UMEM Educational Pearls

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.

A short list of some of the unique food poisonings and the toxicologic effects:

• Ciguatera toxin (fish): hot-cold sensation reversal
• Tetrodotoxin (fugu, puffer fish): paresthesias progressing to paralysis and dysrythmias
• Scrombroid (spoiled fish): flushed face due to histamine ingestion
• Paralytic Shellfish Poisoning (mussels, clams, etc): acts like curare, toxin is saxitoxin
• Amnestic shellfish poisoning (mussels): exactly what it says, loss of memory - very cool

A few days ago Dr. Jump and I had a case of an acute variceal hemorrhage.  Dr. Bond already sent out a great pearl earlier in the year highlighting the importance of octreotide in acute variceal bleeding.  In fact, octreotide alone can result in cessation of hemorrhage in up to 80% of patients.  To add onto Dr. Bond's pearl:

• Don't forget about antibiotics in acute variceal hemorrhage
• These patients have a relatively high incidence of bacteremia, which leads to worse outcomes
• Antibiotics have been shown to decrease infection rates and are associated with decreased rebleeding and the need for transfusions
• A 3rd generation cephalosporin is currently the recommended antibiotic of choice

Patients with aortic dissection (Type A or B) who develop intestinal/renal, etc. ischemia should be considered for aortic fenestration-a procedure in which holes are literally created in the aortic lumen to connect the true and false lumen-this allows perfusion of the involved vessel to occur from true lumen into the false lumen into the involved vessel.

Patients with large vessel malperfusion have a VERY HIGH mortality rate, AND most CT surgeons will not operate even on a Type A unless the involved vessels have been opened up.

This procedure is useful when major vessels (SMA as an example) branch from the aortic false lumen.

So, when to consider this procedure:

• Aortic Dissection (A or B) with severe abdominal pain, elevated lactate, OR imaging study showing malperfusion to a vessel (SMA, renal, etc)
• Most of the time in the ED we will see this on CT in a sick patient.

Who do you call?

• Vascular Surgery and IR-normally perormed percutaneously via a femoral approach

A few pearls regarding pacing a patient with an unstable bradycardia:

If the patient has an implanted pacemaker (which isn't working properly), the transcutaneous pacing pads should be placed at least 10 cm away from the implanted PM pulse generator.

Placement of a transvenous pacemaker is absolutely contraindicated if the patient has a prosthetic tricuspid valve.

Neither transcutaneous or transvenos pacing is likely to work in the setting of severe acidosis or severe hypothermia. Severely hypothermic patients, in fact, have very irritible myocardial tissue and therefore attempts at pacing may produce ventricular dysrhythmias.

Volvulus Quick Facts

• Volvulus causes 10-15% of large bowel obstructions and occurs most commonly in the elderly.
• The most common type of volvulus is sigmoid volvulus.
• Midgut volvulus is most common in the neonatal period.
• Cecal volvulus:
  • Occurs in all ages, but most commonly in the 25- to 35-year-old age group
  • Associated with:
    • previous abdominal surgeries
    • young, healthy marathon runners.
• Sigmoid volvulus most commonly occurs in two groups of individuals:
  • Inactive elderly persons with a history of severe chronic constipation
  • Patients with severe psychiatric or neurologic disease.

Atrial Myxomas:

• Rare primary heart tumor
• Most involve the left side of the heart

• Symptoms may include fatigue, fever, rash, chest pain, syncope, and/or focal neuro deficits
  • Symptomatic emboli occur in 20-45% of pts with atrial myxomas
  • >50% of emboli go to the brain
  • Hemiplegia, aphasia, retinal artery occlusion, embolic “rash” in a child should all raise concern for cardiac source in pediatric pt.
    
    • Embolus from the heart is the most common cause of retinal artery occlusion in pts <40yrs.

• Emboli are most often myxoma tissue and not blood clot (so thrombolytics aren’t of much value)

Majeed Al-Mateen, et al. Cerebral Embolism From Atrial Myxoma in Pediatric Patients. Pediatrics, Aug 2003; 112: e162 - e167.

• Fever in the setting of acute ischemic stroke is associated with increased mortality and morbidity.

• These effects are possibly due to increased metabolic demands, neurotransmitter release, and free radical production.

• Use of antipyretics to achieve normothermia may improve outcome.

• Studies have shown that hypothermia is neuroprotective.

• Look for a potential source of fever, which may have caused or prompted the stroke (i.e. infective endocarditis, complications of pneumonia).

Adams, et al.  Guidelines for the Early Management of Adults with Ischemic Stroke.  AHA/ASA Guidelines.  2007.

Remember that PE can clinically look exactly like pneumonia:

Both can present with:

• Cough
• Pleuritic chest pain
• Leukocytosis (WBC as high as 20-30)
• Elevated temperature (as high as 105F!)
• CXR that "looks" like pneumonia
• Both can present acutely

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

• Acute chest syndrome (ACS) is the leading cause of death in sickle cell patients
• ACS is defined by the presence of a new infiltrate and one of the following: chest pain, wheezing, fever, tachypnea, or cough
• Early and aggressive therapy is needed to minimize mortality
• Up to 50% of patients develop respiratory failure
• Treatment
  • Broad spectrum antibiotics - including a macrolide
  • Pain control to reduce hypoventilation
  • Early use of blood transfusion to improve O2 carrying capacity
  • Incentive spirometry
  • Bronchodilators if wheezing present
  • Hematology consult

Atypical presentations of ACS in the elderly are common.
Only 40% of patients > 85yo present with chest pain. Dyspnea is the most common presenting complaint in these patients. Other atypical presentations include isolated nausea, vomiting, diaphoresis, or syncope.

The presence of an atypical presentation is not reassuring in terms of prognosis. Patients presenting atypically have a 3-fold higher in-hospital mortality (13% vs. 4%). This doesn't even include the patients that are inadvertently discharged home because of failure to diagnose ACS.

Malpractice insurance may not cover the following activities:

• Practicing outside the scope of your specialty (eg: writing admission orders, running upstairs to run resuscitations).
• Undocumented treatment (ie: no ED chart generated)
• Prehospital orders
• EMTALA violations
• Hospital committee work
• Contract violations
• Fraud (including billing mistakes)
• Defamation
• Violation of privacy
• Harassment
• Sexual misconduct
• Assault and battery
• Other crimes

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.

Thanks to Larry Weiss, MD, JD

Rheumatic Fever

• Significant cause of cardiovascular morbidity in developing countries and still present in the USA, although declining in incidence.
• American Heart Association update of the Jones Criteria (1992):
  • Major Criteria
    (1)    Carditis (of any of the layers of the heart)
    (2)    Polyarthritis
    (3)    Subcutaneous Nodules
    (4)    Erythema Marginatum
    (5)    Chorea
  • Minor Criteria
    (1)    Arthralgia (not a criterion if polyarthritis is present)
    (2)    Fever
    (3)    Elevated acute-phase reactants (ESR, CRP)
    (4)    Prolonged P-R interval
• Diagnosis made by presence of TWO MAJOR or ONE MAJOR PLUS TWO MINOR.
• Diagnosis can also be made with presence of chorea and documented strep pharyngitis.

• Acute Management
  • Treat the Infection
    (1)    Penicillin (Pen V for 10 days or Pen G IM)
  • Alleviate Symptoms
    (1)    Salicylates are particularly effective for migratory arthritis
    (2)    High Dose ASA (80-100mg/kg/Day for several weeks, and then taper)
    (3)    NSAIDs for those who cannot tolerate ASA
    (4)    Steroids reserved for moderate to severe carditis.
     

• Apraxia = Inability to carry out physical acts despite intact motor function.

• Agnosia = Inability to recognize and identify objects and/or sounds despite intact sensory function.

Sulfonylureas

• Sulfonylureas cause insuline release via cAMP/protein kinase C
• All sulfonylurea overdoses should be admitted for 24 hrs regardless of symptoms
• Antidote for recurrent hypoglycemia due to sulfonylureas (overdose or therapeutic misadventure) is octreotide, after your glucose
• Octreotide, a somatostatin analogue, turns of insulin secretion completely
• Octreotide 50 mcg SQ q 6 hrs for 24 hrs then observe for hypoglycemia 12-24 hrs

Fasono et al. Comparison of Octreotide and Standard Therapy Versus Standard Therapy Alone for the Treatment of Sulfonylurea-Induced Hypoglycemia. Ann Emerg Med 2007 Aug 29.

• It is traditionally taught that in hypotensive patients the presence of a carotid pulse corresponds to a SBP of 60-70 mmHg, a femoral pulse with a SBP of 70-80 mmHg, and a radial pulse with an SBP of at least 80 mmHg
• These physical exam estimates of BP have been shown to poorly correlate with the patient's actual BP
• Similarly, non-invasive measurements of BP (automated cuff) in patients with hypotension may either overestimate or underestimate SBP by as much as 20 mmHg
• Since physical exam estimates and non-invasive measurements are inaccurate in low-flow states, utilize invasive arterial monitoring
• Radial and femoral artery sites have been found to produce results that are clinically interchangeable

Splenic Artery Aneurysm

• According to autopsy studies, splanchnic artery aneurysms (spleen, celiac, etc.) may be more frequent than AAA
• Most asymptomatic and detected incidentally on CT
• Splenic artery aneurysms most common splanchnic aneurysm
• With increased use of abdominal CT, emergency physicians will be seeing this diagnosis more often

Who cares, you ask?

• Splanchnic artery aneurysms are at risk for rupture
• This type of vascular abnormality will be discovered more often because of increased CT use
• Aneurysms > 2cm indication for repair
• Consider consultation and /or expeditious followup if this is encountered
• May be treated with catheter embolization or surgery

Although CHF is usually associated with low cardiac output, "high output failure" can occur as well. In this condition, cardiac output is normal or even high but not high enough to meet markedly elevated metabolic demands of the heart in certain conditions. Those conditions include: severe anemia, thyrotoxicosis, lartge arteriovenous sunts, Beriberi, and Paget disease of the bone.