UMEM Educational Pearls

Otitis Externa:

Infections of the external ear canal are common and can typically be treated with topical antibiotic solutions (Cortisporin Otic, Cipro Otic, etc...) or antibiotic solutions mixed with topical steroids (Cortisporin HC Otic, Cipro HC Otic, etc...).  Most patients should not require PO or IV antibiotics.

However, you need to always be on the look out for malginant otitis externa (MOE) which is a more deep seated infeciton extending into the temporal bone and can have a mortality rate as high as 50%.  Patients that are diabetic, immunospressed, or have had radiation therapy to the base of the skull are at increased risk.  Patients with MOE typically have pain out of proportion to clinical findings and granulation tissue may be present in the ear canal.  Suspect this diagnosis in patients that have cellulitis or extreme tenderness over the mastoid process.

If you suspect MOE the patient should be started on antibiotics that cover pseudomonas. Consider obtaining a CT scan with temporal bone cuts and an Otolaryngology consultation.

Next time you have to do a full septic work up on a 2 month old with a fever of 104 F consider giving Ketamine 3mg/kg IM before even starting.  Then you can obtain your cath urine, IV, and LP with a calm pain free patient!!

Ketamine induces a catatonic state that provides sedation, analgesia, and amnesia.  It does not affect pharyngeal-laryngeal reflexes and the patient maintains a patent airway.  This makes it very useful when fasting is not assured.   

Route          Onset          Duration             Dose

  IM            3-5 min         20-30min         3-5 mg/kg

  IV             1 min            5-10 min          1-2 mg/kg

Although we tend to think of ACS with cocaine use, there are many other serious complications, including:

• Agitation, psychosis, and anxiety
• Hyperthermia
• Vascular headache of withdrawal
• Seizures
• Hemorrhagic stroke (many of these patients have an underlying vascular abnormality)
• Ischemic stroke
• Acute Renal Failure
• Crack Lung: acute pulmonary syndrome that occurs after inhaling freebase cocaine presents as fever, dyspnea, hypoxemia, diffuse alveolar infiltrates, and respiratory failure
• Intestinal perforations

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Blood Pressure Control in ICH

• Aggressive BP reduction after ICH is currently the focus of an ongoing NINDS study (ATACH Study)
• Current literature recommends that extreme levels of BP after ICH be treated to reduce hematoma expansion
• Mean arterial pressures (MAP) > 130 mmHg should be treated with continous IV medications
• Current recommended medications include labetalol, esmolol, nicardipine, and fenoldopam
• Nitroprusside is avoided by many given its tendency to increase ICP
• Oral and sub-lingual medications are not indicated for immediate and precise BP control

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This pearl is dedicated to Dr. Michael Rolnick....

 

Infections That Cause Temperature-PulseDissociation

Certain infections may cause temperature-pulse dissociation (relative bradycardia in association with fever).

Remember that normally there will be an increase in pulse rate by 10 bpm for every 1 degree increase in temperature. So, if a patient has a temperature of 103 F, expect them to be tachycardic.

Any intracellular organism has the potential to cause a relative bradycardia (Faget's sign)

Infections that cause dissociation:

• Salmonella typhi
• C burnetii (agent of Q fever)
• Chlamydia infections
• Dengue fever

Diastolic dysfunction is recognized as a much more common cause of CHF and cardiogenic pulmonary edema than traditionally recognized. Diastolic dysfunction is associated with impaired relaxation, which results in a decrease in LV filling, which results in pulmonary congestion. Common causes of diastolic dysfunction are cardiac ischemia, LVH, and infiltrative diseases.

It is almost impossible to get through a shift these days with out seeing an abscess that is caused by CA-MRSA.  As of the 2007 Antibiotic nomogram (2008 data not yet available) at University of Maryland CA-MRSA was only 70% sensitive to clindamycin, and >98% sensitive to bactrim and > 96% sensitive to doxcycline.  A local community hospital in Baltimore is showing only 55% sensitivity to clindamycin.

As a New Year's resolution to yourself I recommend that you check with your local hospital's Micrology department to see what the sensitivities are to bactrim, clindamycin, doxycycline.  If sensitivities are less than 80% it would generally be recommended that these medications not be used as initial empiric treatment.

For Baltimore bactrim and doxycycline should probably be the preferred treatment options.

Have a Great New Year.

Propofol is an IV hypnotic that is made in a soy-based emulsion containing soybean oil, egg lecithin, and glycerol.  It has a very rapid onset time (10-50 seconds) and a brief duration of action making it ideal for ED sedation.  Children have a more rapid metabolism of propofol than adults.  Propofol has been shown to be safe and effective for Pediatric ED sedation in several studies.  

Pearls on Propofol

• Dosing is 1mg/kg bolus than 0.5 mg/kg IV q 1-2 min until desired sedation occurs
• Due to high lipid concentration can cause pain at injection site in up to 70% of patients.  This can be prevented by applying a rubber tourniquet well above IV site and injecting 0.5 mg/kg of lidocaine 30 seconds before injecting the propofol. 
• Use is contraindicated in those with allergies to Eggs, Soy, or sulfites, or those with mitochondrial disorders
• PRIS (Propofol Infusion Syndrome) was described in 1992 with case reports of children dying due to metabolic acidosis, rhabdomyolysis, and refractory heart failure when receiving high doses (>4mg/kg/h) for >48 hours.  And it is more associated with children < 4 years old. 
• So while safe for pediatric procedural sedation don't use propofol as a drip for intubated children.

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Watch out for tradename and generic name's of medications.

They can get the patient and yourself into trouble:

• coumadin: warfarin, jantoven
• diphenhydramine: unisom, benadryl, tylenol PM

Classic example is my own case: Insert a central line in a patient - subclavian - and shortly after completion am alerted the patient's INR is 25. No adverse outcome but when I reviewed the med list, I did not see coumadin or warfarin and assumed I was in the clear. Patient was on jantoven.

Happy Holidays

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• The most common anatomical locations for ischemic stroke are in the internal capsule and the basal ganglia.
• Look for hypodensity (i.e. darkening which suggests edema) in these parts of the brain on CT when trying to locate areas of stroke.
• Acute stroke typically takes at least 3 hours to manifest in the form of edema on Head CT.  The larger the stroke, the quicker the abnormality is seen.

Hemofiltration

• Renal replacement therapy (RRT) involves the use of semipermeable membranes to remove fluid and toxic substances from the bloodstream
• The basic methods of RRT are hemodialysis (HD) and hemofiltration (HF)
• There have been a few cases in our ED in which our Renal consultants have used HF
• Hemofiltration can remove large volumes of fluid (up to 3 Liters per hour)
• Major advantages to HF: less likely to produce hypotension than HD, can remove larger molecules than HD
• Disadvantages to HF: must be done continuously to provide effective dialysis, requires anticoagulation to maintain circuit patency, not well suited for hypotensive patients (requires a hydrostatic pressure gradient for solute clearance)

A neutropenic cancer patient that presents with right lower quadrant abdominal pain, fever, and bloody diarrhea should raise suspicion for typhlitis (necrotizing colitis, cecal inflammation). This most commonly occurs in patients with hematologic malignancies who have been treated with cytotoxic agents. This condition is high risk and is associated with high morbidity and mortaiity.

Treatment:

• Broad-spectrum antibiotics
• CT scan of the abdomen and pelvis
• Surgical consultation
• Usually requires ICU admission

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An increasing amount of attention in the literature is now being paid to ways of optimizing care of patients that are post-cardiac arrest. Simple things to focus on for us in the ED are the following:
1. induction of therapeutic hypothermia
2. aggressively manage hypotension and cardiac ischemia
3. treat hyperglycemia aggressively
4. avoid hyperventilation, though maintain adequate oxygenation

 

Critical Care Billing Pearls:

 

Level	RVU	Medicare	Commerical
99285    ED E/M, Level 5	4.71	$170	$304
99291    Critical Care, first hour	5.84	$211	$363

As the table shows Critical Care billing will earn you approximately 25% more with no additional overhead.  Critical care time must be at least 30 minutes, and the following procedures are included in the critical care code:   

• Interpretation of ABG and labs
• Interpretation of CXR
• IV insertation
• Transcutaneous pacing
• Blood Draws
• NG Tube placement

The following procedures are not bundled into critical care time, so they can be billed separately, therefore the time you spend doing these procedures can not be included in your total critical care time:

• Central Line Placement
• Lumbar Puncture
• Intubation
• Transvenious pacemaker placement
• Arterial Line Placement
• Chest Tube Placement
• CPR

Remember critical care time does not need to be continuous but you need to be immediately available to the patient for the time to count.  You can not count time going off the floor to review an xray or CT, but this time can be counted if you do it in the immediate vacinity of the patient.

FINAL CAVEAT  To help your coders bill appropriately it helps to include a statement such as "Critical Care time XX minutes where I was directly involved in the care of this patient exclusive of all other separately billable procedures."

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• Bronchiolitis is the most common lower respiratory tract disease in infants, and RSV (Respiratory syncytial virus) bronchiolitis is the leading cause of hospitalization in infants.  It will infect 90% of children by 2 years of life.
• Bronchiolitis "season" in the US is typically December to March but it does occur year round. 
• Pathology is caused by respiratory epithelial cell death that results in inflammation, edema, smooth muscle contraction, bronchoconstriction and mechanical obstruction by cellular debris and mucus plugging.
• History that suggest Bronchiolitis is cough, rhinorrhea, fever
• Most common PE findings are runny nose, tachypnea, wheezing, cough, crackles, use of accessory muscles,  and/or nasal flaring.
• Respiratory distress, dehydration, sepsis, and RSV associated apnea are feared severe complications.
• RSV associated apnea may be the presenting symptom in some infants. 
  • Infants at greatest risk for this are younger (usually < 3 months), hx of prematurity, hx of apnea of prematurity, and those who are early on in the illness.

 

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The FDA has ruled that Long-Acting Beta Agonists (LABAs) are not worth the risk with increased hospitalization and increased mortality. Serevent has largely been replaced by Advair now. Unfortunately, for the children, it took 3 years to look at the data and finally come to this conclusion. Advair (LABA + fluticasone) has escaped the ruling with lack of evidence.

• Despite guidelines that recommend against opioid use as first-line treatment for migraine headaches,  meperidine (Demerol) is still administered in 36% of all migraine headache ED visits in the U.S.

• Meperidine's lack of efficacy, adverse effects such of seizure, and toxic metabolic accumulation all contribute to its use for migraine headaches being discouraged.

• A recent meta-analysis out of New York again supports the avoidance of using meperidine for migraine headaches, and instead, encourages clinicians to use anti-emetic and dihydroergotamine regimens.

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Catheter Positioning

• Central venous catheters (CVC) inserted from the left side must make an acute angle downward when the enter the SVC from the innominate vein
• CVCs that do no make this turn can end up with the tip pointing directly at the lateral wall of the SVC
• CVCs in this position can cause perforation of the SVC
• If the catheter tip is pointing at the SVC, then advance the catheter further down

There is clearly no way you can document everything on a chest pain chart. However, there are some pretty important things that should be on the chart.

Some key things to consider documenting:

• Why you did not work up someone's chest pain, i.e. what would you want your chart to look like if the patient went home to have an MI and an attorney looked at your chart? You don't think a ECG is warranted? Fine. Just document why. The chart tells all.
• Documentation of risk factors for the three deadly causes of chest pain: ACS/MI, aortic dissection, and PE. Documenting these is proof you were thinking about a differential diagnosis.
• Documenting key chest pain physical exam findings and pertinent negatives-Documenting "legs normal, no DVT" is proof you were thinking about PE the whole time, even if it isn't in your medical decision making section. Writing "no diastolic murmur" is proof you thought about aortic dissection. These kinds of documentation pearls will serve to make the chart defensible. Obviously, you should perform this part of the exam and not just write it on the chart.
• Documentation of why you didn't go after ACS, aortic dissection, or PE. We will all make mistakes in our careers. And remember, we can't diagnose every MI, dissection, and PE. But, remember that you want your chart to show that you thought about these bad boys and WHY you didn't go after them. What is frequently missing on charts of missed MI, AD, and PE is exactly this!

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