Unable to complete a more detailed exam as patient remained confused.

Extremities: no edema, no tenderness or swelling

Skin: pink and warm with diaphoresis, no rashes, lacerations, or abrasions

Pertinent Labs:

(Per Sorian Inpatient) CD4 = 120 on June 2017

Sepsis workup summary (normal if not reported):

  • Trop 0.045ng/ml
  • Sodium 126
  • WBC 5.8       Chloride 93
  • RBC 3.72      CO2 19
  • HBG 10.3      Glucose 116
  • HCT 30.3       BUN 89
  • Platelets 108
  • Cr 2.90 (↑ from baseline)
  • Bands 27        Total Bili 4.5
  • Lymphs 3       Total Protein 5.7
  • Monos 2         Albumin 2.6
  • Lymphocytes 0.2
  • Alk Phos 346   Monocytes 0.1
  • AST 143
  • ALT 58
  • Lactic acid 3.4
  • U/A negative
  • CSF negative

Pertinent Imaging and other tests:

EKG remarkable for sinus tachycardia, left axis deviation, and an old RBBB

CT head w/o contrast remarkable for only mild frontal volume loss

Chest XR – unremarkable

RUQ Bedside US and then official US completed and showed:

Working Diagnosis:

Hepatic hydatid cysts from Echinococcus tape worm

Hepatic abscesses

Metastatic cancer

Multiple biliary hamartomas

Polycystic liver disease

Caroli Disease

ED/Hospital course:

In the ED, the patient received IV Fluid boluses of NS 30mg/kg and one 1000mL of NS along with Tylenol, Vancomycin and Zosyn. The patient was admitted to Infectious Disease service. Throughout the hospital stay, CT Scan of abdomen and pelvis w/o contrast (due to AKI) was remarkable for infiltrated liver, splenic lesions, and destructive lesions of the bilateral iliac wings and L5 with pathologic fracture of the posterior right rib, which may be due to metastatic disease. The underlying etiology is uncertain. Without contrast, it was not certain if there was underlying macronodular cirrhosis. There was also associated ascites. Initial blood cultures from the ED grew Salmonella species. The patient was initially admitted the medical floor but was transferred to the Medical ICU on day 7 of hospitalization for increased lethargy and worsening lactic acidosis, transaminitis, and AKI. He later went into multisystem organ failure and was intubated thereafter. His code status was also changed to DNR/DNI. The patient unfortunately expired before endoscopy, colonoscopy, and biopsy could be performed.

Official Ultrasound read – Findings consistent with metastatic disease to the liver.

Pearls:

Hepatic Hydatid infection

  • Caused by Echinococcus granulosus or Echinococcus multilocularis
  • granulosus – Endemic in North America & Australia with dogs & wolves main as main host
  • multilocularis – Found in Northern Hemisphere with red fox, dogs, & cats as main host
  • Ultrasound would show a multiseptate cyst with daughter cysts
  • X-ray would show calcified rings
  • CT Abd/Pelvis may show the water-lily sign, which occurs when the endocystic membrane becomes detached, resulting in floating membranes within the pericyst, which mimics the appearance of a water lily ( Refer to Figure 1).

Figure 1. A detached membrane within the contents of the cyst, known as the water-lily sign

Pearls

Hepatic Hydatid infection

  • Infection may be asymptomatic for many years, with a long latent period (up to 50 years of age!)
  • Albendazole for confirmed infection
  • Reserve antibiotics for those in which diagnosis is uncertain due to risk of anaphylaxis
  • Most cases in U.S. occur in immigrants from endemic countries (South America, Middle East, eastern Mediterranean, sub Saharan, African, West China, former Soviet Union)
  • Confirmed cases in U.S. are rare

Patients with HIV

  • Always ask for CD4+ count and if they are on medications for their HIV/AIDs
  • Have a low threshold for doing an aggressive workup for these individuals, especially if poor follow up
  • HIV is a risk factor for Salmonella bacteremia
    • Other risk factors include any immunosuppressed state, liver disease, hemoglobinopathies (decreased splenic function)
    • Most salmonella bacteremia can have a preceding diarrheal illness
    • Major complication is endovascular infection
    • Treatment is IV fluoroquinolones or 3rd generation cephalosporin

Case presented by Jessica Williams, MD, PGY1