UMEM Educational Pearls

• IA lytics for stroke emerged to increase the 3-hour window for treatment.

• IA tPA may also be indicated for:

              --  candidates with severe neurological deficits (NIHSS score > 10)

              --  candidates with a recent history of major surgical procedures

              --  candidates with occlusion of major cervical or intracranial vessels

• Early IA lytic trials utilized urokinase and tPA, usually within a 6-hour window, though some reports extended the window to 12 hours for posterior circulation ischemic strokes.

• Studies have shown that THERE IS NO SIGNIFICANT DIFFERENCE IN RECANALIZATION RATE, SYMPTOMATIC HEMORRHAGE, AND NIHSS FOR IV PLUS IA LYSIS VERSUS IA LYSIS ALONE.

Zaidat OO, Saurez JL, Santillan C, et al.  "Response to intra-arterial and combined intravenous and intra-arterial thrombolytic therapy in patients with distal internal carotid artery occlusion."  Stroke 2002, 33:  1821-1826.

Bellolio MF, et al.  "Stroke Update 2007:  Better Early Stroke Treatment (BEST)," Emergency Medicine Practice, Augst 2007, Volume 9, Number 8.

Unilateral Pulmonary Edema

• unilateral pulmonary edema is a well recognized and well documented entity
• although there are several causes, the most likely scenarios for EPs are severe mitral valve insufficiency, aortic dissection (with compression of the pulmonary artery), airway obstruction, and heroin use
• even though radiology will read the xray as likely pneumonia, if the story/exam fit with edema then treat as such

Subarachnoid hemorrhage: Unilateral or bilateral headache?

Pretty good evidence exists that most patients with subarachnoid hemorrhage will have a bilateral headache.

In fact, unilateral headache is helpful in the history in ruling out SAH in most cases. Presence of an unruptured aneurysm, however can be present with a unilateral headache.

J NeuroSurg 2006

Women are more likely to present with atypical presentaitons for ACS.

Women are more likely to present without chest pain, but instead with middle or upper back pain, neck pain, jaw pain, dyspnea, vomiting, indigestion, weakness/fatigue, loss of appetite, cough, or palpitations than men.

EMTALA (Part Two)

• Hospitals may not delay screening examinations to inquire about payment.
• Emergency departments should not contact HMOs before completion of the screening examinations and stabilizing treatment.
• Triage does not constitute a MSE.
• For the purposes of EMTALA, a patient has come to the ED when he arrives on hospital property.
• EMTALA does not apply to offsite clinics unless (1) the clinic is licensed as an emergency department, (2) the hospital advertises the clinic as an ED, or (3) during the preceding year, 1/3 of all outpatient visits were for EMCs.
• EMTALA does not apply to inpatients, unless the hospital admitted the patient in bad faith.
• Since Nov. 2003, a specialty represented at the hospital does not always have to be on call.

Thanks to Larry Weiss, MD, JD

Disclaimer: This information does not constitute legal advice, is general in nature, and because individual circumstances differ it should not be interpreted as legal advice.The speaker provides this information only for Continuing Medical Education purposes.

The Premature Infant Delivered in Your Department

An ode to my final NICU Call… just because you don’t work in a Pediatric ED, doesn’t mean you won’t encounter premature infants.

What do you need to remember when a premature infant is born in your ED (or the ambulance / cab / car)?

• Warm them and keep them warm
  • Cold stress, often overlooked, worsens acidosis and decreases surfactant function.
• Neonatal Respiratory Distress Syndrome manifests as cyanosis, tachypnea, grunting, retractions, and/or respiratory failure.
  • CXR has “ground-glass” appearance and air bronchograms
  • It is due primarily to inadequate surfactant.
  • Early administration of surfactant has proven to improve outcomes
  • Contact a neonatologist ASAP and determine if you have easy access to a surfactant product (it really is an amazing therapy).
  • You administer it down the ETT… you’ve likely intubated them by now.
• Fluids
  • Fluid Boluses are done with normal saline (10ml/kg)
  • Maintenance Fluids should be D5W or D10 (no electrolytes at first!)
• Antibiotics
  • One of the most common reasons for premature delivery is neonatal infections… don’t be stingy, start Amp/Gent (consider acyclovir) and send blood cultures at least.
     

Everything you need to know about anti-emetics, mechanism of action, potency and toxicity:

1) 5-HT3 Blockers - Ondansetron, Granistron

- The most potent anti-emetic, only toxicity is really cost

2) Dopamine Blockers - Metoclopramide

- Can titrate to high doses, causes dystonia, akathisia and mild QT prolongation

3) Anticholinergic - Promethazine, meclizine, diphenhydramine

- Cannot titrate, most sedating, urinary retention in elderly, mild QT prolongation

• 325 mg of aspirin should be given within 48 hours of symptom onset in ischemic stroke; while its good form to give it when appropriate while the patient is still in the ED, per recent guidelines, it is not imperative.

• Aspirin should not be given to stroke patients who will receive tPA.

• Prior administration of aspirin is not a contraindication to giving tPA, however.

• If dysphagia and/or aspiration risk is suspected, give 300 mg of aspirin per rectum.

2007 AHA and ASA Guidelines for the Early Management of Adults with Ischemic Stroke and Guidelines for the Management of Spontaneous Intracerebral Hemorrhage in Adults.

ECG gating CTs for aortic dissection/aneurysm rule out

• Increasing evidence supports the use of ECG gating when performing CTs to rule out aortic pathology-dissection and aneurysm.
• The most common artifact on CT is a "psuedo-dissection" flap caused by excessive motion at the aortic root. Administering beta blockers before CT will limit this motion and decrease the chance of this false positive.

AJR 2007

Massive hemoptysis

• Massive hemoptysis is defined by most as the expectoration of > 600 ml in 24 hrs
• Chronic lung inflammatory disease and bronchogenic CA are the most common causes in the US
• TB remains the most common cause worldwide
• The bronchial artery causes approximately 90% of cases
• Get a STAT portable and place the patient in the lateral decubitus position toward the affected side (this is theorectical and has not been proven)
• Options for bleeding control can include endobronchial tamponade methods(pulmonary), bronchial artery embolization (interventional radiology), and emergent surgical resection (surgery)
• Bronchial artery embolization is now the most successful non-surgical treatment of massive hemoptysis

Rheumatic heart disease (RHD) has traditionally been considered the most common underlying condition predisoposing to infective endocarditis. While RHD is still common in developing countries, its prevalence has declined and "mitral valve prolapse is now the most common underlying condition in patients with infective endocarditis."

(from AHA Guideline on Prevention of Infective Endocarditis, Circulation, October 9, 2007)

EMTALA (Part One):

• The three general duties created by EMTALA are to provide (1) an appropriate medical screening examination (MSE), (2) stabilizing care, and (3) appropriate transfer of unstable patients.
• An appropriate MSE is an exam comparable to similarly situated patients (ie: non-discrimatory).
• Patients are stable if it is reasonably likely they will not deteriorate during a transfer.
• The duty to stabilize arises only if the physician diagnoses an emergency medical condition (EMC).
• Once stabilized, the hospital and physician have fulfilled their duties under EMTALA.
• The transfer criteria only apply to unstable patients.
• Receiving hospitals may get fined if they fail to report an inappropriate transfer.
• A hospital with specialized capabilities must accept appropriate transfers if it has the capacity to care for the patient.

Thanks to Larry Weiss, MD, JD

Disclaimer: This information does not constitute legal advice, is general in nature, and because individual circumstances differ it should not be interpreted as legal advice.The speaker provides this information only for Continuing Medical Education purposes.

Pierre Robin Syndrome

• The prime features of this condition are a small jaw (micrognathia), cleft palate, and posteriorly positioned tongue.
• In the newborn period, respiratory compromise from obstruction is of greatest concern.
  • Because the tongue is positioned in the back of the mouth, it tends to block the airway and cause respiratory distress.
  • In severe cases, a tracheostomy may be required to provide a stable airway for the patient. (We just had an emergent tracheostomy done in our NICU this month).
• Severity of airway obstruction varies from mild to life-threatening.
  • With only mild distress, attempt to relieve the obstruction by placing the child on his or her stomach; gravity will help to keep the tongue out of the airway.
  • Resuscitation of babies with more severe obstruction may be difficult because the micrognathia and the posteriorly protruded tongue can contribute to inadequate face-mask ventilation and make endotracheal intubation difficult (or impossible).
  • Consider LMA as a bridge to tracheostomy.
  • As soon as you recognize the presence of mirognathia, have someone call pediatric anesthesia and pediatric surgery.

Baraka, A. Laryngeal Mask Airway for Resuscitation of a Newborn with Pierre-Robin Syndrome. Anesthesiology. 83(3):646-647, September 1995.

• Risk Factors for RCIN: Renal insufficiency, >60 yr old, DM, Renal Transplant, Hypovolemia, EF <30%, concomitant nephrotoxic drugs
• Consider Prophylaxis with anyone of three methods (no method has been found superior.
  • Normal Saline: 1 ml/kg/h IV pre and post study
  • NaHCO3: 3 ml/kg IV bolus over 1 hr then 1 ml/kg/h pre and post
  • IV Acetylcysteine 150 mg/kg bolus over 1hr then 50 mg/kg over 4h

Today's joint conference with the UMMS' Neurology Department was quite beneficial and applicable to our daily practice in the Emergency Department (ED).

The topics discussed included:

• Third Nerve Palsy (aneurysmal versus vasculopathic)
• Painful Post-ganglionic Horner's Syndrome
• Cluster Headache
• Carotid Dissection
• Pituitary Apolplexy

While the information provided for each of these clinical topics was comprehensive, be sure to review these disorders in the near future, in order to commit them to memory and increase your comfort level with diagnosing and treating them in the ED.  If you'd like a copy of the handouts, just let me know.

Today's pearl will highlight pituitary apoplexy.

Take Home Points about Pituitary Apoplexy:

• Defined as hemorrhage or infarction of a pituitary tumor.
• Neurologic emergency that can be fatal, usually due to hemorrhage.
• Typically presents with acute onset of headache +/- meningeal irritation, altered mental status,  photophobia, and  ophthalmoplegia (usually 3rd cranial nerve palsy, followed by 6th and 4th cranial nerve dyfunction).
• CT head (dry) may appear normal.  MRI typically makes the diagnosis.
• Ophthalmoplegia (of 3rd CN) + CSF with significant red cells may prompt an angiogram in search of a PCOM (posterior communicating artery) aneurysm, when an MRI is acutally all that's needed.
• Treatment:  high dose steroids (hydrocortisone 100 mg IV q 6-8 h) +/- decompressive surgery via Neurosurgery.

Acute Liver Failure

• Acute liver failure (ALF) is defined as the onset of encephalopathy and coagulopathy within 26 weeks of jaundice in a patient without prior history of liver disease
• ALF has an extremely high mortality
• The most common cause of ALF include Tylenol, HSV, autoimmune hepatitis, HBV, and acute fatty liver of pregnancy/HELLP
• Complications EPs are likely to see/manage include hepatic encephalopathy, infection, circulatory dysfunction, bleeding, and seizures
• Fungal infections may be present in one-third of patients with ALF (Candida)
• Non-convulsive seizure activity occurs in a high proportion of patients with ALF and encephalopathy - consider EEG for severly encephalopathic patients and those with a sudden deterioration in neuro status

Stravitz RT, et al. Intensive care of patients with acute liver failure. Crit Care Med 2007;35:2498-2508.

A few pearls regarding Acute Aortic Dissection...

• CXR has been shown to have an overall sensitivity of only 67%!
• Recent literature and a large, recently published, authoratative book by one of the world's leading authorities on aortic dissection support the notion that a negative highly sensitive d-dimer rules out aortic dissection.
• CT scan is the test of choice, but be aware that many authorities are starting to recommend beta blockade before CT to reduce the most common artifact, motion at the aortic root that simulates a dissection flap
• MRI and TTE are reasonable alternatives if a CT can not be ontained
• The most common theme found in malpractice claims against emergency physicians is failure to address the combination of chest/back, back/abdominal pain.

Elefteriades. Acute Aortic Disorders. 2007

Abdominal pain can be very confusing. Occasionally, serious etiologies may masquarade as benign complaints. Always consider the following pitfalls when addressing abdominal complaints.

• Be aware of extra-abdominal disease processes presenting as abdominal pain
  • AMI, pneumonia, pelvic diesases
• If you suspect appendicitis - than pursue the diagnosis
  • Do not delay notification of surgeon, and request consultation early
    • It is reasonable for them to examine the patient without CT results
    • It is not reasonable to withhold pain medications until they see the patient
  • Time all calls, and document all discussions with consultant name
• UTI and gastroenteritis should be considered diagnoses of exclusion. Be wary of using, if any red flags exist
  
  • fever, hypotension, blood in stool, weight loss, abdominal tenderness
• Unless the diagnosis/etiology is clearly not pelvic in origin, always do a pelvic exam in a women
• Always consider, and document your consideration of testicular and ovarian torsion
• In a septic patient with UTI, consider obstructing pyelonephritis.
  • Patients with a kidney stone and obstructing pyelo will not get better unless the stone is removed. CT for stones, prior to dispo.
• Consider vascular etiologies in high risk populations: elderly, diabetic, hypertensive
  • AAA - pain to back, tearing sensation
  • Dissection - pain, decreased pulses, neuro findings
  • Mesenteric Ischemia / schemic Colitis - pain out of proportion to exam findings
  • Torsion - radiating pain to abdomen - document a genital exam

Disclaimer: This information does not constitute legal advice, is general in nature, and because individual circumstances differ it should not be interpreted as legal advice. The speaker provides this information only for Continuing Medical Education purposes.

Content abstracted from: Nguyen Anh, Nguyen Dung. Learning from Medical Errors. Radcliffe Publishing, UK. 2005. P 11-13.

The standard dose for adenosine in treating SVT is 6 mg given as a rapid IV push. The dose should be immediately followed by a saline flush and works best if the drug is administered through a good, proximal (e.g. antecubital) IV line.

A few points:

1. The initial dose of adenosine should be reduced to 3 mg if the dose is administered through a central line, if the patient has a transplanted heart, or if the patient is taking carbamazepine or dipyridimole.
2. The initial dose of adenosine should be increased to 9-12 mg if the patient is taking theophylline or large doses of caffeine.
3. ALWAYS warn the patient that he/she will experience 5-10 seconds of chest pressure, warmth, dyspnea, and perhaps a feeling of "impending doom" as the adenosine kicks-in, and reassure the patient that the sensation will resolve. Failure to warn the patient of these symptoms may result in the patient refusing to ever take the medication again...plus it's just plain cruel to not warn the patient.

Proteinuria

• Proteinuria on U/A may suggest underlying renal disease; however, it may be present for benign reasons as well:
  • A very concentrated urine (SG ≥ 1.020)
  • Alkaline urine (pH ≥ 7.5)
  • Presence of mucoproteins
  • Acute illness

• Benign processes almost never produce proteinuria above 1+.
• If proteinuria is detected in the ED in an asymptomatic patient:
  • Have the patient f/u with PMD for repeat u/a within 1-2 weeks
  • Recommend checking a first morning urine sample and urine protein: creatinine ratio (to rule out orthostatic/transient proteinuria).

• If proteinuria persists or is evident on first morning urine sample, then a renal biopsy may be indicated.
• Chemistry panels, CBC’s, renal ultrasound, and 24-hour urine collection rarely change the plan.
   

Chandar J, Gomez-Martin O, del Pozo R, et al. Role of routine urinalysis in asymptomatic pediatric patients.  Clin Pediatr (Phila). 2005; 44:44-48.

Hogg RJ, Portman Rj, Milliner D, Lemley KV, Eddy A, Ingelfinger J. Evaluation and management of proteinuria and nephritic syndrome in children recommendations from a pediatric nephrology panel established at the National Kidney Foundation Conference on Proteinuria, Albuminuria, Risk, Assessment, Detection, and Elimination (PARADE). Pediatrics. 2000; 105: 1242-1249.