Case of the Week (COW) #5

CC: Vomiting for 2 days

HPI: 47 year old female with PMHX of HTN and ETOH abuse presents with abdominal pain. Patient states that beginning two days ago she was woken up from her sleep with sudden onset non-bloody vomiting as well as epigastric pain which radiates to the back and is sharp in nature. She admits to over 15 episodes of vomiting. She is also having cramping of her feet bilaterally. She admits to daily ETOH use, and states her last intake was two days ago, denies illicit drug use. Denies taking any medication prior to arrival. Denies fever, chills, chest pain, SOB or dysuria. Denies recent travel or sick contacts. PMHX/PSHX: none Meds: none Allergies: none

Physical Exam: Vitals: BP 150/96 P 98 RR 16 O2 sat 98% RA General: Awake, alert, anxious Cardiac: Regular rate, no murmurs Lungs: CTAB, no rales, no rhonchi, no wheezing Abd: soft, non-distended, Mild tenderness to palpation epigastric area

Labs: Magnesium- 1.3 Potassium- 3.5 Troponin- 0.017

EKG:

DX: Prolonged QT interval with non-sustained polymorphic Ventricular tachycardia secondary to Hypomagnesemia

ED/Hospital course:  Upon arrival to ED patient had Epigastric pain with vomiting, Patient started on IVF and received Pepcid and Zofran. EKG at this time showed QT prolongation and patient found to have magnesium of 1.3. While waiting for magnesium, she started to have short runs of polymorphic ventricular tachycardia and during these times she complained of chest tightness. After 2 grams of magnesium patients repeat EKG showed normal QT and runs of ventricular tachycardia stopped. She received another 2mg of Magnesium and 40 mEq of Potassium Chloride. Patient was then admitted to Telemetry floor. Patient observed for 24hours and discharged to home with follow up with a cardiologist and Norvasc 5 mg 1tab PO daily, Losartan 100 mg 1tab PO daily, Ranitidine 150mg 1tab PO BI.

Pearls:

  • An abnormally prolonged QTc, especially >500 is associated with an increased risk of ventricular arrhythmias, Torsade’s de Pointes
  • Prolonged QT with prolonged T wave is due to: HypoK, HypoMg, Medications, Elevated ICP, Cardiac ischemia, Congenital.
  • Prolonged QT with prolonged ST-segment is due to: HypoCa, Hypothermia.
  • If EKG reveals long QT start by reviewing drug history and checking electrolytes. Stop any offending agents. Suppress early after depolarization with IV magnesium sulfate and keep potassium >4.5meq/L.
  • If non responsive to magnesium, may consider cardiac pacing and rarely isoproterenol infusion. Acceleration of the heart rate may produce suppression of arrhythmias, with a reduction in the QT interval.
  • Unstable patients should undergo non-synchronized electrical defibrillation.

Post by: Dr. Kerri Clayton, DO

 

Steroids for SJS and TEN?

Here’s a quick hit summary of the evidence regarding the use of systemic corticosteroids in the treatment of SJS/TEN

  • Small amount of evidence, NO RCT to date
  • Small retrospective study (n=30, groups comparable) in 1984 from a burn center found survival benefit (66% versus 33% survival) in NOT giving steroids. Also found decreased complications such as Candida sepsis & esophageal ulcer in patients who did NOT receive steroids.
  • Cohort of ~500 patients from RegiSCAR (International Registry of Severe Cutaneous Adverse Reactions to Drugs)
    • No statistical diff in Hazard Ratio among treatment groups (supportive care vs. corticosteroids vs. IVIG).
  • Systematic Review of literature from 2001-2009 (only used Pubmed, not great)
    • Pooled analysis demonstrated no statistically significant difference in Mortality Ratio among groups (supportive care vs. corticosteroids vs. IVIG).
    • B.: i2 statistic not reported but authors mention no problematic heterogeneity.
  • Very small study (n=12 over 10 years) demonstrated potential benefit to early pulse-dose IV steroids (1.5 mg/kg/day dexamethasone for 3 days) in the form of (1) disease halt at 3 days (2) 1 actual death versus 4 predicted deaths.
  • Interestingly, a case-control study (case n=92; control n=381) demonstrated that pre-existing chronic steroid use delayed onset of SJS/TEN in patients using high-risk drugs by 7 days but also prolonged disease course by 2 days.

Bottom line

  • Systemic corticosteroids have not been shown to consistently correlate or provide a survival benefit in patients with SJS/TEN.
  • Paucity of evidence may show benefit to pulse-dose IV steroids such as are used in the treatment of autoimmune diseases such as pemphigus vulgaris.
  • Supportive care is the standard of care.

Post by: Dr. Katrina D’Amore DO, MPH

Case of the Week #3 – Why my flap sunken?

CC: Altered mental status and frequent falls

HPI: 55 y/o male presents from rehab with altered mental status (lethargy and agitation) and frequent falls for the past 2 days. Patient has a PMHx of large traumatic subdural hematoma 9 months ago treated with a craniectomy, seizure disorder, and HTN. Patient complains of headache and is a difficult historian. Pt does answer some questions appropriately.

Pertinent PE and Vitals: BP 121/81 HR 98 RR 16 Temp 98.1 100% on RA

GCS=14 and in no acute distress

L pupil dilated at 4 mm and nonreactive. R pupil 1 mm and reactive.

Pt. with moderate R arm and leg weakness (patient has baseline weakness but this is worse).

Pertinent Labs (if any): Unremarkable workup

Imaging

Working Diagnosis at time of Disposition Sinking Skin Flap Syndrome (also known as Syndrome of the Trephined) with possible Paradoxical Herniation

ED & Hospital Course Patient was admitted and received neurology and neurosurgical consultations. Medications were adjusted to control agitation. It is questionable per the consultants if his symptoms were due to paradoxical brain herniation. Plan is for an outpatient cranioplasty.

Pearls & Takeaways

  • Sinking skin flap syndrome is a delayed complication of a decompressive craniectomy. As the herniated brain tissue recedes, the skin flap from the surgical site can become sunken.
  • Symptoms include headaches, dizziness, seizure, and mood changes.
  •  Symptoms worsen when is head elevated vs reclined; treatment option is cranioplasty. Symptoms are much worse in an upright posture.
  • If atmospheric pressure exceeds intracranial pressure, patients can get paradoxical herniation and midline shift. This is more of an emergency and symptoms include focal deficits, pupillary changes, and alterations in consciousness.
  •  Paradoxical herniation is a state of low intracranial pressures; therefore traditional measures to treat midline shift and ICP will worsen the condition such as mannitol, hyperventilation, etc.
  • Treatment of sunken skin flap with paradoxical herniation is to elevate the intracranial pressure, including Trendelenburg position, hydration, and clamping of any CSF drains. Definitive treatment is cranioplasty.

Antibiotics for chest tubes

Things to keep in mind:

Prophylactic antibiotics for surgical patients in tube thoracostomy is usually limited to 24hrs duration and is 1st generation cephalosporin. It is meant to cover s. aureus the most common organism found in post traumatic empyema

increasing antibiotic use is leading to increase incidence of drug resistance

Potential infectious complications of penetrating or blunt chest trauma:

  • Post Traumatic Empyema
  • Pneumonia

Literature is mixed on whether antibiotics should be given for chest tubes placed for trauma.

In 1998 EAST guidelines gave a level 3* recommendation to give antibiotics prophylacticly to reduce incidence of pneumonia based off of Class I and Class II** data. AND there was insufficient data to give prophylactic antibiotics for post traumatic empyema

This recommendation remains controversial because 

  •    In order for antibiotics to be prophylactic they have to be given prior to a procedure and must reach a steady state concentration in the tissue before an incision is made.
  •    In the case of antibiotics given after a trauma has already occurred, the pleura has already been violated regardless of whether it is penetrating or blunt trauma. Therefore antibiotics do not reach needed concentration before contamination has concerned so these antibiotics are considered presumptive antibiotics.
  •    Non standard definitions of pneumonia and empyema were used, as well as various antibiotics were used in the different studies

In 2012 EAST guidelines reviewed the use of presumptive antibiotics for chest tubes (Tube thoracostomy):

They decided that they cannot make a recommendation for or against the routine use of presumptive antibiotics for chest tubes placed for traumatic hemopneumothorax.

Nor are they able to recommend an optimal duration of antibiotic prophylaxis when antibiotics are administered for traumatic hemopneumothorax because there are insufficient published data to support the routine use of antibiotics.

They concluded:

No single published study has been powered to adequately address the practice of administering presumptive antibiotics in TT for traumatic hemopneumothorax to decrease the incidence of empyema or pneumonia. Until a large and likely multicenter, randomized, controlled trial can be performed, the routine practice of presumptive antibiotics in TT for chest trauma will remain controversial.

If you want to read the article it isn’t a long read:
Post by: Dr. Ashley Guthrie, DO

Case of the Week #2 – I can’t pee!!

CC: Urinary retention

HPI: 44 yo F presents with suprapubic abdominal pain since this AM. She also complains of dysuria and denies fever, chills, hematuria, vaginal bleeding or discharge, flank pain, N/V/D, CP, SOB or any other symptoms. This is her third visit to the ED in the past 3 days for urinary retention. On patient’s initial visit, she c/o pelvic pain, dysuria and urinary retention for 12 hours.  A straight urinary catheter was placed, and 2 liters of urine was drained and the pt was d/c’d home and told to follow up with her PMD. Yesterday, pt returned once again to the ED c/o urinary retention during which a Foley catheter was placed and 900 cc of urine was collected. No UTI was documented. Today, pt still c/o a sense of fullness and has been unable to urinate since 4 am despite having the Foley catheter in place and emptying the bag. Pt called her PMD last night during which he prescribed her Ciprofloxacin for a presumed UTI.

PMH/PSH: None

Meds/Allergies: None

Social: Denies

Physical Exam: Vitals: BP 130/84 P 144 RR 17 O2 sat 100% RA Temp 98.2F

General: Awake, alert, in no acute distress, comfortable
Cardiac: RRR , S1 S2, no murmurs
Lungs: CTAB, no rales, no rhonchi, no wheezing
Abd: Soft, with mild tenderness in suprapubic area. No distention. No rebound or guarding
Back: No CVA tenderness
GU: Foley catheter in place with empty bag
Extremities: No edema or rashes. Able to move all extremities
Neuro: AAO x 3

Labs

WBC: 10. 5
Hg/Hct: 13.3/40
Platelet: 215

Na: 141
K+4.6
CL –: 102
CO2: 26
BUN: 9
Cr: 0.83

Urine HCG: Negative

Urinalysis:
Ketones: Small
Blood: Small
Nitrite Urine: NEG
Leukocyte Esterase: Moderate
RBC: 0-3
WBC: 11-20
Bacteria: Rare

Imaging: 

DDX: Vaginal Mass vs Urinary Retention vs UTI

ED Course: 

Upon evaluation, the Foley catheter’s leg bag straps were fitted incorrectly causing a drainage bag obstruction. In the ED, the obstruction was resolved and catheter was successful draining urine.

The reading of the CT abd/pelvis was: CT Abd/Pelvis W/ and w/o Contrast: There is a 9.9 x 9.4 x 9.9 cm vaginal mass, which displaces the uterus cephalad, and likely the cervix and the bladder anteriorly which is quite effaced. The mass is likely centered in the mid and posterior vagina, which is worrisome for a vaginal or possibly a cervical malignancy although could be of other etiology and warrants a follow up MRI. The most worrisome component is anteriorly to the left where there is either a lymph node measuring 3.7 x 2.5 x 4.7 cm or extrusion of the mass. A left ovary is likely seen with an involuting cyst measuring 2.1 x 1.6 x 1.7 cm quite cephalad to the lesion

OB/GYN was consulted. They came down to evaluate the patient and perform a vaginal speculum exam, which revealed a small amount of malodorous thick discharge similar to pus and a palpable mass in left vaginal wall. OB-GYN recommended patient continues to take Ciprofloxacin as prescribed by her PMD and return to the Emergency Dept. in 3-4 days for re-evaluation and admission to the hospital for a Diagnostic laparoscopy

Pt returned to the ED 4 days later, during which she was admitted and underwent a diagnostic laparoscopy, Left salpingo-oophorectomy and resection of vaginal mass. Foley Catheter was inserted in operating room and pt was d/c home from Same day Surgery.

Discussion:

• Acute Urinary Retention (AUR) in women is rare. It is estimated that are 3 cases of AUR per 100,000 women per year.

• The female to male incidence ration is 1:13

• The most common cause of AUR is obstruction. In women, it is usually secondary to anatomic distortion, including pelvic organ prolapse, pelvic masses, or less likely urethral diverticulum.

• Other less common etiologies include neurogenic causes (MS, Cauda equine syndrome, metastatic spinal cord lesion, neuropathy) and infectious causes (cystitis, Herpes simplex (genital), local abscess, PID).

• Evaluation should include: UA with urine cultures, Chemistry, CBC if you suspect infection or massive hematuria, and a bedside ultrasound to verify retention. Then bladder decompression by inserting Foley catheter. Incomplete retention is PVR > 50mL and > 100mL in patients > 65 years of age

• Pearls: Urinary retention in women is rare. Think of a pelvic mass as a cause, especially if urine is clean. Have a low threshold for obtaining a CT Abd/pelvis to confirm diagnosis.

Post by: Dr. Yenis Paez-Perez, DO

 

Who got that stank?

Neutralizing ED Stank

Patients that stink can really hinder an ED. It creates a difficult work environment for ED staff and makes nearby patients, families and visitors uncomfortable. Here are a few ways I came across to neutralize the stank:

Nebulize stuff in the patients room

 

  • Nebulized OJ (works well for malodorous feet)
  • Nebulized coffee (works well for melena)
  • Will partially mask the smell
  • Works better in enclosed rooms w doors

 

image1.JPG

For when you have to remove shoes & socks (malodorous feet):

1. Maalox booties

  • Place feet in large trauma booties
  • Fill w Maalox and allow to soak

2. Towel Soaks

  • Mix warm water, betadine, peroxide and hibiclens (chlorhexidine) in basin
  • Soak towels in solution then wrap feet
  • Wrap feet and towel w blue pad
  • Allow 15 minute soak

3. Topical sodium bicarb

  • Use 1 amp per foot, apply topically
  • Neutralizes most odors
Post by: Dr. David Traficante (@davetraf)
References:
 

Case of the Week #1

CC Chest pain and palpitations

HPI Pt is a 23 y/o male with no PMHx presenting with c/o palpitations, chest pain since last night. Pt states the pain is localized to the mid sternal chest wall with radiation to b/l upper extremities at times. Pt states the pain came on suddenly last night and he didn’t think anything of it so he went to bed. He woke up this morning with same pain and now with associated nausea and dizziness prompting the visit to the ED. Pt has never had pain like this in the past. Denies vomiting, F/C, recent illness, sudden cardiac death in the family other than a 70 y/o uncle who was obese. Pt denies drug use and states he was drinking over the weekend 2 days ago.

PMHx: none

Meds: none

Allergies: none

PSHx: none

Social: occasional ETOH, (-) drugs

Pertinent PE and Vitals: BP 90/62 P 186 RR 22 O2 sat 100% RA

General: Awake, alert, mild distress Cardiac: (+) tachycardic; no murmurs Lungs: CTAB, no rales, no rhonchi, no wheezing Abd: soft, nontender, nondistended Skin: diaphoretic; mild pallor

Pertinent Labs (if any) Troponin: 0.439

DDX: SVT with aberrancy vs VTach

ED Course: Pt placed on cardiac monitor immediately and IVF bolus initiated. Adenosine 12 mg IVP given while rhythm strip running with no change. A second dose of Adenosine 12 mg IVP given again with no change. 150 mg Amiodarone given with improvement of HR from 190’s to 170’s still wide complex. Second dose of 150 mg Amiodarone given with improvement of HR from 170‘s to 150’s and eventually converted to a NSR rate 85. Pt remained in stable condition and BP responsive to IVF. Pt admitted to telemetry and Cardiology consulted. While still in the ED, pt reverted back to wide complex tachycardia. 3rd dose of 150 mg Amiodarone given and recommendation from Cardiology was to try a 20 mg IVP of Cardizem. Cardizem given and pt immediately converted to NSR. Pt started on Cardizem drip and upgraded to the CCU. Pt underwent EPS and AV dissociation was noted. Determination was Verapamil Sensitive Ventricular Tachycardia. Pt remained stable throughout hospital course and started on Verapamil. Discharged on hospital day #3 with follow up with cardiology clinic.

Final Dx:  Idiopathic Fascicular Left Ventricular Tachycardia AKA • Fascicular Tachycardia • Verapamil-sensitive VT • Belhassen-type VT

Discussion:  MC type of idiopathic tachycardia of LEFT ventricle ! It is a reentrant tachycardia typically seen in young patients without structural heart disease ! Verapamil is first line treatment • Dose: 10 mg IVP over 1 minute ! EKG features: • Monomorphic V tach • QRS 100-140 ms (narrower than other forms of Tach) • Short RS interval 60-80 ms • RBBB pattern • Axis deviation depends on anatomical site of re-entry circuit ! Often misdiagnosed as SVT with RBBB ! Keys to dx: • Observe features of VT such as caption/fusion beats, AV dissociation • Usually unresponsive to adenosine, vagal maneuvers, or beta blockers

Post by: Kristen Pena, DO

Getting ready to intubate? Let’s pray they don’t DESATurate!

You head over to bed 44 to meet the BLS crew as they start telling you about an 82 year old man who has been having trouble breathing and is “confused” as per his family.  His oxygen saturation when you check is 76% and quicker than you can say “sepsis”, the eager resident has popped the grey airway box open and is setting up to intubate.

You slap the NRB on and turn the O2 up all the way.  So why is the resident so focused on finding and placing a nasal cannula too?!

Apneic oxygenation (AO) is used to extend the time until critical arterial desaturation (SaO2 88-90%) following cessation of breathing/ventilation that occurs during intubation.  AO, similar to our other RSI preparation, premedication, and positioning, is used to optimize the patient prior to the first intubation attempt.

First demonstrated by anesthesiologists over 50 years ago, the alveoli of the lungs will continue to take up oxygen even in the absence of active breathing.  AO focuses on increasing a patient’s oxygen saturation through “nitrogen washout” in first the alveoli, and then throughout the circulation.  This effectively replaces the nitrogen one inhales in normal atmospheric air with oxygen and increases the patient’s overall oxygen storage in both the lungs (95% of a person’s natural reservoir) and bloodstream.  Maximizing pre-oxygenation provides us an additional buffer of time for “safe apnea” during oral intubation.  In a 2011 article in the Annals of Emergency Medicine, Weingart et al outline recommendations to reduce the risk of hypoxemia during emergency tracheal intubations which include emphasis on:

Pre-oxygenation for every patient

  • Nasal Cannula set at 15 L/min is the most effective method of AO
  • Non-rebreather mask at rates as high as possible
  • HOB elevated 20-30 degrees or Reverse Trendelenburg in suspected C-spine injuries
  • Minimum of 3 minutes total or 8 deep breaths, if possible

Take home:  Keep in mind the acronym “NO DESAT” which stands for “Nasal Oxygen During Efforts Securing A Tube”.  A nasal cannula with high flow rates should be placed on every patient prior to endotracheal intubation and left in place during attempts in order to reduce the risk of hypoxemia and deterioration.

AMA after Narcan – Is it safe?

In comes a 34-year-old male who is obtunded with pinpoint pupils and breathing at five times a minute; likely due to heroin abuse.  He wakes up after Narcan is appropriately administered, but now he wants to leave.  What is the risk of death if he leaves?  Do we restrain him against his will to monitor him for possible recurrent respiratory depression?

We have some pre-hospital literature that looked into this issue.  The studies looked at patients who refused care after pre-hospital providers administered Narcan for a suspected opiate overdose.  They then searched the death registry to see if those patients later died after refusing care (transport to the hospital).

Wampler et al. looked at 552 patients and found that no one died until at least 4 days later (1).  These deaths four days later were unlikely to be from the initial overdose.  A second study recently published in March of 2016 had 205 patients and showed only one death in 24 hours (2).  Two others died in the 30-day follow up period which again were not likely due to the initial overdose.  Combining the numbers from these two studies equates to 1/757 (0.13%) deaths.

There are limitations with all studies, but death seems unlikely after refusal of care post-narcan administration.  However, our practice should not change as it relates to monitoring patients for about 4 hours to those willing.  Recurrent respiratory depression is a real concern particularly seen in those patients who abuse long acting opiates.  Despite this, some patients who have the capacity to make decisions may not choose the wisest care plan and may leave AMA.  We must still make considerable attempts at providing substance abuse referrals and other appropriate resources as these patients are in great need of help.

Post by: Joe Bove  (@jjbove08)

  1. Wampler D, Molina D, McManus J, Laws P, Manifold C. No deaths associated with patient refusal of transport after naloxone-reversed opioid overdose. Prehosp Emerg Care. 2011;15(3):320-324.
  2. Levine M, Sanko S, Eckstein M. Assessing the Risk of Prehospital Administration of Naloxone with Subsequent Refusal of Care. Prehosp Emerg Care. March 2016:1-4.

Habitat for Humanity Day of Service

As a residency we have been wanting to get more involved with our surrounding community instead of just interacting with the residents of Paterson in the ED.  A couple weeks ago we went to Habitat for Humanity in Paterson to help with some construction instead of being cooped up at St. Joe’s for conference.  Joe “Handy-man-chester” single-handedly constructed a single-family home in 8 hours while Dr. Patel did an amazing job observing everyone else working and providing endless amounts of encouragement.  It was a lot of fun and we’ll be back soon!

HAPPY THANKSGIVING!!