UMEM Educational Pearls - Misc

Happy Memorial Day! With all the recent attention in the news about swimming and drowning I thought I would share this article

Show References

Post Operative Fever is extremely common, and with the increase in same day surgery this is a common complaint presenting to the ED.  The mnemonic "5Ws" are often taught to remember the causes. They are:

• Wind - Pneumonia, aspiration, pulmonary embolism, and atelectasis
• Water - urinary tract infection
• Walking - Deep Venous Thrombosis or pulmonary embolism
• Wound - surgical wound infection
• Wonder drugs - Drug fever, or infection due to indwelling lines, or a reaction to blood products

Though many surgical textbooks report that atelectasis is the most common cause of early post-operative fever,  some even claiming that it is responsible for over 90% of febrile episodes in the first 48 hours after surgery; a recent review in CHEST (reference below) showed that there is no evidence to support this. We often see atelectasis in medical patients too, and few if any of them have fever.  The CHEST review found that there was no clear evidence that atelectasis causes fever at all.

Pearl:  Temperature >38.9C should raise concern for a true infection, where lower temperatures can be due to pulmonary embolism, DVT, drug fever, etc….
 

Show References

• If less than 24 hours since injury, consider diagnostic angiography and  intra-arterial TPA, and heparin infusion, Prostacyclin infusion.
• Angiography and Bone Scan can be used to prognosticate clinical course.
• Consider Hyperbaric Oxygen Therapy for moderate to severe frostbite- multiple case reports of significant improvement with HBOT even if delayed by several days. 

Show References

Lactate levels help to confirm septic arthritis but what about bacterial meningitis.  As reported in the daily electronic ACEP newsletter a small study of 45 patients showed that all patients with a confirmed diagnosis of bacterial meningitis had a CSF lactate level > 3.5 mmol/L.  Therefore, it might be true that viral meningitis will only have  CSF lactate levels < 3.5 mmol/L. 

With only 45 patients, this finding is clearly not ready for Prime Time but consider adding it to your next CSF study so more data can be collected on the utility of this test.

The story as seen in ACEP eNews on September 14th, 2012 is:

CSF Levels Of Lactate May Be A Marker Of Viral Versus Bacterial Meningitis.

MedPage Today (9/14, Gever) reports, "Cerebrospinal fluid (CSF) levels of lactate were a perfect marker of viral versus bacterial meningitis in a small study, a researcher reported" at the Interscience Conference on Antimicrobial Agents and Chemotherapy. Researchers found that, "among 45 adults in whom the etiology of meningitis was microbiologically confirmed, all those with CSF lactate levels above 3.5 mmol/L had the bacterial form, whereas every patient with lower levels had viral meningitis."

Apologies for the long pearl, I did not want to split this into 3 parts)

Disruptions in sleep and circadian rhythms (from travel across time zones and jet lag) are known to alter cognitive functions. Mood and complex mental performance tasks deteriorate faster than do simpler mental performance tasks.

An athlete’s circadian rhythms are believed to be optimal for performance in the early evening (reaction time to light and sound in the fastest). Interestingly, the evening is the time of day when most world records have been broken. However, activities that require fine motor control and accuracy (hand steadiness and balance) are best in the morning.

In the normal population, travel effects are seen in inattention and an increase in errors and injuries in the workplace.

Athletes who perform in international competitions immediately after time zone transitions demonstrate a decline in performance involving complex mental activities, with an associated feeling of lethargy and a general loss of motivation.

British Olympic athletes demonstrated a decrease in leg and back strength in addition to reaction time when traveling westward across 4 time zones. In the NFL, west coast teams consistently beat east coast teams in evening games.

Of course, this type of outcome data is multifactorial and travel effects likely are only one of many complex factors.

Treatment:

Full adaptation to the new time zone is NOT recommended for short trips (1 – 2 days), only for longer stays (> 3 days).

Nonpharmacologic: 

Preadaptation and bright light therapy: Remember that exposure to light is the primary cue for circadian rhythms. Bright light exposure in the mornings (after eastward travel) will advance the body clock, while exposure in the evenings (after westward travel) will delay it (Level B).

Shifting the sleep schedule 1 - 2 hours towards the destination time zone in the days preceding departure may shorten the duration of jet lag (Level B).

Strategic napping: Napping in the new time zone during typical sleep times in the destination time zone will delay adaptation. Power naps (20 minutes) may be helpful in decreasing daytime sleepiness in those with jet lag (Level B). The best time to nap (in flight or post flight) is nighttime in the destination time zone (Level B).

Pharmacologic:

Melatonin: Cochrane review concludes that it is safe and effective in both treating and preventing jet lag. It is recommended for adults traveling across 5 or more times zones; and may be effective for travel across 2 to 4 time zones. Take melatonin in the morning when traveling westward, and at the local bedtime when traveling eastward (Level B). Doses of 0.5 to 5mg were similarly effective. Melatonin taken in the evening and at higher doses are effective at inducing sleep (Level A).

Sleep aids:  Hypnotic sleep aids reliably induce insomnia secondary to jet lag. Benzodiazepines improve sleep quality but may cause a “hangover” effect the next day, possibly impairing performance.

Ambien (zolpidem) and Lunesta (zopiclone) can be effective while limiting the hangover effect especially in those who have previosly tolerated the medication (Level A). Zolpidem may be more effective than melatonin and placebo at countering jet lag symptoms. Note: the use of both medicines together was not more effective than zolpidem alone but did cause daytime somnolence.

Stimulants: Care should be used in the athlete as most of these medications are banned in competition. There is a potential off label use for Provigil (modafinil) for improving daytime sleepiness associated with jet lag (currently approved for narcolepsy).

Caffeine, while not banned for the World Anti-Doping Agency, is a monitored substance.  It increases daytime alertness and may accelerate entrainment in new time zones when consumed in the morning (later ingestion may interfere with sleep induction) (Level A).

Show References

Travel across time zones is regularly required of profession and collegiate athletes (in addition to the some of us professionally)

Jet lag is defined as insomnia or excessive daytime sleepiness/malaise following travel across at least 2 time zones

                Symptoms usually persist 1 day for each time zone crossed

The sleep schedule is primarily modulated by light and melatonin

Secretion of melatonin helps induce sleep

Exposure to light stimulates arousal and inhibits melatonin secretion

Who is at risk?

Those with more rigid sleep habits have more symptoms

“Morning” people have less difficulty flying eastward

“Evening” people have less difficulty flying west

However, overall, eastward travel causes the most severe symptoms which persist for up to 7 days (versus <3 days with westward travel)

                (The length of the day gets shortened and the circadian system must shorten to reestablish a normal rhythm. The human body demonstrates a natural tendency toward periods longer than 24 hours)

Those with higher levels of physical fitness adjust more quickly

Effects similar in men and women

Midday arrivals experience fewer symptoms than morning arrivals

Symptoms are less in those who have traveled the journey previously

Symptoms are less in those who had a shorter interval their last full nocturnal sleep in the departure city and their first full nocturnal sleep in the destination city

Contrast Allergy:

Many patients will report that they have a allergy to iodinated contrast by saying that they are allergic to iodine

Iodine, itself, is not an allergen and is a required element for thyroid homrone production.  Plus could you imagine the hordes of people that would be having allergic reactions everyday when they add salt to their french fries.  Our EDs would be completely swamped.

A recent meta-analysis by Drs. Schabelman and Witting also showed the following:

• The risk of a reaction to contrast ranges from 0.2% to 17% depending on the type used, and the severity of the reaction considered.
• The risk of a reaction in patients with a seafood allergy is similar to that in patients with other food allergies or asthma.  Seafood is not unique to contrast media.
• A history of prior reaction to contrast increases the risk of mild reactions to as high as 7-17% but has not been shown to increase the rate of severe reactions.
• The risk of death due to contrast is estimated to be 0.0006 - 0.006%.

As we enter Crab eating season in Maryland, lets stop giving shellfish a bad name. A patent with any allergy is at increased risk, but shellfish is no higher a risk than those allergic to Strawberries.

Show References

START Triage

START triage is a simple system to implement that does not require any special equipment in order to determine who needs immediate, delayed or non-urgent care during a mass causality.

START stands for Simple Triage And Rapid Treatment. Patients are triaged based on 4 factors:

• Ability to walk away from the scene
• Respiration > or < 30 respirations per minute
• Pulse (radial pulse present or not) or Capillary refill > or < 2 seconds
• Mental Status – ability to follow simple commands or not

The steps are:

1. If a patient can leave the scene they are minor and do not need immediate help. Category GREEN
2. If there are no respirations or respirations > 30 they require immediate care Category RED
3. Otherwise check pulse. If pulse is absent or capillary refill > 2 seconds they require immediate care Category RED
4. Otherwise check mental status.  If they are not able to follow commands they need immediate care.  Category RED
5. If they can follow commands they are delayed treatment. Category YELLOW

So those that can leave are green, those that do not meet any of the START criteria are YELLOW, and those with any of the four factors are RED or DEAD.

Weird and Unusual Symptoms

Bet you didn't know that severe and intense pruritus of the nostrils, known as Wartenberg's symptom, is an uncommon but characteristic symptom of a brain tumor.

Etiologies include astrocytoma, glioblastoma, oligodendroglioma, medulloblastoma, and metastatic tumors.

Show References

Wound Repair

A pearl last year addressed the irrigation of wound and the fact that the type of fluid (sterile versus tap water) does not affect infection rates but rather the volume of irrigation is most important.

Sterile versus unsterile gloves have also been studied, and it turns out that clean unsterile gloves have the same rate of infection as sterile gloves but come with a substantial cost savings.

When caring for a contaminated wound it is most important to remove any gross contamination, and then irrigate the wound as much as possible.  A 20 mL syringe with an 18G angio-catheter provides the proper pressure to remove debris without causing tissue damage. The wound can then be closed wearing the gloves that are most comfortable or accessible to you.

Finally, from a medicolegal standpoint it is always best to inform the patient that you have tried to remove all of the contamination but there is still a chance that the wound can get infected. 

Dose of Epinephrine for Patients with Anaphylaxis

Many of us are familiar with 0.3-0.5 mg IM of 1:1,000. Important to give IM and not SC.

In severe cases, consider IV Epinephrine:

• Take 1 mg of crash cart Epinephrine (1:10,000) and inject into 1 liter of normal saline
• Start drip at 1 cc/min which is 1 microgram/min
• "Titrate to life" (i.e. titrate up or down according to severity)

Show References

Pneumoperitoneum on CXR and CT

Pneumoperitoneum may be seen on an upright CXR up to 7 days after laparoscopic abdominal surgery/laparotomy and may be seen on abdominal CT for as long as three weeks after surgery. 

Submitted on behalf of Dr. Michael Abraham

Thyrotropin (TSH) 

• Different types of test available:
  • The first tests available were radioimmunoassay. 
  • The next type of test available is the immunometric test.

• As each test is developed there has been a trend to use the term ‘generation’ for a 10 fold increase in sensitivity. ¹

• Indications for ordering in the ED:   Hypothyroidism, Graves Disease, Hashimoto’s Thyroiditis, Thyroid storm.

• Diagnostic Accuracy
  • The original TSH benchmark was the ability to measure euthyroid (0.4 – 4mIU/L) from very low (<0.01 mIU/L) which is suggestive of Graves disease. 
  • Most new tests have a functional sensitivity of <0.02mIU/L. 
  • The clinical sensitivity and specificity have to be determined by each laboratory’s staff. This requires testing of samples over a 6-8 week period as should include a sample of the population that is being tested.²
• Average turnaround time to complete test: 
  • The tests are mainly run on large lab analyzers. There are many commercially available tests the turnaround time is dependent on the manufacturer of the machine.

Show References

Critical Care billing is time dependent and includes all time spent caring for and coordinating (i.e.: reviewing records, talking to consultants or family) the care of the patient except for the time spent doing separately billable procedures (i.e. central line, CPR, etc).  The following procedures taken from the ACEP website are included in the Critical Care code so the time spent doing these procedures should BE included in your total Critical Care time . 

They are :

• The interpretation of cardiac output measurements
• Interpretation of chest x-rays
• Interpretation of pulse oximetry
• Interpretation of blood gases, and information data stored in computers
• Placement of Oral or Nasal gastric tube
• Temporary transcutaneous pacing
• Ventilatory management (i.e.: Adjusting the vent, but not the intubation)
• Vascular access procedures (i.e.: peripherial access)

ACADEMIC MEDICINE CAVEAT: For the reporting of time-based services, such as critical care or moderate sedation, the teaching physician must be directly present during the entire reported time period.

Show References

Altered Mental Status-Does Your Patient Have Non-Convulsive Status Epilepticus?

Ever intubated a patient in status epilepticus and wondered if they were still seizing after sedation and paralysis? Ever taken care of an altered patient and wondered if you should consult neurology and attempt to get an EEG?

NCSE is defined as continuous seizure activity without obvious outward manifestations of a seizure. This is important for emergency physicians to consider because it has to be detected early to prevent morbidity and mortality.

When to consider NCSE:

• Prolonged postictal period
• Unexplained altered mental status in a patient with a history of seizures
• Altered mental status associated with "eye twitching" or blinking
• Stroke patient who clinically looks worse than expected

Temporal Arteritis (TA) is commonly associated with the sudden onset of a unilateral headache centered around the temporal region.  The most devastating consequence of TA is blindness though this is only reported in up to 50% of cases though can be bilateral in up to 33% of patients.

According to the American College of Rheumatology criteria for classification of temporal arteritis this diagnosis can be made in the ED without a biopsy.  You just need at least 3 of the following 5 items to be present (sensitivity 93.5%, specificity 91.2%) to make the diagnosis :

1. Age of onset older than 50 years
2. New-onset headache or localized head pain
3. Temporal artery tenderness to palpation or reduced pulsation
4. Erythrocyte sedimentation rate (ESR) greater than 50 mm/h
5. Abnormal arterial biopsy (necrotizing vasculitis with granulomatous proliferation and infiltration)

Show References

 Wernicke's Encephalopathy

Wernicke's encephalopathy, considered a unique complication of alcoholism, is also seen in malnourished patients, bariatric surgery patients, and patients who have undergone bone marrow transplantation.

Some pearls about Wernicke's encephalopathy:

• The classic triad of confusion, ataxia, and opthalmoplegia is seen in only about 10-15% of cases
• The diagnosis is made before death in only about 10_15% of cases
• Most authorities on the disease have suggested that opthalmoplegia be replaced by ocular, since many ocular findings may be seen in these patients (nystagmus, retinal hemorhages, cranial nerve palsies)
• Essentially any alcoholic who presents with confusion (ever see these patients in your ED?) could have the disease, so give Thiamine liberally when the patient arrives. 
• It is a myth that administration of thiamine before glucose will precipitate Wernicke's. This dogma is based on a case series of 4 patients from the Irish Journal of Medical Sciences. 

Hypothermia Pearls:

• Lidocaine is generally ineffective in preventing ventricular arrhythmias, as is cardiac pacing or atropine to increase the heart rate.
• Should the patient fully arrest be prepared to perform CPR for a long time.  If your ED does not have a automatic CPR device consider calling your local fire department or ambulance service as they might have one that can be loaned to your department.
• Warm fluids, heated blankets and heat lamps will typically increase a patients temperature about 1' C an hour.
• Gastric lavage, peritoneal lavage and heated IV fluids can warm as much as 3' an hour.
• To rewarm quickly as high as 18'C an hour requires cardiac bypass or thoracic lavage.

Finally, remember to monitor the patient closely when you first start rewarming as this can induce cardiac arrest.  This is thought to occur as colder peripherial blood returns to the central circulation as peripherial veins and arteries dilated from the warm fluid.

Reimburshment Pearls:

Often charts are down coded as it is not clear from the documentation that your medical decision making was complex.

For instance, if your final diagnosis is GERD, and you do not document that you were also concerned about angina or a pneumothorax your level 5 chart could be coded as a level 3, since the final diganosis does not seem that complex.  In order to prevent this document:

• Your differential diagnosis and ideally why you were concerned about them
• Instead of just checking a box stating that you reviewed old records take 5 seconds to summarize their last visit.  (i.e.: Admitted in May for CHF exacarebation, EF 50% by Echo, discharge on lasix).  This helps the coders prove that you looked at the chart and gives you 2 points for medical decision making.
• Document the response or initial lack of response to therapy. (i.e.: Asthmatics might get discharged home and still qualify for critical care time or a level 5 chart if you document how they initially responded to nebulizers and it was the magnesium that finally broke the cycle.)

I realize that when you are busy this might be the last thing on your mind, but the difference between a level III chart and a level V chart is about $100, and the only additional work is the 3 minutes it would take to document what you did for the patient.

More to come...

Show References

This week's monday pearl is from our very own Azher Merchant....who recently gave an excellent talk on the risks of radiation.

Be afraid....be very afraid....

Radiation Risk:
Risk is based on acute exposure and is extrapolated largely from atomic bomb survivors.
Effective radiation dose = Sievert (Sv)

Adults:
Lifetime Attributable Risk of Cancer 1:1000 at 10mSv
Lifetime Attributable Risk of Cancer Mortality 1:2000 at 10mSv
 
Risk estimates follow a linear rate of change such that:
Lifetime Attributable Risk of Cancer in Adults = Radiation Dose (mSv) x 0.0001
Risk is Cumulative

Pediatrics:
Lifetime Attributable Risk of Cancer is greater than for adults and is age-dependent
Lifetime Attributable Risk of Cancer Mortality 1:1000 at 10mSv

Common Effective Dose Estimates (mSv)

Background radiation                     3.5/year (chronic exposure)
CXR                                             0.1
CT
    Head, Face                               2
    Neck, Cervical Spine                 2
    Chest, Thoracic Spine                8
    Abdomen                                7.5
    Pelvis                                     7.5
    Abdomen/Pelvis, Lumbar Spine 15
    Extremity                               0.5
 

Note that it doesn't take very much radiation to reach the 10 mSv level!

Bottom line: CT if you need to, but carefully consider whether it is worth it or not

One last pearl, carefully consider whether or not you want that d-dimer and don't order one unless you are prepared to order a CT scan.