UMEM Educational Pearls

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]

Most people are familiar with the Ottawa Ankle Rules, but there are also Ottawa Knee and Foot rules.  The Ottawa rules help to limit the number of x-rays you may need in patients that present with ankle, foot or knee pain after an injury.

The Ottawa Ankle Rule

An ankle x-ray is only needed if there pain in the mallelolar area and any of the following:

• Bone tenderness at the posterior tip of the base of the lateral mallelous
• Bone tenderness at the posterior tip of the base of the medial mallelous
• Inability to weight bear immediately and in the Emergency Department

The Ottawa Foot Rule

A foot x-ray is only needed if there is pain in the midfoot and any of the following:

• Bone tenderness at the base of the 5th metatarsal
• Bone tenderness over the navicular
• Inability to weight bear immediately and in the Emergency Department

The Ottawa Knee Rule

A knee x-ray is only needed for knee injury patients when they have any of the following:

• Age 55 or over
• Isolated tenderness of the patella (no bone tenderness of the knee other than the patella)
• Tenderness at the head of the fibula
• Inability to flex to 90 degrees
• Inability to weight bear both immediately and in the Emergency Department (4 steps - unable to transfer weight twice onto each lower limb regardless of limping).

• Pediatric seizures are common and 4-6% of all children will have a seizure by the time they are 16 years old.
• Afebrile neonatal seizures require an evaluation of electrolytes, glucose, calcium, magnesium, LP, blood and urine cultures.
• Simple Febrile seizures usually do not require any lab testing or admission if the child appears well.
• Dilution of formula with too much water is a common cause of hyponatremic seizures in infants.  (Treat with 3ml/kg of 3% hypertonic saline)
• Complex febrile seizures have a higher risk for meningitis than simple febrile seizures, so perform an LP, give antibiotics, and admit.
• When intubating for Status Epilepticus consider using thiopental or propofol for induction given their antiepileptic properties.

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As the economy worsens and our patients pay for more prescriptions out of pocket, here are some tips that may help you better serve your patients: 1) Ondansetron (zofran) is now off patent. Write generic on your script for zofran - for pediatrics the ODT (dissolving tablets) - are all much cheaper ($0.50 to $1.00 per pill or ODT). IV formulation is now cheaper than phenergan. Reglan is probably still the cheapest in most pharmacies. 2) Typical $4 antibiotics are the following: SMP-TMZ (Bactrim), Cephalexin, Amoxicillin, Penicillin, Ciprofloxacin. 3) Albuterol MDIs are now much more expensive because they have to be CFC free. Unfortunately, after this federal regulation, patients will have difficulty getting these inhalers which can be quite expensive. If you write a script and the patient is self-pay, they are going to have difficulty. Hospitals are beginning to discourage "to go" inhalers and even pills due to the fact that insurance companies DO NOT reimburse these costs - only IV meds.

The Crashing Intubated ED Patient

• For intubated ED patients who develop respiratory distress and are hemodynamically unstable, perform the following:
  • Immediately disconnect from the ventilator
  • Manually ventilate with 100% F_iO₂
  • Exclude tension pneumothorax (decompress)
  • Exclude auto-PEEP (allow for lung deflation)
  • Check ET tube for kinks, twisting, or obstruction
  • Check for air leak (check pilot balloon and listen for air coming from mouth/nose during manual ventilation)
  • Check the ventilator circuit

Brugada syndrome ECG findings are now well-recognized by many emergency physicians, but we need to be aware of mimics as well. Conditions that have been reported to induce a Brugada-ECG pattern include hyperkalemia, hypercalcemia, cocaine intoxication, and conditions that impinge on the right ventricle (e.g., tumors, pericardial fluid). There's debate in the cardiology community regarding how to manage these patients...but this debate is best left to your cardiology consultants. When you see a Brugada-like finding, get an electrophysiologist involved in the case!

Bleeding AV Fistulas

It is not an uncommon complaint for dialysis patients to present with bleeding from their fistula.  They can lose a large amount of blood in a short period of time if not treated promptly, and if treated too agressive their fistula can clot off. Some tips on how to control the bleeding.

Most of the bleeding occurs at the site that the needle puntured the fistula. If it is due to an ulcer eroding into the fistula these tips may not be effective.

• The easiest and safest way to control the bleeding is with simple diret pressure directly over the site of bleeding with a single finger. No guaze.  [Gown up and wear goggles or eye protection]. The use of a big wad of guaze or a pressure dressing tends to just hide the continued bleeding or result in the clotting off of the fistula.
• Injecting lidocaine with epinephrine at the site can also help and helps set you up for the next step,
• A figure eight stitch at the puncture site can help close the puncture wound.
• Of course you should call your vascular surgeon if you are having trouble controlling the bleeding, want close follow up or finger is going numb from holding pressure.

I typically check a CBC and coags.  Once the bleeding is controlled observe the patient for awhile [typically the hour to hour and half to get the labs back] and then road test them with a walk around the Emergency Department to ensure it does not start bleeding again.

 

 

• An acute bacterial infection of a joint.
• Peak incidence in children is younger than 2 years of age.
• Risk factors:
  • history of trauma
  • preceding URI
  • immunodeficiency
  • hemoglobinopathy
  • Diabetes.
• Age is the most important determinant of cause.
  • In all age groups, S aureus is the primary organism accounting for more than 50% of cases.
  • Among neonates, enteric gram-negative organisms and group B Streptococcus are the most frequent causes.
  • Group A Streptococcus, S pneumoniae, and K kingae are common causes in children younger than 5 years old.
• Blood culture, joint fluid aspiration and analysis, gram stain, and culture of fluid is recommended.
• In pyogenic arthritis, the joint fluid is usually cloudy and has a leukocyte count of at least 50 x 10000/mcL, with a predominance of polymorphonuclear cells, low glucose concentrations, and high protein values.
• Treatment involves a combination of parenteral antibiotics, surgical drainage, and decompression of the affected joint.
• All children who have pyogenic arthritis of the hip or shoulder require prompt open surgical drainage and irrigation to prevent permanent joint damage as the increased intra-articular pressure can compromise blood flow resulting in avascular necrosis of the femoral or humeral head and predisposing the patient to dislocations.
• Open surgical drainage of other joints usually is not required.

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Rocuronium is fast becoming the agent of choice for RSI in the Emergency Department. Here is a head to head comparison of the two drugs to understand why:

	Rocuronium	Succinycholine
Dose	1-1.2mg/kg	1mg/kg
Onset	1-1.5min	1min
Duration	7-12min	30-40min
Histamine Release	No	Minimal Yes
CVS Effect	Tachycardia rare	Severe Brady rare
Other Adverse Effect	No fasciculations, No ICP effect, No Rhabdo	Fasciculations, increase ICP, rhabdo, movement of displaced Fxs

 

• Cavernous sinus thrombosis, one of the three dural sinus thrombosis syndromes, is extremely rare and results from infection often originating from the face, sinuses, dental cavity, ears, and mastoids.

• Cranial nerves III, IV, V1, V2, and VI course along the walls of the cavernous sinus such that extraocular motion abnormalities (palsy/paralysis) commonly manifest with cavernous sinus thrombosis.

• Headache (usually sharp, unilateral, and in the distribution of V1 and V2 branches) is typically the initial presenting symptom, followed by eom palsy, mydriasis, diplopia, periorbital edema, visual abnormalities, mental status deficit, and coma.

Sepsis in Pregnancy

• Sepsis in the setting of pregnancy is primarily the result of pelvic infections such as chorioamnionitis, endometritis, septic abortion, or urinary tract infection
• In these patients, aerobic gram-negative rods (E. coli, Enterococci, Beta-hemolytic strep) are the principal etiologic agents
• An empiric broad spectrum antibiotic regimen is ampicillin, gentamicin, and clindamycin (or metronidazole)

 

 

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BEWARE sudden onset thoracic back pain

Just reviewed a case last week of a person who presented with back pain (thoracic) as the sole manifestation of an aortic dissection. No chest pain, belly pain, etc. JUST severe, acute, thoracic back pain.

Keys to staying out of trouble:

• Any sudden onset pain should be explained. Musculoskeletal pain doesn't normally present like this. Look for risk factors like HTN. If a person with HTN (even if not that high in the ED) presents with acute, severe, thoracic back pain the diagnosis of dissection should at the very least be considered.
• The key to making the diagnosis begins with thinking about the diagnosis.
• At the very least, include aortic dissection in EVERY patient you see with back pain, especially if sudden onset. I am not talking about the 95%+ people who don't really have anything wrong with them and who stumble into urgent care asking (begging) for Percocet.
• Sudden onset back pain should also prompt consideration for a AAA
• Just like all else in Emergency Medicine, always ask yourself if a "worst case scenario" could be present?, and the list for acute back pain is pretty short: dissection, AAA, fracture (by history), cancer, infection. Most of these, however, do not present acutely.

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Although intubation, oxygenation, and ventilation have been downplayed in recent years in the early management of patients with cardiac arrest, late-term pregnant patients DO require early airway support. Paients in the later stages of pregnancy have increased oxygen consumption and therefore have much lower oxygen reserves than non-pregnant patients. As a result, they tend to have central circulation desaturation much sooner. Additionally, they are at higher risk for aspiration because of delayed gastric emptying and lower esophageal sphincter relaxation. "This need for rapid intubation is a key difference between the pregnant women in cardiac arrest and nonpregnant patients." [reference: Atta E, Gardner M. Cardiopulmonary resuscitation in pregnancy. Obstet Gynecol Clin N Am 2007;34:585-597.]

Ankle sprains are typically treated with a short period of immbolization and then functional exercises are prescribed to rehabilitate the ankle.  A study published in the Lancet this week might just change that.  Lamb et al looked at 584 people with severe ankle sprains (unable to weight bear 3 days out from injury) that were randomized to be treated with a 10 day below knee cast, Aircast, Bledshoe Shoe or Tubular Compression dressing (similar to Ace Wrap).  Those that were treated with the Cast and Aircast had quicker return to function and less disability at 3 months.  There was no increased risk of DVTs in the cast group.

A commentary in the same issue points out that severe ankle sprains are associated with:

• lower levels of physical activity levels
• recurrent ankle sprains are often reported for months and years after initial injury.
• About 30% of patients with an initial ankle sprain develop chronic ankle instability, or repetitive giving way of the ankle during functional activities.
• There is also emergent evidence to link severe and repetitive ankle sprains to increased risk of ankle osteoarthritis.

Based on this article I think it is prudent to treat all patients with severe Ankle Sprains with a prolonged period of forced immobilzation (Posterior Splint, Short Leg Cast or Aircast).  I would also recommend the Aircast be used to prevent recurrent sprains especially if the patient is involved in sports that require jumping (Basketball, Volleyball) where the risk of reinjury is higher.

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You have a 44 y/o female patient with an arterial line monitoring her blood pressure which is reading 302/156 mm Hg.  Her heart rate is 140 bpm.  Her history reveals she is taking a monoamine oxidase inhibitor (MAOI) and has inadvertantly ingested tyramine at her friend's cheese/wine party.   What do you do?

• Conditions producing hypertensive crisis from catecholamine surges (phenylephrine overdose, cocaine, tyramine interactions, pheochromocytoma) can be treated with phentolamine
• Phentolamine is a nonspecifc alpha blocking agent which produces peripheral vasodilation with a resultant fall in blood pressure in most patients.
• Other uses include extravasation of some vasopressors (e.g. norepineprhine)
• May see an increase in HR after administration (once alpha blockade is established, beta-blocker can be administered)
• Dose: 5-15 mg IV/IM
• Duration: 30-45 minutes

Hyphema is an urgent ophthalmologic condition. Due to the high risk of rebleeding and increased intra-ocular pressure, strict follow up with an ophthalmologist is warranted. SELECTED low grade hyphemas in reliable patients may be managed on an outpatient basis. Some pointers that may be helpful for the EM inservice exam: 

• Measurement of intra-ocular pressure (IOP)  is crucial to proper treatment and prognosis.
• Many drugs are available to lower IOP, these are generally used in association with opthalmologic consultation
  ->acetazolamide (has potential to "sickle" RBC's)
  ->aminocaproic acid
  ->B blockers
• Hyphema > 5 days are associated with high incidence of synechiae formation
• Avoid NSAIDs/ ASA
• Eye patching,  HOB (head of bed) elevation recommended
• Corneal bloodstaining indicates a poor prognosis
• Incidence of rebleeding estimated at 30-40%
• Graded from 0-IV. Grade IV hyphemas cover the entire anteror chamber; often called, "8 ball" or "blackball" hyphema. Grade 0=only visible on slit lamp.
• Trauma is most common etiology
• Low IOP and trauma? ---> Rule out globe rupture! 

General indications for "very urgent" ophthalmologic consultation:

• Severely impaired visual acuity=greater rebleeding risk
• Patient with known SCD or sickle cell trait
• Visible blood staining of cornea
• High grade, covering > 1/3 of anterior chamber
• Delayed presentation (risk of synechiae / vision loss due to IOP) 

 

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• Angioedema occurs in less than 1% of stroke cases treated with tPA.
• Particularly associated with ACE inhibitor and beta blocker (less so) use.
• Symptoms are usually mild affecting the lips, tongue, and oropharynx.
• Check the patient for such symptoms at 45, 60, and 75 minutes post tPA administration.
• When present, consider treating with some or all of the following agents: 
   

             -- Diphenhydramine (Benadryl) 50 mg IV
             -- Ranitidine (Zantac) 50 mg IV
             -- Methyprednisolone (Solumedrol) 50 - 100 mg IV
             -- Racemic Epinephrine
             -- Anesthesia consult re: airway management

Pitfalls in ED Teaching

One of the best ways to improve as a teacher is to understand what mistakes expert educators have made in the past.

The following is a short list of pitfalls offered from some of the great teachers in our specialty:

• Trying to teach for too long: "Teaching less is more"-that is to say, more will be remembered if the teaching session is brief.
• Trying to teach too much: Trying to Stick to one main point, the "Educational Hit and Run," and move on
• Failure to be enthusiastic when you teach: You must have some enthusiasm when you teach. Students/Residents won't learn as much or be as enthusiastic about learning without your enthusiasm!