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Case of the Week COW #14

Presenting Resident

Traficante

Chief Complaint

Cardiac arrest

Brief HPI

Hispanic male in his mid 30s who presented to the ED as John Doe after he was found unresponsive in the field with cardiac arrest. Unknown downtime. As per EMS endorsement from bystanders, the patient allegedly had a witnessed syncopal episode followed by seizure-like activity after which he became unresponsive. No bystander CPR. EMS arrived at the scene and found him pulseless, CPR started. On ALS arrival patient found to be in PEA. CPR, intubated, epi x 2, bicarb then ROSC achieved. Initial rhythm in ED was sinus tach on monitor. After 5 min in ED patient became bradycardic and went into PEA, compressions started, received epi x 1 w ROSC. Pt then went into wide complex tachycardia on monitor – SVT vs Vtach – pt was cardioverted 200J and given Amiodarone 150mg. Post cardioversion, rhythm changed to afib v aflutter. EKG was obtained after 10 min (below).

Pertinent PE and Vitals

On arrival: BP 81/50; P113; SpO2 95% ambubag 100% FiO2; Temp 37.0; BS 136

PE:
Gen: Unresponsive, intubated, occasional myoclonic jerks
HEENT: 2 cm hematoma right occiput, pupils constricted 1-2 mm b/l and non-reactive CV: tachycardic, s1/s2, no murmurs
Resp: Assisted breathing, good air entry b/l
Abd: Soft, NT
Neuro: GCS 3, has occasional myoclonic jerks

On admission: BP 153/83; P153; SpO2 98% on vent 100% FiO2

Pertinent Labs

ABG done on patient arrival = 6.80/86/253/14; Na+ 133; K+ 4.4, Ca++ 1.04; Glu 246, Lac 8.8, BE -10.2 These were the only labs available at the time of admission.

Pertinent Imaging/EKG

Case d/w Cardio fellow who came to evaluate pt at bedside, decision made to transfer pt directly to cath lab. EKG was repeated after 5 minutes prior to patient being transferred, which is shown below.


Working Diagnosis at time of Disposition

Cardiac Arrest
STEMI – possible LMCA, LAD or Triple vessel dx

ED & Hospital Course

Interventional cardiologist advised immediate transfer to cath lab for diagnostic cath (did not want to wait for CT Head). Cath showed normal coronaries with LVEF 75%.

Patient transferred to the CCU post cath. He was noted to have no brainstem reflexes off sedation. CT Head showed findings c/w anoxic encephalopathy, no bleed. Neuro was consulted who stated patient’s exams and further diagnostic studies were significant for loss of all cortical and brain stem function, consistent with brain death. Patient was pronounced on Day 10 (delay with identifying patient and determining NOK).

Pearls & Takeaways

Is ST-Segment Elevation in Lead aVR Getting Too Much Respect?

Introduction

ECG reading is all about pattern recognition. And this particular pattern of ST-Elevation in aVR with diffuse ST Depression is a very important ECG pattern that you must be able to recognize. But what’s probably more important than being able to recognize the pattern, is understanding what it represents. There appears to be a common misconception that the ST-Elevation in aVR always represents “STEMI”, or acute transmural (full- thickness) ischemia. If this were the case the patient would most likely be dead or at the very least in profound cardiogenic shock. The key to understanding what this pattern represents lies in understanding that the ST-Elevation in aVR is reciprocal to the diffuse ST-Depression – and that this diffuse ST-Depression represents global subendocardial ischemia. So the real question that you must answer is: What is causing the global subendocardial ischemia?

What Else can Cause STE in aVR that Won’t Benefit from Going to the Cath Lab?

Worrisome Diagnoses:

  • –  Thoracic Aortic Dissection
  • –  Massive Pulmonary Embolism
  • –  Massive Gastro Intestinal Hemorrhage

Non-Worrisome Diagnoses:

  • –  Left Bundle Branch Block (LBBB)
  • –  Left Ventricular Hypertrophy (LVH) with Strain Pattern
  • –  Severe Atrial Tachydysrhythmias (i.e. SVT)

It is critical to realize that more often than not the cause is global myocardial strain from a Non-ACS etiology! (profound sepsis, tachycardia, anemia, hypoxemia, etc). In our patient above it may have been because of the SVT he was in during the code in addition to being in Afib w/ RVR at the time of the ECG. It is also very important to understand that in these Non-ACS settings, you can see this pattern with or without underlying coronary artery disease.

But of course it could be ACS. And if it is, then you are dealing with Left Main, Proximal LAD, or even multi-vessel plaque instability. But keep in mind that even if it is ACS you are still dealing with subendocardial and not transmural ischemia.

Take Home Points

    1. STE in aVR Should be Concerning IF you have a patient with:
      1. Worrisome/Concerning Symptoms (Cardiopulmonary Symptoms) AND…
      2. ST-Segment Depression in Several Other Leads

    2. Don’t worry so much about STE 0.5mm or less in lead aVR, because it lacks specificity. Using 1.0mm or greater in lead aVR, has better specificity

    3. Patients with ACS due to LMCA Blockage, Triple Vessel Disease, or Proximal LAD Blockage will look “sick” due to global cardiac ischemia. This narrows the number of patients we would consider activating the cath lab for with STE in aVR.

    4. The key to ECG reading is pattern recognition. The pattern of ST-Elevation of at least 1mm in lead aVR + diffuse ST-Depression with a maximal depression vector towards leads II & V5 is a pattern you must know. It represents global subendocardial ischemia.

    5. When you see this pattern you should divide the differential for the diffuse subendocardial ischemia into two main categories: ACS vs Non-ACS. Do not automatically assume that it is ACS. I have seen this mistake made many times as ACS becomes the focus, at the expense of appropriate resuscitation addressing the underlying cause. It is very important to keep in mind that the etiology is far more likely to be Non-ACS than ACS!

    6. The key to determining the etiology is through history, physical exam, clinical picture, laboratory data, Echo, and vigilant monitoring and frequent reassessment. If you have identified and addressed potentially reversible causes of the ischemia, and the ECG pattern persists then you are dealing with ACS until proven otherwise.

    7. Refrain from using dual-antiplatelet therapy in these patients as there is a high likelihood they will require CABG.

    8. Remember that if this ECG pattern does represent ACS, the ST-Elevation in aVR is not the result of direct injury (or transmural ischemia) and that the ST-Elevation in aVR is reciprocal to the diffuse ST-Depression. Therefore these ACS cases do not represent a clear “STEMI”. However, while there is not great data to guide the timing of cath for these patients, I would advocate going to the cath lab with a much stronger sense of urgency than for other “NSTEMIs”. The reasoning is that ACS is a very dynamic process and without the advantage of optimal medical therapy (a second platelet inhibitor should be withheld) there is a higher chance of the culprit vessel suddenly occluding and evolving to transmural ischemia. If this happens in the Proximal LAD, Left Main, or in the setting of Multi-vessel involvement the myocardial territory in jeopardy is so large that there is a good chance the patient will arrest and die before any reperfusion can be established! If your patient looks sick or has persistent chest pain, they should be going to the cath lab ASAP.

    9. With diffuse subendocardial ischemia, you may not see any wall motion abnormality. Global function can even be normal, although it may be globally depressed as well. A normal bedside echo does not help in:
      1. differentiating the cause of the STE in aVR
      2. ruling out ACS

References: http://hqmeded-ecg.blogspot.com/2018/02/st-elevation-in-avr-with-diffuse-st.html

Pediatric Pneumonia

 3-year-old boy presents to the ED with a 4-day history of cough and 1-day history of fever. Per family patient has been having rigors and chills with vomiting. He also reports chest pain with coughing. His immunizations are UTD. The child does not appear toxic,

VS: Temp 103.3F,  BP 90/65,  HR 100,  RR 30,  96% O2 Saturation on RA.
Patient has some intercostal retractions, with decreased air entry on the right side with audible crackles.

Questions for EM physician

  • How do you make the diagnosis of pneumonia?
  • Distinguishing patients with bacterial pneumonia, who would benefit from antibiotics, from those with nonbacterial pneumonia who would not.
  • Who requires inpatient management vs. patients that can be safely discharged home on oral antibiotics.
  • Pneumonia is the number 1 killer of children worldwide.
  • Pneumonia occurs more often in early childhood than at any other age and causes significant morbidity and mortality.
  • Identifying the cause of pneumonia in children is difficult due to a lack of rapid, accurate, commercially available laboratory tests for most pathogens. Empirical therapy based on patient’s age, clinical scenario and risk factor is the most common course in most cases.
 Age-specific causes of pneumonia in otherwise healthy children. Pathogen listed in order of frequency
Neonates GBS, E. Coli, Listeria Monocytogenes, Staphylococcus
1 month – 2 years RSV, Parainfluenza virus, Metapneumovirus, Influenza virus, Adenovirus, S. Pneumoniae

 **3 weeks to 3 months of age (Pneumonitis syndrome/Afebrile Pneumonia Syndrome (APS))*: Chlamydia trachomatis, RSV, Parainfluenza virus, Bordetella pertussis

2 – 5 years RSV, S. Pneumoniae, Non-typeable H. Influenzae (NTHi), Group A Streptococcus, Mycoplasma pneumonia, Chlamydia pneumonia
6 – 18 years Mycoplasma pneumonia, Chlamydophila pneumonia, Streptococcus pneumonia, NTHi, Influza virus A , other respiratory viruses
  *Infants (1 – 3 months of age) may present with a characteristic syndrome of cough, tachypnea, progressive respiratory distress, and radiographic evidence of bilateral diffuse pulmonary infiltrates with air trapping. Most are afebrile. This syndrome is also called APS. The most common pathogen included Chlamydia trachomatis and respiratory viruses. Infection of Bordetella pertussis should also be considered due to recent dec. in immunization. Acutely, APS is generally benign and self-limiting disease. In such cases, infants often have viral illness, which does not respond to antibiotic therapy, but differentiating bacterial from viral illness is often difficult. Consider empiric antibiotic therapy.

Diagnosis of pneumonia:

    • Definition: Essentially it is infection of lower respiratory tract in the presence of radiographic abnormalities on CXR.
    • WHO guidelines for pneumonia in children is cough and tachypnea
      • Age < 2 months: Tachypnea is >60 RR
      • Age 2 months to 5 months: Tachypnea is >50 RR
      • Age >12 months: Tachypnea is > 40 RR
    • Clinical features
      • Fever and tachypnea are sensitive but not specific
      • Cough
      • Productive cough is rarely seen before late childhood
      • Consider pneumonia in any child presenting with prolonged fever, prolonged cough, high fever, as well as focal respiratory findings not including wheezing, especially with the presence of multiple symptoms.

Evaluation
Absence of tachypnea, respiratory distress, and rales/decreased breath sound rules-out pneumonia with 100% sensitivity

  • CXR: Cannot differentiate between viral and bacterial (but lobar infiltrate more often bacterial)
      • Consider for:
        • Age 0-3mo (as part of sepsis work up)
        • <5yr with temperature >102.2, WBC >20K and no clear source of infection
        • Ambiguous clinical findings
        • Pneumonia that is prolonged or not responsive to antibiotics
    • Consider RSV, Influenza 

Treatment

 Empiric Antimicrobial Therapy For Children with Pneumonia by Age group
Age group Outpatient Inpatient
Neonates NOT RECOMMENDED Ampicillin 200 mg/kg/d IV divided Q6H

+ Gentamycin 7.5 mg/kg/d IV divided Q8H

OR

+ Cefotaxime 150mg/kg/day IV divided Q8H

Consider Cloxacillin and Nafcillin for patient with S. aureus infection or Vancomycin for MRSA

3 wk – 3 mo NOT RECOMMENDED Azithromycin 10 mg/kg IV first dose, then 5 mg/kg IV QD for 4 days

 

3 mo – 5 yr* Amoxicillin 80 – 100mg/kg/day in 2 divided doses Ampicillin 200 mg/kg/d IV divided Q6H

OR

Ceftriaxone 50 mg/kg Q24hrs

Consider Azithromycin 10 mg/kg IV first dose, then 5 mg/kg IV QD for 4 days

Consider Vancomycin for seriously ill patients

6yr – 18yr* Azithromycin 10 mg/kg for first dose, then 5 mg/kg daily for 4 days Azithromycin 10 mg/kg IV first dose, then 5 mg/kg IV QD for 4 days

PLUS

Ceftriaxone 50 mg/kg Q24hrs

Consider Vancomycin for seriously ill patients

*Refer to AAP guideline on management of pediatric pneumonia below

Disposition

  • Consider Admission For
    • Age: <2-3 months old (Consider up to 6 months)
    • History of severe or relevant congenital disorders (Cystic fibrosis)
    • Suspected complication (Empyema)
    • Vomiting, dehydration, unable to tolerate PO
    • Immune suppression (HIV, SCD, malignancy)
    • Toxic appearance/respiratory distress
    • SpO2 <90-93%
    • Social circumstances

Post by Dr. Michael Hong

Case of the Week COW#13

CC: Chest Pain

HPI: 49-year-old female brought in via ALS presents complaining of Chest pain. As per the Paramedics, the patient was found to be in no acute distress, stating she had exertional chest pain, which had subsided. The pre-hospital ECG was suspicious for ischemia and she was given ASA. Patient states she was walking home from the store when she began to have a pressure like pain on the left side of her chest, which was non-radiating and persisted when she laid down. She admits to feeling similar symptoms over the past few months, but today was the most severe. Upon arrival to Emergency Department, she denied chest pain, SOB, palpitations, abdominal pain, nausea or vomiting. Denied ETOH or illicit drugs use

 Physical Exam:
BP:128/91, Hr:88, RR: 14, Temp: 98.0, Pulse O2: 100% RA
General: Patient lying comfortably in bed, in no distress
HEENT: NCAT, pupils PERRLA, neck supple
Respiratory: non-labored, CTA B/L, no wheezing, rales or rhonchi
Cardiac: +S1/S2, no MRG, regular rate and rhythm
Abdomen: soft NT ND, + BS
Neuro exam: AAO X 3, lucid, strength is 5/5 in all extremities, muscle tone is intact,
Skin: No rash or peripheral edema.

Pertinent Labs:
CBC: Unremarkable
CMP: Unremarkable
Troponin: Negative (< 0.010)

Pertinent Imaging/ECG
CXR: no acute infiltrate, No Pneumothorax or cardiomegaly. Normal Chest X-ray
Pre-Hospital ECG

ECG in the ED

Working Diagnosis: Left Main Insufficiency

ED Course: Repeat ECG in ED showed NSR and had completely normalized. Case was discussed with Interventional cardiologist on call. A Code STEMI was activated and patient was taken emergently to the Cath lab. She was given a Heparin bolus as well as Plavix.

ED/Hospital course:  The catheterization report revealed 80-90% Distal left main, 30 % mid LAD, and LM stenosis improved partially during catheterization with nitroglycerin. Patient admitted to recently using cocaine. CT surgery was called due to the fact that patient had recent cocaine use and it was believed she might have had Left Main Coronary spasm. On hospital day 2, patient went back for repeat catheterization, which revealed Left main distal 30% and LAD mid 30% stenosis. Patient was transferred to telemetry, and discharged on hospital day 4.

Pearls:

aVR in ACS
Typical ECG findings with left main coronary artery (LMCA) occlusion:

  1. Widespread horizontal ST depression, most prominent in Leads I, II and V4-6
  2. ST elevation in aVR ≥ 1mm
  3. ST elevation in aVR ≥ V1

(Don’t worry so much about STE 0.5mm or less in lead aVR, because it lacks specificity. Using 1.0mm or greater in lead aVR, has better specificity)

ST-Segment Elevation in lead aVR foreshadows a worse prognosis in ACS and often predicts the need for CABG. Patients with NSTEMI and ST elevation ≥ 1mm in aVR are likely to have multi-vessel or LMCA disease and are likely to require CABG, therefore withholding Clopidogrel may be prudent. ST-segment elevation in aVR can be caused by any of the following 4 mechanisms

  1. Critical narrowing of the LMCA causing sub-endocardial ischemia due to insufficient blood flow. (LMCA insufficiency)
  2. Transmural infarction of the basal septum due to a very proximal LAD occlusion or complete LMCA occlusion (patient will be VERY sick)
  3. Severe multi-vessel coronary artery disease.
  4. Diffuse sub-endocardial ischemia from oxygen supply/demand mismatch.

Patients with complete occlusion of the LMCA (mechanism 2), often present in cardiogenic shock and require immediate revascularization. Patients with acute coronary occlusions typically will have active symptoms and look sick!

There is an estimated 70% mortality without immediate PCI. Medical therapy (including thrombolytic) does not improve mortality. Emergency PCI may decrease mortality to 40%.

 What Else can Cause STE in aVR that Won’t Benefit from Going to the Cath Lab?

Other causes of global cardiac ischemia
o Thoracic aortic dissection
o Large pulmonary embolism
o Severe anemia
o Post-arrest (within 15 min. of epinephrine or defibrillation)

oMiscellaneous causes
o Supraventricular Tachycardia (esp. AVRT)
o Left bundle branch block (LBBB) & paced rhythms
o LVH with strain (from severe hypertension)
o Severe hypokalemia
o Na+ channel blockade (TCA toxicity, hyperkalemia, Brugada, etc.)

REMEMBER: ST-Segment Elevation in Lead aVR is NOT SPECIFIC for an acute LMCA Lesion, Acute Proximal LAD Lesion, or Acute Triple Vessel DiseasE

    • Correlate Your ECG with the Patient’s Clinical Status
    • Patients with ACS due to LMCA Blockage, Triple Vessel Disease, or Proximal LAD blockage will look “sick” due to global cardiac ischemia

Case presented by Dr. Kerri Clayton.

Pediatric Pearls – Bronchiolitis

Pathophysiology
  • Disorder that is commonly caused by a viral lower respiratory tract infection in infants
  • Characterized by acute inflammation, edema and necrosis of epithelial cells lining small airways and increased mucus production

  • Etiology
    • Coronavirus
    • Influenza
    • Rhino virus
    • Adenovirus
    • Parainfluenza virus
    • RSV (respiratory syncytial virus) – MOST COMMON!
  • Incidence – December-March
      • Most infections occur within first 2 years of life
      • About 40% experience lower respiratory infection during initial infection
      • RSV doesn’t grant permanent or long-term immunity – RE-INFECTION COMMON
      • The risk of significant viral or bacterial lower respiratory tract infection or pneumonia in an infant is low
  • Transmission
    • Direct contact with secretions
    • Young children shed virus for >2 weeks
    • 30-70% of household contacts become ill
  • Natural history
    • Begins with URI – Rhinorrhea, congestion, cough
    • Progresses to LRI in 2-6 days – Airway obstruction (tachypnea, wheezing, respiratory distress)
    • Variable and dynamic course
    • Lasts 2-4 weeks

Case

7-month-old male presents to the emergency room with his parents due to cough, runny nose, congestion and SOB that started 3 days ago.

VS: RR – 65, HR – 140, Temp – 99.1°F, O2 sat – 93% on RA


History
  • Typical Presentation of Bronchiolitis
    • Viral URI and cough with signs of lower respiratory tract infection
      • Work of breathing – grunting, nasal flaring, intercostal/subcostal retractions
      • Tachypnea
      • Wheeze
      • Coarse rales

Physical Exam
  • TIPS for a better exam
    • Upper airway obstruction can contribute to work of breathing
    • Suctioning and positioning may decrease the work of breathing and improve the quality of your examination
    • Counting respiratory rate over the course of 1 min is more accurate than shorter observations
  • Assess mental status, respiratory rate, work of breathing, oxygen status, listen to breath sounds, and assess hydration status


Diagnosis
  • DIAGNOSIS IS CLINICAL – NO LABS OR RADIOLOGICIAL STUDIES ARE NEEDED
    • When to consider CXR – if child has had >2 days of fever, an asymmetric chest exam, does not demonstrate improvement or has an unusually high O2 need
    • Diagnostic testing may be considered if:
      • Need cohorting – this is why we get testing for those we admit
      • Uncertain clinical diagnosis
      • Age <2 months
      • To assess for influenza – also needed this for those we admit

Management

Classify patient as mild, moderate, or severe based on the above physical exam

Mild Moderate Severe
1. Consider suction bulb

2. Discharge

1. Suction bulb

2. No bronchodilators

3. Discharge or admit

1. Suction bulb or wall

2. No bronchodilators

3. If no improvement consider starting high flow NC

4. Admit

  • Rehydration
    • IVF – moderately or severely dehydrated, secretions are thick and difficult to mobilize or severe respiratory distress
    • PO feeds – mildly to moderately dehydrated and can tolerate PO
  • Considerations for severely ill patients
    • Consider ONE TIME albuterol MDI trial if:
      • Severe respiratory distress OR
      • Increased risk for asthma
        • >12 months old, wheeze and once of the following
          • personal history of atopy or recurrent wheezing
          • strong family history of atopy or asthma
        • if responds to albuterol then consider switching to asthma pathway
      • Consider HFNC for significant hypoxia OR severe respiratory distress not improving with rigorous supportive care

 

Discharge criteria Admission criteria
–       Oxygen saturation >90%

–       Awake

–       Adequate oral intake

–       Mild/moderate work of breathing

–       Reliable caretaker

–       Able to obtain follow up care

–       MDI/spacer teaching if response to albuterol

–       Admit if discharge criteria not met:

o   Inpatient: Requires 02 or progression expected

o   OBS: Mild disease with expected LOS < 24 hours

o   ICU: Apnea, severe distress; Requires HFNC / CPAP / intubation

–       Infants with these risk factors present early in the illness have higher risk of progression:

o   Gestational age < 34 weeks

o   Respiratory rate ≥ 70

o   Age < 3 months

Additional Notes
  • Differentiate infants with probable viral bronchiolitis from those with other disorders
  • The above management points to do take into consideration patients with significant medical history such as congenital heart disease, anatomic airway defects, neuromuscular disease, immunodeficiency, chronic lung disease – ADMIT, HIGH RISK!
  • The physical exam will vary from minute to minute depending on child’s position, level of alertness, response to treatment – CONSTANTLY RE-EVALUATE!
  • If patient presents within the first couple of days, they may worsen and need admission at a later point – PARENT EDUCATION IS KEY!
    • Viral illness, treated by hydration and suction
    • Signs of respiratory distress
    • How to suction
    • When to suction
    • Frequent feeds and watch hydration status
    • Cough may last 2-4 weeks, do not use OTC cough and cold medications
    • Avoid tobacco smoke
  • NOT RECOMMENDED!
    • Albuterol – Wheezing is due to the airways being clogged with debris not bronchospasm
    • Racemic epinephrine
    • Corticosteroids
    • Chest physiotherapy
    • Montelukast
    • Antibiotics
    • Hypertonic Saline
    • Routine testing
    • Chest X-rays

References

  1. http://pediatrics.aappublications.org/content/134/5/e1474
  2. http://www.chop.edu/clinical-pathway/bronchiolitis-emergent-evaluation-clinical-pathway
  3. http://www.cochrane.org/CD001266/ARI_bronchodilators-for-bronchiolitis-for-infants-with-first-time-wheezing
  4. http://www.seattlechildrens.org/healthcare-professionals/gateway/pathways/

Special thanks to Dr. Hima Khamar, MD PGY-2 for her contribution to this month’s Pediatric Pearls!

Varicella in Pregnancy

Varicella-zoster virus

Varicella (chickenpox) is a highly contagious disease caused by primary infection with varicella-zoster virus (VZV)2 and may cause maternal mortality or serious morbidity

> Reactivation of latent infection, usually many years after the primary infection, may result in herpes zoster (shingles), a painful vesicular eruption in the distribution of sensory nerve roots2

> Both varicella (chickenpox) and zoster (shingles) are notifiable diseases. Notification must be made to the Communicable Disease Control Branch of SA Health as soon as possible and at least within three days of suspicion of diagnosis, by telephone or post.


Route of transmission

> Infection with chickenpox is transmitted through airborne / respiratory droplets and direct contact with vesicle fluid


Incubation period

> 10 to 21 days (may be up to 35 days in contacts given high titre zoster immunoglobulin, ZIG)


 Period of infectivity

> 48 hours before the onset of rash until crusting of all lesions (usually day 6 of rash)

> Infectious period may be prolonged in people with impaired immunity


Infection Control

> Non-immune staff should not care for the woman / baby infected with chickenpox

> Varicella (and herpes zoster) vesicles contain large numbers of virus particles. Ensure appropriate transmission based (standard, contact and airborne) precautions including:

> A negative pressure room with door shut (chickenpox and disseminated shingles)

> Immune staff in attendance

> Gloves, gown

> All dressing materials should be treated as medical waste

> Chickenpox and disseminated shingles use standard, contact and airborne precautions

> Localized shingles use contact precautions (only immune staff in attendance, single room, gloves, gown)

> In herpes zoster (shingles), transmission of infection usually requires contact with vesicle fluid; however, there is also evidence of respiratory spread. Localized shingles requires standard and contact precautions (not airborne precautions)


Susceptibility to varicella

> Women and babies susceptible to infection with VZV (may be severe or life-threatening) include:

> No history of varicella (chickenpox or shingles)

> Seronegative for varicella antibodies (VZV-IgG negative)

> No documented evidence of varicella vaccination 


Significant Exposure

> For the purpose of infection control and prophylaxis, significant exposure of a susceptible woman who is pregnant to varicella includes:

> Living in the same household as a person with active varicella or herpes zoster

OR

> Direct face to face contact with a person with varicella or herpes zoster for at least 5 minutes

OR

> Being in the same room for at least 1 hour

> Chickenpox cases are infectious from 2 days before rash until lesions crusted


Management of maternal exposure to varicella-zoster virus

History of previous chickenpox

> No action required

No or uncertain history of chickenpox

> Obtain serology for antibody status (VZV-IgG) (if practicable)

> ZIG if required should be given within 96 hours. Testing should only be done if ZIG would still be able to be given, if required, within this window


Within 96 hours from exposure

> Zoster immunoglobulin (ZIG) should be given to all seronegative women within 96 hours (see adult dose under ZIG dosage below)

> However there may be some limited effect out to as late as 10 days post exposure

> Advise to seek medical care immediately if chickenpox develops


More than 96 hours following exposure

> Oral aciclovir or valaciclovir (see dosage below) should be considered for women:

> In the second half of pregnancy

> With a history of an underlying lung disease

> Who are immuno-compromised

> Who are smokers

Note: Advise women to seek medical care immediately if chickenpox develops


Management of varicella-zoster in pregnancy

Less than 24 hours since appearance of rash

> Oral aciclovir 800 mg 5 times a day for 7 days OR oral valaciclovir 1 g three times a day for 7 days]

> Monitor at home

More than 24 hours since onset of rash

> No oral aciclovir / valaciclovir and monitor at home if:

> No underlying lung disease

> Not immunocompromised

> Non-smoker

> Monitor in hospital if any of the above risk factors

> Offer appropriate fetal medicine counselling


Complications

> Advise to seek medical attention for the following complications:

> Respiratory symptoms

> Haemorrhagic rash or bleeding

> New pocks developing after 6 days

> Persistent fever

> 6 days

> Neurological symptoms

> Give aciclovir 10 mg / kg every 8 hours for 7 to 10 days (IV followed by oral [see dosage below]) and administer supportive therapy

Consider caesarean section if:

> Signs of significant fetal compromise

> Evidence of maternal respiratory failure exacerbated by advanced


Risk of fetal varicella syndrome (FVS) after maternal VZV

Timing of maternal infection:

>Less than 12 weeks gestation-  0.55%

>12-28 weeks gestation- 1.4%

>More than 28 weeks gestation- No cases of FVS reported


Refer to maternal fetal specialist for prenatal diagnosis and counselling

> Detailed fetal ultrasound for anomalies is recommended at least five weeks after primary infection

> Repeat ultrasounds until delivery. If abnormal may consider fetal MRI

> VZV fetal serology is unhelpful

> Amniocentesis not routinely advised if ultrasound normal, because risks of FVS low but negative VZV PCR may be reassuring


Management of infants exposed to maternal varicella zoster

Maternal chickenpox > 7 days before delivery

> No zoster immunoglobulin (ZIG) required

> No isolation required

> Encourage breastfeeding

> No other interventions even if baby has chickenpox at or very soon after birth unless preterm < 28 weeks gestation or low birth weight < 1,000 g > Very preterm infants (≤ 28 weeks gestation) born with chickenpox should receive intravenous aciclovir 20 mg / kg / dose every 8 hours as a slow infusion (1-2 hours)

 

Thank you to Christine DeFranco PGY-4 EM Resident for this review of VZV in pregnancy!

Managing Dislocations of the Hip in the ED

Source: EM Practice Podcast – Dec 2017
** There are no existing ACEP guidelines on this topic.


Pre-Hospital Management
  • Stabilizing and pain control
  • Neurovascular compromise
    • If suspected then d/w med control for considerate of immediate reduction and splinting vs. rapid transport to ED
    • If no suspicion the patient can be immobilized in current position
  • Don’t forget C-spine precautions as these injuries are often distracting

Overview

Etiology:

  • Typically traumatic in origin
  • Over 2/3 Hip dislocations occur in patients who present after MVCs without seat belts with the knee hitting the dashboard and the body moving forward over a fixed femur.
    • Often associated with posterior wall/lip fractures of the acetabulum

Definitions:

  • Simple vs. Complex
    • Simple Dislocation – does not involve fracture
    • Complex Dislocation – involves fracture

Pathophysiology:

  • Posterior & Inferior dislocations are most common – about 90% of dislocations
  • Fracture of >40% of the acetabular rim is considered an UNSTABLE FRACTURE (requires ORIF)
    • If there is a posterior acetabular fracture you must get a CT to eval for unstable fractures
  • Sciatic nerve injury
    • Seen in about 14% of traumatic hip dislocations
    • Check sensory along the posterior leg, ability to dorsiflex the ankle and ankle reflexes
  • 95% of traumatic hip dislocations will have another associated injury
    • Be sure to complete a full trauma survey on these patients per ATLS guidelines

Imaging
  • Initial image should be a bedside AP pelvic radiograph
  • Look for Shenton’s Line

  • Lateral film can seal the diagnosis if unsure based on initial bedside AP
  • CT if neeeded

Treatment for Native Hips (non-prosthetic)

Consultation

  • Ortho Consultation are required for the following:
    • Complex hip dislocations
    • Irreducible dislocations
    • Non-concentric reductions
    • Neurovascular deficits despite reduction

Reductions

Who:
– Simple dislocations can & should be reduced by the ED physician!

When:
– Reduction should be performed within 6 hours of injury to decrease risk of avascular necrosis
– No more than 3 attempts at reduction should be made by the ED provider

Transfers:
– If patient requires transfer to a different hospital, an attempt at reduction should be made by the ED provider.
– Patients transferred without reduction had a 4-fold risk of severe sciatic nerve compared to those transferred after reduction (16% vs 4%).

Analgesia:
– Be sure pain is controlled prior to attempting reduction

  • Ultrasound guided fascia iliaca compartmental block work great
    • Reduces need for systemic analgesics
    • Improves patient comfort
    • Increases likelihood of successful reduction
    • Reduce need for procedural sedation
    • Be sure to have completed a full neurological exam prior to blocking your patient
      LINK TO VIDEO
  • In many cases, procedural sedation and systemic analgesia may also be needed (in addition to nerve block) in order to adequate pain control and muscle relaxation.

Reduction Techniques

Old School:
Allis’s Maneuver

Newer techniques:
Captain Morgan
Over-Under/Whistler
East Baltimore Lift

No evidence exists to recommend one technique over the other.


Immobilization

After successful reduction the hip should be immobilized in extension and external rotation with slight abduction
– Use an abduction pillow to help hold this position
– Knee immobilizer can be used if no abduction pillow is available

Don’t forget to obtain a post reduction film to confirm alignment


Other Recommendations
– Early passive range of motion and rehab is usually recommended
– Patients should remain non-weight bearing until seen by an Orthopedist


Notes on Prosthetic Hip Dislocations
  • Quite common
    • Incidence of ~2% of patients who undergo THA
    • 60% occur within first 3 mo, 77% occur within the first year
  • Often the result of minimal force like bending over to pick something up off the floor
  • Use the same techniques as a native hip reduction
  • Do not need abduction bracing after the reduction
  • If the patient can walk after the reduction, they can be safely discharged (after discussion with their orthopedist)
  • Less urgency, no risk of avascular necrosis as the femoral head has already been replaced
  • Remember, these injuries are painful and although less urgent, the reduction should occur as soon as possible

 

Case of the Week COW #12

CC: Left leg pain

HPI: 52 year old male with PMH of IDDM presents to the Emergency Dept. (ED) with left leg pain for the past 9 days which has become progressively worse. He is a taxi driver and reports that a part of the seat, which supports his legs, has been rubbing against his left hip/buttock/thigh and he thinks this is what’s causing the pain. He reports pain to the back of his left buttock, which radiates down the leg “like a shooting pain.” The patient has been to the ED multiple times already for similar complaints, requesting for stronger pain medications. He is upset because he feels the medicine just isn’t working. At this point, the patient is uncooperative and refuses to answer any more questions. Further history was obtained from his previous visit history, which stated he was discharged yesterday with a diagnosis of sciatica and a prescription for Lidoderm patch, Motrin and Percocet.

PMH/Birth History: N/A

Social History: N/A, refused to answer any further questions

PHYSICAL EXAM

VS: BP 125/59     HR 108     RR18   T: 98F   98% RA

General: In moderate acute distress, appears stated age, in moderate pain, uncomfortable and diaphoretic.

HEENT: Atraumatic, normo-cephalic. No deformities. PEERLA

Respiratory: Lungs CTA bilaterally.

Cardiac: +S1/S2, no MRG, regular rate and rhythm

Abdomen: soft NT ND

Extremities: B/L DP 2+, Cap refill < 3 seconds, positive straight leg (LLE); pain isolated to (L) buttock and posterior lateral thigh.

Neuro exam: CN III –XII intact. 5/5 strength in all 4 extremities with limited ROM in the LLE secondary to pain.

Skin: Diffuse erythema over the Left buttock extending down to the posterior lateral left thigh, with pitting edema. No fluctuance or streaking noted.

Labs:

WBC: 24.7     H/H: 13.1 / 39.4     Platelets 245     PMH: 22.1  Lymph: 0.7     Mono: 1.5

Na: 126     K: 5.5                 Cl: 89       CO2: 22           Glucose: 438

Bun: 38     Cr: 1.17         Alk P: 140       LFT: WNL         Albumin 3.2

Acetone: NEG

ESR: 65

CRP: 30

Lactic acid: 1.4

Images:

Repeat Vital Signs 139/81   89   16     99.7F   97% ON RA

MRI

 

 

Working Differential Diagnosis: Pyomyositis

ED/Hospital course:  Orthopedic Surgery was consulted. X-Ray did not show obvious bony involvement and ESR/CRP was not suggestive of osteomyelitis. MRI was performed on the LLE, which sowed a hyper-intense signal within multiple muscles of the pelvis and left thigh consistent with myositis. Collection within the Obturator Externus and Gluteus Maximus muscles likely represented an abscess consistent with pyomyositis. The patient was started on Vancomycin and Zosyn and sent to Interventional Radiology for drainage of the abscess. The cultures grew back MSSA. The left knee tap did not grow any organisms on Gram Stain. IR drainage was followed by orthopedic washout and debridement of the musculature with insertion of JP drain for continuous drainage. The patient’s antibiotics were switched to Levaquin and he was subsequently discharged home with Clindamycin and Bactrim for 2 more weeks. He tested negative for HIV.

Pearls & Takeaways:

  1. Don’t blow off patient’s complaints! Our patient presented with History and Physical exam consistent with sciatica with a positive straight leg test. He was on Percocet and kept asking for stronger medications for his previously diagnosed Sciatica.
  2. Make sure to undress the patient and examine the skin!
  3. If the patient is complaining of pain out of proportion to his/her exam, dig a little deeper for alternative differential!
  4. Since his Accucheck was High, further laboratory testing was done which revealed leukocytosis. The elevated white count prompted me to perform a further work up
  5. Always re-evaluate the patient! On re-evaluation, he appeared sicker and with cool, damp skin on his back and neck, solidifying my gestalt that maybe I am missing something
  6. Pyomyositis is a purulent infection of skeletal muscle that arises from hematogenous spread, usually with abscess formation.
  7. Risk Factors: immunodeficiency (HIV).
  8. auerus is the most common cause of pyomyositis; it causes up to 75 – 90% of cases.
  9. Pyomyositis presents with fever and pain and cramping localized to a single muscle group. It develops most often in the lower extremity (sites include the thigh, calf and gluteal muscles) but any group of muscles can be involved including iliopsoas, pelvic, trunk, Paraspinal and upper extremities.
  10. MRI is the most useful imaging modality for diagnosing the disease. It can distinguish the defining sites of infection and rule out other entities.
  11. Nonspecific lab findings include Leukocytosis and elevated inflammatory markers but CPK are often normal.
  12. Empiric antibiotics should be directed against Staph/Strep for immunocompetent. Immunocompromised should be covered for Gram negative, gram positive and anaerobic organisms should be considered.
  13. Pyomyositis is graded based on stages.
    • Stage 1 (Invasive stage, 1-2 weeks, may only have pain) can be treated with Antibiotics alone.
    • Most patients present with Stage 2 (Suppurative stage, weeks 3-4)
    • Stage 3 (Late stage) due to delay in diagnosis and usually requires drainage for definitive management.

Case presented by Dr. Michael Hong

Pain Pearls – Nitrous Oxide

Nitrous Oxide


Introduction to Nitrous in the ED

  • Tasteless colorless gas administered in combination with oxygen
    • Maximum concentration 70% N20
  • Absorbed via pulmonary vasculature and does not combine with hemoglobin or other body tissues
  • Rapid onset and elimination
    • <60 seconds
  • Analgesic and anxiolytic agent
    • Use along with local anesthetic or other non-opioid pain medications
  • Administered via facemask
  • Only monitoring needed is pulse oximetry
  • No NPO requirements, patient can drive after administration, no IV line needed, no RN necessary at bedside
  • Nitrous is NOT procedural sedation and should be thought of as a pain medication
  • Studies show it is similar to morphine 10 mg IM
  • It works only when the patient is breathing it in and stops working immediately when the gas is off

Contraindications

  • Severe COPD or asthma
  • Active Otitis Media/Sinusitis
  • Active Bowel Obstruction
  • 1st -2nd trimester pregnancy
  • Altered level of consciousness
  • Severe Psychiatric disease
  • EtOH
  • Head Injury
  • Complex Advanced Active Cardiac Disease

Indications (really any procedural pain)

  • Laceration repair
  • Incision & Drainage
  • Wound Care
  • Foreign body removal
  • Central Venous Access
  • Peripheral venous access
  • Fecal Disimpaction
  • Adjunct for
    • Dislocations
    • Splinting

Nitrous as an adjunct

  • If using nitrous to try and reduce a joint
    • Use IN ketamine
    • Intra-articular lidocaine
  • Concomitant admin of nitrous with opioids, benzos, or propofol is considered PSA
  • If giving an IV opioid you should wait 30-45 minutes before using nitrous to avoid excessive sedation or airway issues

What do we have?

Porter Standard Flowmeter

  • Stored in the trauma bay
    • Extra tank rack across from peds resus bed
  • Must use disposable breathing circuit
    • Located next to desk in trauma bay
    • There are adults small, youth medium, and peds small
Safety Features
  • Nitrous oxide flow stops if oxygen is shut off or supply becomes limited
    • Can never supply more than 70% nitrous oxide
  • Exhaled gas is scavenged away to avoid unnecessary exposure to providers

Getting started

  • Wheel to bedside
  • Plug green oxygen tube into oxygen port in the wall (may have to remove Christmas tree)
  • The gray tube scavenging tube plug into to the suction port in the wall
  • Breathing circuit only fits one way, push big lumen tube into top (by gray bag) and the clear little tube below breathing bag

Positioning

  • Position the patient comfortably
  • Bring unit close to the patient so you can reach the dials
  • Make sure pulse oximetry is connected and you can see the waveform
  • Once the mask is on…
  • Set oxygen flow rate then titrate nitrous oxide to desired percentage
  • Watch gray breathing bag as a guide to adjust flow (titrate flow)
    • If bag is fully collapsing, increase overall flow
    • If bag is not moving, decrease overall flow
    • Once nitrous oxide percentage is set, regardless of flow rate, percentage stays the same

During The Procedure

  • Titrate nitrous oxide up and down as needed for “desired analgesia”, watch breathing bag to determine overall flow
  • Once procedure is complete, turn off nitrous oxide, allow patient to breath oxygen only for 60 seconds
    • Continue to watch breathing bag
  • Then remove mask completely

Your Done!!

  • Patient can be discharged with no driving or work restrictions
  • Throw away the breathing circuit
  • Return it to the trauma bay

REFERENCES:
  • Becker 2008
  • Babl 2015
  • Zhang 1999
  • Champman 1979
  • Jastek 1991

Special thanks to Dr. Alexis LaPietra for her contribution! Watch out for next times pain pearls…….. Haldol as an analgesic!!!

Case of the week COW #11

CC: Can’t see for 2 months

HPI: 10 year old male with no significant past medical history presents to the Emergency Dept. complaining of painless vision loss in the right eye for 2-3 months. Patient states he has been having difficulty seeing out of his right eye for 2 months despite changing positions in class, taking on and off his glasses and using eye drops. Vision loss has become progressively worse and now he can only distinguish whether lights are on or off. Mother states she did not do anything about this problem because she thought he was kidding and she didn’t’ have money or health insurance to seek medical attention. Patient has been wearing Bifocals for myopia since the age of 6, with corrective vision lenses at age 5. Denies associated trauma. Patient moved to the U.S from Nigeria 5 years ago. He lives with his mother and sister. Vaccines are up to date.

PMH/Birth History: NSVD at 39 weeks, 1 day. Birth took place in Nigeria and mother denies any infection during or after pregnancy. Following birth, patient did not have any complications such as pneumonia, eye infections or rashes.

Social History: Denies drug abuse. Denies exposure to chemicals. Denies contact with dirt, dogs or pigs. Patient did not live on a farm. As per mother, there was no domestic abuse in the family

PHYSICAL EXAM 

Vitals within normal Limits

General: In no acute distress, appears stated age.

Head: Atraumatic, normocephalic. No deformities.

Eye: Right (OD): pupil non-reactive and remains white in color and approximately 2mm. Afferent reflex is present CN II; efferent reflex is absent. There is a complete visual field defect on the right side. Visual Acuity: Can only distinguish between light and dark. Unable to count fingers at any distance or visual objects even in motion. On Fundoscopic exam, the fundus is gray/dull, with no retina visualized. ALL CONSISTENT WITH LEUKOCORIA

Respiratory: Lungs CTA bilaterally.

Cardiac: +S1/S2, no MRG, regular rate and rhythm

Abdomen: soft NT ND

Neuro exam: CN III –XII intact. No motor, sensory, vibratory, temperature or pain deficits. Gait is steady and normal, without any difficulty. Cerebellar function intact, no dysmetria bilaterally.

Extremities: Full ROM in all extremities. 5/5 strength in all extremities

Skin: No edema, rashes, lacerations, or abrasions. Skin is warm, pink, moist and intact.

LABS

CBC: Unremarkable with        WBC: 7.1     Hemoglobin: 13.5       Platelets 211.

CMP: WNL       CRP and ESR = WNL

Tonometry: IOP approx. 17-18 x 3 times

Wood lamp: No corneal abrasion, dendritic ulcers, lesions or depositions OU

Bedside U/S: Completed within 10 minutes of arrival ( Only Right eye is shown)

Working Differential Diagnosis:

  • Retinoblastoma
  • Intraocular Mass
  • Cataract
  • Syphilis
  • Parasitic infiltrate
  • Posterior Infarct

CT Max/Facial w/o Contrast to rule out intracranial pathologies: Negative for masses; positive for homologous material in the right lobe. MRI was recommended for further evaluation

ED/Hospital course:  Ophthalmologist on call was consulted, and said there was nothing more to do. Unfortunately because his vision loss was > 2 months, no life saving surgery was imminent as the retina was already detached causing ischemia to the rods and cones within it.  Patient was to follow up in ophthalmology clinic the following day. Patient’s Pediatrician was also contacted and he referred the patient to a Pediatric Ophthalmic specialist in University Hospital, with a scheduled appointment within the same week. Approximately one week ago, patient underwent surgery and the leading diagnosis was Toxocariasis as per MRI. Biopsy results to follow. As per mother, the patient is still without vision in his right eye.

LEUKOCORIA, UNILATERAL, 10 YO MALE DIFFERENTIALS

Coats disease is an exudative retinal vascular disorder characterized by retinal telangiectasias and subretinal exudation leading to serous retinal detachment. Presenting complaints include decreased visual acuity, strabismus, or leukocoria. The leukocoria in Coats disease is generally more yellow than white due to the presence of subretinal lipid. Coats disease is almost always unilateral and the vast majority of cases occur in boys. The majority of cases presenting with leukocoria are diagnosed between five and nine years of age, which is older than the majority of retinoblastoma patients.

Clinical examination: subretinal lipid and abnormal telangiectatic vessels US: demonstrates complete retinal detachment with massive subretinal lipid. Intraocular calcification is almost never present in Coats disease, another feature that helps to distinguish it from retinoblastoma.

The retinal photograph depicts bullous retinal detachment in the Left eye of a 1-year-old child with Coat’s disease simulating retinoblastoma. The magnetic resonance images confirm the diagnosis of retinal detachment and exclude retinoblastoma because of the absence of intraocular mass.

 

Toxocariasis — Toxocariasis, or visceral larva migrans, is an infection caused by the dog ascarid Toxocara canis or, less commonly, the cat ascarid Toxocara catis. There may be a history of living in an underdeveloped country, and exposure to dirt or undomesticated dogs. It occurs most commonly in children one to five years of age. Common presenting signs of toxocariasis are strabismus and poor vision. The ocular lesion is caused by the inflammatory response to the second-stage larva, which may localize in the one eye or both eyes

Chorioretinitis characteristic of toxoplasmosis. A pigmented scar is seen with an adjacent area of active chorioretinitis. The diagnosis of toxoplasmosis is based primarily on the appearance of the chorioretinal lesion rather than serologic studies. Courtesy of James T Rosenbaum, MD.

 Retinopathy of prematurity (ROP) — developmental vascular proliferative disorder that occurs in the incompletely vascularized retina of preterm infants and can lead to retinal detachment and permanent blindness. The most important risk factor for developing ROP is prematurity. There needs to be a history of prematurity, and/or mother mentions patient was on O2 for awhile.

Vitreous hemorrhage — Vitreous hemorrhage causes leukocoria when there is extensive organization of the blood into a clot before degradation. With time, the reddish hue of the blood is lost and the hemorrhage transforms into “whitish debris.” Etiology includes advanced ROP,  trauma (MOST common), leukemia or hemorrhagic disease of newborn

Retinablastoma– Retinoblastoma is the most common primary intraocular malignancy of childhood and accounts for 10 to 15 percent of cancers that occur within the first year of life. Retinoblastoma typically presents as leukocoria in a child under the age of two years. Untreated retinoblastoma is a deadly disease; however, with advances in treatment, survival in the contemporary era is >95 percent. Most common age group is birth- 2 years. Very uncommon in children over the age of 5, although 1-2 case reports have occurred in 18 year old males

 Pearls & Takeaways:

  • Leukocoria Requires further investigation – On exam, History and Diagnostic
  • The use of tonometry, fundoscopy and ocular ultrasound are an easy, noninvasive way to add to your ophthalmic exam. Slit-lamp exam could have been considered here
  • Ocular ultrasound is really cool and fun!
  • Advocate for your patients!  Make sure they have proper follow up with a specialist
  • If any abuse or neglect is suspected, be sure to turn on “Sherlock Holmes” senses and investigate.

 

Case presented by Dr. Sarah Bolan