UMEM Educational Pearls

Safety of Thoracentesis

• Thoracentesis is routinely performed in both acute and non-acute patients while patients are admitted to the hospital for respiratory distress
• A recent 12 year cohort study of 9320 thoracenteses was published from Cedars-Sinai Hospital
• The clinicians that perform these procedures are well experienced
• The most common complications include pneumothorax, re-expansion pulmonary edema, and bleeding

Results after 24 hours of followup post-procedure

• 0.61% of iatrogenic pneumothoraces
• 0.01% rate of re-expansion pulmonary edema
• 0.18% of bleeding episodes

Other interesting points:

• Pneumothorax was associated with removing >1500 mL of fluid and more than one needle pass
• Ultrasound was routinely used
• A safety-tipped needle/catheter was used
• Fluid was removed by manual hand pumping (not vacuum bottles)
• CXR only done post-procedure if patients were symptomatic
• No blood products were given for low platelets or thrombocytopenia

Bottom line: Use your ultrasound to direct your tap and dont take out more than 1500 mL routinely

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Question

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Aside from sodium chloride and sodium bicarbonate, several commonly used emergency department medications (namely IV antibiotics) contain a significant amount of sodium. In patients with heart failure or other conditions requiring sodium restriction, judicious use should be considered.

Notes:

• Available references all quote slightly differing sodum contents. Therefore, the daily totals are approximate, but within 100 mg of the various references.
• To convert mg to mEq or mmoL, divide by 23.

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There are some studies that have shown that NSTEMI patients have done worse when administered opioids. Most studies were not well controled and the exact mechanism was not clear. This study adds a biological mechanism to these fidnings.

Hobl et al. showed clopidogre concentrations delayt peak yhours, have overall decrease AUC and actually decrease active metabolites when morphine is administered IV. Morphine may not be the right choice in any ACS that receives clopidogrel.

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A Lancet Commission on Global Surgery has just published a 56 page article about the need to improve access to surgery and anesthesia care.  Its five key messages are:

• 5 billion people lack access to safe, affordable surgical and anaesthesia care when needed
• 143 million additional surgical procedures are needed each year to save lives and prevent disability
• 33 million individuals face catastrophic health expenditure due to payment for surgery and anaesthesia each year
• Investment in surgical and anaesthesia services is affordable, saves lives, and promotes economic growth
• Surgery is an indivisible, indispensable part of health care

The need for high quality acute care, both for urgencies and emergencies, is clearly an important component of providing “universal access to safe, affordable surgical and anaesthesia care”- the vision of the Commission.

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SIRS and Severe Sepsis Screening

• Sepsis remains one of the most common critical illnesses managed by emergency medicine and critical care physicians.
• Many EDs and ICUs have screening protocols for early detection of the patient with sepsis. Most protocols use the systemic inflammatory response syndrome (SIRS) as a central component of early identification.
• A recent study stresses caution when simply using the SIRS criteria to screen for severe sepsis:
  • Retrospective review of the ANZICS Adult Database
  • Divided patients into SIRS-positive ( 2 SIRS criteria with at least 1 organ failure) and SIRS-negative ( < 2 SIRS criteria with at least 1 organ failure)
  • 109,663 patients
  • 12% of patients diagnosed with severe sepsis or at least 1 organ failure had < 2 SIRS criteria at admission.
  • Mortality for the SIRS-negative cohort remained relatively high at 16.1%
• Take Home Point
  • Using the SIRS criteria to screen patients for severe sepsis will miss 1 out of every 8 patients with infection and organ dysfunction.

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Question

70 year-old female presents from a nursing home with fever and abdominal pain. A right upper quadrant ultrasound is shown, what's the diagnosis?

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In cases of suspected spinal infection, the sensitivity of an elevated WBC count (35-61%), ESR (76-95%) and CRP (82-98%) may help guide further evaluation or consideration of other entities.

Incorporation of ESR/CRP into an ED decision guideline may help differentiate those patients in whom MRI may be performed on a nonemergent basis.

An elevated ESR (>20 mm/hour) also has a role in the diagnostic evaluation of occult malignancy (sensitivity 78%, specificity 67%).

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Some medical issues arise in patients with brain tumors:

// Steroids are used to decrease vasogenic edema, especially preop or during radiation therapy. Patients are ideally gradually weaned off steroids. Dexamethasone is most commonly used. 1-2% of patients are at risk for adrenal suppression.

// Infections: Post-op wound infections can be delayed up to months, especially in patients on steroids.

// Antiepileptics: Although technically not recommended in patients with brain tumors who have not had seizures (American Academy of Neurology 2010), many surgeons continue to prescribe antiepileptics preoperatively and then discontinue them by 1 month postop if the patients remain seizure-free. Levetiracetam is emerging as the drug of choice due to favorable side effect profile.

// Thromboembolism: Brain tumors are considered very high risk for venous thromboembolism. Low-molecular-weight heparin is the treatment of choice, with warfarin being an acceptable substitute.

// Arterial thrombosis and ischemic stroke: Risk is increased with certain medications, and thrombolysis is contraindicated.

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Updates in the Management of Large Hemispheric Infarction

Large hemispheric infarctions (LHI) are estimated to occur in 2-8% of all hospitalized ischemic strokes and 10 15% of all MCA territory infarcts. LHI carry high rates of morbidity and mortality, in fact, if left untreated associated cerebral edema can rapidly progress to transtentorial herniation and death in 40 80% of patients.

Recognized risk factors for progressive cerebral edema include:

• NIH stroke scale > 20 in dominant hemispheric infarct
• NIH stroke scale > 15 in nondominant hemispheric infarct
• Rapid decline in level of consciousness (LOC) indicates effect on contralateral hemisphere (due to ipsilateral swelling)

Evidence based medical strategies for LHI include:

• Positioning: Elevation of the head of the bed (HOB) > 30 degrees
• Glucose control: 140 180 mg/dL (hyperglycemia associated with increased ICP and progression to hemorrhagic conversion)
• Blood pressure control: 15% reduction MAP over 24 hours if BP exceeds 220/120 (likely best accomplished with nicardipine infusion to avoid overcorrection)
• Osmotic therapy: In the deteriorating patient, consider hypertonic saline (23%) with goal Na of 160 mEq/L or mannitol with goal plasma osmolality of 320 mOsm/kg.
• Adjunctive therapies: Prevent fever and hypercapnea

Prophylactic hemicraniectomy

• Consider early neurosurgical consultation for patients with LHI as newer evidence suggests prophylactic hemicraniectomy may improve survival if performed within 24 48 hours.

Bottom Line: Early recognition of large hemispheric stroke is critical as it is associated with a high rate of morbidity and mortality. Aggressive medical management and early neurosurgical involvement may improve outcomes.

References

1. Zha AM, Sari M, Torbey MT. Recommendations for management of large hemispheric infarction. Curr Opin Crit Care. 2015;21(2):91-8.

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Question

You see the following on a parasternal long-axis view; what's the diagnosis and what coronary distribution is involved?

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Cardiac Sarcoidosis

- Cardiac Sarcoidosis (CS) is reported to involve ~2-5% of patients with systemic sarcoidosis. An increasing proportion of patients are presenting with isolated CS.

- Isolated CS is associated with a higher female predominance; severe LV involvement, heart failure, and poor prognosis.

- Manifestations range from symptomatic conduction disturbances, dysrhythmias, progressive heart failure, and silent myocardial granulomas - leading to sudden cardiac death.

- CS is a serious condition with a quoted 5-year survival ~60-75%.

- Corticosteroid therapy is considered cornerstone in management, but evidence is largely observational and no randomized trials have been performed to date.

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Is acetaminophen good for pain control in patients with Osteoarthritic of the Knee or Hip or Low Back Pain?  Most of my patients request narcotics, but conventional teaching is that we should try to start with Acetaminophen or NSAIDs.

This recent study, http://www.bmj.com/content/350/bmj.h1225, published in the BMJ analyzed 13 studies looking at over 5400 patients.  In the end, they found that acetaminophen did not appear to improve pain, disability or the patient’s quality of life in patients with back pain. Also, there was a small improvement in pain and disability in those with hip and knee pain, but it was not deemed clinically significant.

Even worse, patients taking acetaminophen had a 4x greater chance of having abnormal liver function tests.

This meta-analysis really questions whether Acetaminophen should be first line therapy in patients with osteoarthritis of the knees or hips, or in those with low back pain.  For now I will stick with a course of a NSAID.  Especially with the risk of unintentional overdose if they are taking other over the counter medicaitons that might also contain acetaminophen.

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Approximately ¼ of lumbar punctures (LP) are traumatic or unsuccessful in infants.  What is the implication of this?

A retrospective cross sectional study over a 10 year period at Boston Children’s Hospital looked at infants aged 28 to 60 days who had blood cultures sent from the Emergency Department and who had LPs performed. The ED clinicians at this facility routinely follow the “Boston Criteria” to identify infants at low risk for spontaneous bacterial infection (SBI).  Traumatic LPs were defined as CSF red cell count greater than or equal to 10x10^9 cells/L while an unsuccessful LP was defined as one where no CSF was available for cell counts.  A small portion of the unsuccessful LPs did not have CSF cultures sent.

173 infants had traumatic or unsuccessful LPs.  The SBI rate did not differ between the normal LP and the traumatic and unsuccessful LP infants.  Median hospital charges were higher in the traumatic or unsuccessful LPs compared to the normal LP group ($ 5117 US dollars versus $ 2083 US dollars).

Bottom Line:  Traumatic or unsuccessful LPs lead to higher hospital charges.

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In 2011, approximately 630,00 children under 15 died from unintentional injuries. Injuries are the leading cause of childhood deaths in children over 9 years old.  Ninety-five percent of these childhood injuries occur in lower- and middle-income countries.

The 2008 World Report on Child Injury Prevention listed the following as the top five causes of pediatric injury deaths globally:

1)   Road Crashes- approximately 260,000/year

2)   Drowning- approximately 175,0000/year

3)   Burns- approximately 96,000/year

4)   Falls- approximately 47,000/year

5)   Poisoning (unintentional)- approximately 45,000/year

Many of these deaths occur around the home and could be prevented through proven prevention measures, which include:

·      Child appropriate seatbelts and helmets

·      Separate children from vehicular traffic

·      Limit hot tap water temperature

·      Placing medications and potentially harmful household products in child proof containers

·      Draining unnecessary water from baths and buckets

·      Redesigning nursery furniture, toys and playground equipment

·      Strengthening emergency medical services

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Question

You decide to do a R.U.S.H. exam on your hypotensive patient and perform an apical four-chamber view.You see one of the two clips below; are there any tricks to figure out which is the left ventricle and which is the right ventricle?

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Question

Patient presents with leg and ankle pain after a fall 3 weeks earlier. Initial ankle Xrays were negative. Patient presents today with persistent leg and ankle pain. What's the diagnosis and what other imaging would you perform and why?

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Proximal fibula fracture; have a high-clinical suspicion for a Maisonneuve fracture and consider CT scan of the ankle

Maisonneuve fracture

• Fracture of proximal third of the fibula with associated injury of the tibiofibular syndesmosis and interosseous membrane; there is typically an associated fracture of the medial malleolus or ruptured deltoid ligament.
• This patient had a normal ankle X-ray, but the proximal fibular fracture and the persistent ankle pain lead to an ankle CT scan demonstrating a non-displaced fracture at the medial aspect of the posterior malleolus, extending into the tibiotalar joint (see below). 
• The take home point is to always look for an associated ankle injury when a proximal fibular fracture is discovered and Xray above and below the fracture. If Xrays are negative but there is still high clinical suspicion consider advanced imaging such as CT scan.

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A new study from South Korea identified 3 potential clinical predictors of developing delirium tremens in patients presenting to the ED with alcohol withdrawal seizures.

1. Low platelet count
2. High blood level of homocysteine
3. Low blood level of pyridoxine

If one or more is present, these findings may help assess alcohol withdrawal patients for the risk of developing DTs.

Application to Clinical Practice

• The problem is that in the U.S., homocysteine and pyridoxine levels may not be readily available at all institutions.
• Adjunctive treatment options including vitamin B12, folate, and pyridoxine may be considered if levels are available, but it is unknown if 'treating the numbers' actually prevents development of DTs.
• At the very least, these clinical predictors may help risk assess patients for appropriate disposition.

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Prognostication in intracerebral hemorrhage - A self-fulfilling prophecy?

The ICH Score is a validated outcome prediction model for intracerebral hemorrhage (ICH) developed from clinical and neuroimaging characteristics on presentation.

While predictive models are often used in clinical care for prognostication, is it a self-fulfilling prophecy to make early decisions to limit medical treatments based on these models?

Morgenstern et al. conducted an observational study across 5 hospitals looking at 30-day mortality of patients with ICH with initial GCS <12 who received full medical care for at least 5-days following symptom onset.

• 417/972 (42.9%) of patients had GCS < 12
• 148/417 (35.5%) of patients were made DNR by family or physician before day 5
• 109/417 (26.1%) of patients were included in the study
• Overall observed 30-day mortality was 20.2%, which was 29.8% less than the ICH Score-predicted mortality
• Each increase in the ICH Score was associated with both an increase in predicted and observed 30-day mortality 

Take Home Point: The ICH Score is a useful tool for stratifying patient severity, but one should be cautious in using the model to provide specific numerical values as outcome predictions.

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• A recent meta-analysis found that non-invasive ventilation can improve survival in acute care settings.
• Consider using NIPPV in:
  • COPD exacerbation
  • Obesity hypoventilation syndrome
  • Asthma
  • Hypoxemic respiratory failure
  • Cardiogenic pulmonary edema
  • ARDS
• Make sure to reassess your patients for improvement within one hour of applying NIPPV. If gas exchange has not significantly improved then endotracheal intubation and mechanical ventilation should be considered.
• Adverse effects:
  • Gastric distension
  • Pressure ulcers on the face
  • Can be uncomfortable
• In cardiogenic pulmonary edema there are cardiac performance benefits:
  • Decreases preload
  • Decreases left ventricular afterload
  • Improved cardiac ouput

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