UMEM Educational Pearls

Documentation of the Chest Pain Patient

Chest pain is a high risk entity in emergency medicine. And since many patients we see with chest pain are eventually discharged, we should consider what our charts should look like should we discharge a patient who has a missed life-threatening diagnosis. In other words, what would an attorney look for?

Considerations for the chart:

• Consider documenting some type of medical decision making in the chart. What were you thinking? Why didn't you think the patient needed cardiac enzymes, a CT, or admission? The chart should support your decision to send the patient home.
• Document a thorough history...enough said
• Document risk factors for the deadliy causes of chest pain (ACS, PE, dissection, etc.). This is frequently missing on charts.
• Consider documenting important, pertinent negative "chest pain physical exam findings," such as a normal leg exam (frequently missing on missed PE charts), no murmurs, equal pulses. Comments like this in the chart prove that you were thinking about a differential diagnosis. A question to ask yourself is, "Does my physical exam look like I was searching for the bad players of chest pain?"

Traditional teaching for patients with hypotension in the setting of MI and heart failure (i.e. not just RV MI) is to give dobutamine as a first-line agent when the SBP is 80-100, and to use dopamine when the SBP is 70-80s [note that this recommendation is NOT based on good evidence, but primarily on consensus opinion]. The problem with using these medications, especially at higher doses (e.g >10-15 mcg/kg/min) is that they result in excessive alpha-1 adrenergic stimulation that can produce end-organ ischemia.

However, there is some evidence that rather than using high dosages of dobutamine or dopamine, "the deliberate combination of dopamine and dobutamine at a dose of 7.5 mcg/kg/min each was shown to improve hemodynamics and limit important side effects compared with [high dosages of] either agent [alone]."

[Overgaard CB, Dzavik V. Inotropes and vasopressors: review of physiology and clinical use in cardiovascular disease. Circulation 2008;118:1047-1056.]

Lunate Dislocation and perilunate dislocation are broken down into 4 stages that relates to the progressive disruption of the carpal ligaments due to hyperextension and ulnar deviation of the wrist:

• Stage 1: Scapholunate Dislocation
  • Has the characteristic sign of widening of the scapholunate joint on the PA view known as the Terry Thomas Sign as it resembles the gap between his teeth
  • Gap between scaphoid and lunate should be less than 2 mm
• Stage II: Perilunate dislocation
  • Best seen on lateral view of the wrist
  • Associated with scaphoid fractures
  • Lunate stays in its normal position with the capitate dislocation posterior when you use the distal radius as your reference point
• Stage III: Perilunate dislocation
  • Also includes dislocation or fracture of the triguetrum
  • Triquetrial and scaphoid malrotation
  • In lateral view, all other carpal bones are dislocated posterior with respect to lunate
• Stage IV:  Lunate dislocation
  • On PA view you will see a triangular view of the lunate on the PA view that looks like a "piece of pie". 
  • On the lateral view of the wrist the lunate will look like a tea cup tipped in the volar direction AKA the "spilled teacup sign"
  • Associated with a scaphoid fracture
     

For a good indepth review of lunate and perilunate injuries please read the article by Andy Perron with this attached link.... doi:10.1053/ajem.2001.21306   

If you are interested in seeing some xray examples please visit LearningRadiology.com

 

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Goldfrank's sniffing bar: no this is not a pub where toxicologist's hang out but rather a bar that assists with teaching the recognition of odors related to toxicology. Certain drugs and compounds have a distinct aroma.

The following is a list odors, see if you can name a medication or compound that has that odor - scroll down further to see the corresponding answers (if you really got all 5 email me and convince me):

1) Bitter Almond

2) Rotten Eggs

3) Wintergreen

4) Garlic

5) Sweet, Fruity (acetone)

 

Answers:

1) Cyanide; 2) N-acetylcysteine or Hydrogen Sulfide; 3) Methylsalicylate (like bengay); 4) Arsenic, organophosphate insecticides; 5) Chloroform, chloral hydrate

• A patient's blood pressure should be maintained at less than 185/110 prior to receiving thrombolytics for stroke.

• The following medications should be used to address blood pressure control in these patients:

               Labetalol 10 to 20 mg IV over 1 to 2 minutes, may repeat x 1  

               OR

               Nitropaste 1 to 2 inches

               OR

               Nicardipine infusion at 5 mg per hour, titrate by 0.25 mg/hr at 5 to 10 minute intervals up to a maximum

               dose of of 15 mg/hr.  Once desired blood pressure is achieved, titrate down in increments of 3 mg/hr. 

          

Early Critical Care Management of Aneurysmal SAH

• 30,000 patients per year have an SAH
• Early ED management certainly should focus on airway assessment, emergent CT scanning, continuous caridac monitoring, and serial neurologic exams
• A few other pearls regarding management:
  • Volume management - maintain euvolemia with an isotonic crystalloid fluid
  • Anticonvulsants - routine use is associated with cognitive impairment and is not recommended
  • Steroids - once used to reduce meningeal irritation, however, there is no convincing evidence of a beneficial effect.  As such, corticosteroids are no longer recommended.
  • Rebleeding - risk of rebleeding is highest in first 24 hours after initial SAH.  Definitive prevention is done by repair via surgery or endovascular coiling.  A large, prospective study found outcome was better with endovascular coiling.

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Keys to a Successful Intubation

• Use both hands-bimanual laryngoscopy should be a routine part of ED intubations.
• Don't forget that you CAN let up cricoid pressure-this can actually obscure your view and make your job more difficult.
• For obese patients, make sure you elevate them. You want their ear level with their sternal notch. This might require A LOT of pillows or towels.
• Use a "straight-to-cuff" technique for stylet shaping. This is accomplished by making the stylet straight down to the cuff and then making a 15-20 degree bend at the cuff.

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A lot of what is taught about fracture patterns in abused children has been extrapolated from post-mortem studies which is a different population then what you will see in the Emergency Department. The study referenced did a metanalysis of all the literature in an attempt to determine what fractures suggest abuse and looked at all comers that had fractures.  Some of the patterns they were able to extrapolate are:

 

• Fractures from abuse predominately occurred in infants and toddlers
  • In children less than 12 one study showed that 80% of all fractures from abuse occurred in children less than 18 months old.
  • In children over 5 years old 85% of fractures are not caused by abuse
• In children under 3 years old, skull fractures were by far the most common fracture type in both abused and non-abused children.
  • However, the presense of a skull fracture only has a 1:3 chance of being from abuse.
  • Skull fractures location and type are similar between abuse and non-abuse, though multiple fractures and fractures that cross suture lines are more highly associated with abuse.
• There is a strong relationship between multiple fractures and abuse
  • 74% of abused children had two or more fractures compared to 16% of non-abused
• In the absence of a confirmed traumatic case, rib fractures have the highest probability (71%) of being caused by abuse.
• Humeral fractures have a 1:2 chance of being the result of abuse.
• Femur fracture like skull fractures have a 1:3 chance of being the result of abuse.

 

 

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• For children under 5 years of age the rate of missing an appendicitis remains very high.  (57%-67%)
• The rate of misdiagnosis increases as the age decreases. 
• In cases of missed appendicitis the most common incorrect diagnosis is gastroenteritis.
• Think twice before you label vomiting alone, or diarrhea alone as gastroenteritis.
• If an appendicitis is missed there is an increased risk of perforation, abscess formation, and higher morbidity. 

 

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Add metoclopramide (Reglan) to the laundry list of medications with black box warnings from the FDA. Why was a black box warning added?

• Long-term metoclopramide use has been linked to tardive dyskinesia (involuntary and repetitive body movements) even after the drug is no longer being taken.
• Risk factors: Long-term or high-dose use, elderly, female gender.
• Recommended that metoclopramide treatment not exceed 3 months.

• None really.
• Just be aware of the dopamine antagonist effects (EPS - dystonic reactions) that are possible whenever you order metoclopramide in the acute setting.
• These effects can be treated effectively with an anticholinergic agent, such as diphenhydramine or benztropine.

When performing the NIH Stroke Scale, keep the following conventions in mind:

-- Administer scale items in their exact order.
-- Avoid coaching the patient.
-- Accept the patient's first effort.
-- Be consistent.
-- Score only what the patient actually does.
-- Include all deficits in scoring.

Follow-up for the Hypertensive Patient

We see hypertensive patients every day, every shift. And, we discharge many of them. So, when do you get them follow-up?

The JNC-7 recommends that patients with BPs > 180/110 mm Hg have follow-up within 7 days. Like most of the HTN recommendations in the primary care setting, this recommendation is based on a "smart person" concensus....and no data.

This is a tremendous issue for us in the ED, because we don't want to see a bad outcome in our discharged hypertensive patients.

Some pearls regarding discharging the very hypertensive (but asymtomatic) patient:

• Since there isn't any realy data on follow-up, it would be wise to use caution and have very high BPs checked the next day and to NOT wait a week.
• Discharge instructions should note when/where (if you have to...use the ED as a recheck) the patient is to follow-up
• ALWAYS warn patients about what can/will happen if they don't seek follow-up: MI, stroke, renal failure/need for dialysis, death, and disability and write this in the chart. The last thing you want to hear is that the patient went on to develop renal failure/stroke, etc. and that they claim they were not warned about what could happen.
• When it is possible, contact the patient's doctor to discuss management

Non-invasive ventilation and standard mechanical ventilation can have very deleterious hemodynamic effects on patients with cardiac tamponade because of the drop in preload that results from positive pressure ventilation. The threshold for intubation in these patients should probably be raised. If you are ever caring for a patient with cardiac tamponade that definitely needs to be intubated and ventilated, be prepared for a significant drop in blood pressure and the potential need for pericardiocentesis. Once the patient is intubated, do everything possible to avoid high ventilatory pressures. [Ho AM, Graham CA, Ng CSH, et al. Timing of tracheal intubation in traumatic cardiac tamponade: a word of caution. Resuscitation 2009;80:272-274.]

The Galeazzi Fracture:

• It is a fracture of the distal to middle third of the radial shaft with dislocation of the Distal Radio-Ulnar Joint. 
• Typical mechanism of injury is a fall onto a outstretched hyperpronated forearm.
• Estimated to represent 7% of adult forearm fractures.
• This fracture requires surgical repair (Open reduction and internal fixation) in order to prevent presistant or recurrent dislocation of the distal ulnar which typically occurs with closed reduction techniques.
• Associated with injury to the Anterior interosseous nerve which is a purely motor branch of the median nerve.  Injury results in paralys of the flexor pollicis longus (FPL) and flexor digitorum profundus (FDP) to the index finger, resulting in loss of the pinch mechanism between the thumb and index finger.

To see a photo of a Galeazzi fracture please visit the Learning Radiology Website by clicking on the following link:

http://www.learningradiology.com/caseofweek/caseoftheweekpix2/cow157lg.jpg

Rocky Mountain spotted fever (RMSF)

Systemic small vessel vasculitis caused by R rickettsii which is transmitted by a tick bite.

 

Clinical features: fever, headache, myalgia, nausea, vomiting, and characteristic rash. Rash usually appears before the sixth day of the illness initially on the wrists and ankles, and spreads to the trunk within hours.  Initially. It is erythematous and macular, later becoming petechial.

Laboratory findings: thrombocytopenia, anemia, and hyponatremia.

Complications: meningitis, multiorgan involvement, DIC, shock, and death. 

Treatment: doxcycycline (even despite the risk of dental staining in children younger than 8 years old)

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Clevidipine

• A new intravenous antihypertensive agent
• Has a very rapid onset (2-4 min) and offset (5-15 min), in contrast to the available IV calcium channel blocker nicardipine, which has a duration of action of 3-6 hours
• Contraindicated in patients with soy or egg allergies, and in those with defective lipid metabolism
• Most common ADR's reported were headache, nausea, and vomiting
• Initiate at 1-2 mg/hr, most respond at doses between 4-6 mg/hr
• Maximum recommended dose is 16 mg/hr
• Costs between $86 to $140 per 50 mg vial

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• Fever is present in 80% of cases.
   

• Treatment includes high dose intravenous antibiotics.  Anti-coagulation therapy is controversial and often held.
   

• Mortality is 30% with an additional 30% enduring sequelae such as oculomotor weakness, blindness, and pituitary insufficiency.

Evaluation of End Organ Damage in Hypertensive Patients

No evidence to date supports the ED workup for end-organ damage in asymptomatic hypertensive patients.

End-Organ Damage Pearls:

• Rarely, if ever, will an aimless search for lab abnormalities lead to any clinically meaningful change in patient management
• An elevated creatinine does NOT define acute, end-organ damage. Most of the time it is due to the effects of chronic hypertension.
• There is some evidence that a UA that has BOTH no protein and no red cells predicts a normal creatinine. The studies that have looked at this, however, are very small. Also, HTN in and of itself may cause some protein leak, even in the setting of normal renal function
• A CXR and/or ECG is not needed in an asymptomatic patient.
• Prompt followup is always necessary especially if no ED workup is started. All of this can be dome in the primary care doctor's office.

 

Neuromuscular Blocking Agent (NMBA)

• NMBAs are used to facilitate intubation when performing RSI
• Importantly, NMBAs have no analgesic or amnestic effects
• Indiscriminate and repeated dosing of NMBA can lead to prolonged recovery and critical illness polyneuromyopathy, a devastating complication of critical illness that prolongs ventilation, ICU/hospital length of stay, and increases mortality
• Take Home Point: provide adequate amounts of sedation and analgesia to your intubated ED patients rather then reflexively giving repeated doses of NMBA

Initially normal ECGs may be found in 8% of patients with an acute MI, and 35% of patients with acute MI may have an initially non-specific ECG. The sensitivity of electrocardiography increases with serial ECG testing, but never reaches 100% in terms of sensitivity or reliability. The bottom line is that although ECGs are very good for ruling IN acute MI, they are not so great at ruling OUT acute MI. The HPI is the most important tool. ["Prognostic Value of a Normal or Nonspecific Initial ECG in AMI," JAMA 2001]