UMEM Educational Pearls

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?

Show Answer

Show References

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%).

Show References

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.

Show References

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.

Follow me on Twitter @JohnGreenwoodMD

Question

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

Show Answer

Show References

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.

Show References

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.

Show References

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.

Show References

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

Show References

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?

Show Answer

Show References

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?

Show Answer

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.

Show References

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.

Show References

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.

Show References

• 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

Show References

Question

25 year-old male with the acute onset of right flank pain. Ultrasound of the right flank is shown. What's the diagnosis?

Show Answer

Show References

The Heart Is Just a Muscle

- Heart failure and peripheral myopathies share similar symptoms such as exertional fatigue, weakness, and dyspnea.

- The role of endomyocardial biopsy (EMB) to aid in the diagnosis of new-onset heart failure is controversial and major society guidelines recommend against this procedure in the routine evaluation of patients with heat failure.

- Nevertheless when symptoms of heart failure persist despite conventional imaging modalities and treatment one must consider uncommon conditions, such as mitochondrial disorders. 

 - Mitochondrial disorders are characterized as clinical syndromes and patients can present with any one of the following: ophthalmoplegia, proximal muscle weakness, isolated myopathy with exercise intolerance and myalgia, severe myopathy of infancy or childhood, or multisystem involvement with myopathy.

- Myocardial tissue is highly dependent on mitochondria for energy production and is therefore susceptible to defects in mitochondrial function. Cardiac manifestations of these syndromes include both arrhythmias and cardiomyopathy. 

Show References

For many institutions, clindamycin is not as good as it used to be for methicillin-resistant Staph aureus (MRSA). When treating skin and soft tissue infections (SSTI), this can be challenging. Clindamycin still covers skin strep species very well, but not always the staph. On the other hand, trimethoprim-sulfamethoxazole (TMP-SMX) covers staph really well, but not so much the strep.

What They Did

A new double-blind, multicenter, randomized study in NEJM compared these two antibiotics in 524 patients with uncomplicated skin infections who had cellulitis, abscess larger than 5 cm, or both. All abscesses underwent incision and drainage. The primary outcome was clinical cure rate 7-10 days after the end of treatment.

What They Found

There was no difference in clinical cure rate between the two groups (80.3% for clindamycin, 77.7% for TMP-SMX).

Problems with the Study

• Uncomplicated abscess shouldn't require antibiotics.
• The dose of TMP-SMX was one DS tab equivalent, yet weights weren't reported. That dose may not be sufficient for all patients.
• Only 12% of the MRSA that grew was resistant to clindamycin, which is less than local patterns at many institutions. This limits generalizability.

Application to Clinical Practice

Unknown. This study seems to suggest TMP-SMX might be ok in uncomplicated cellulitis even though we assume strep species are the causitive organism. However, we already know cephalexin is equivalent to cephalexin + TMP-SMX from the 2013 study by Pallin et al. Why not just use cephalexin which has less adverse effects than TMP-SMX?

With such low clindamycin resistance, even to the staph species, perhaps that is why the two treatments were similar. Also, why did successfully drained abscesses need antibiotics? Finally, there were many exclusion criteria which eliminated many of the patients we see in the ED.

For a different, critical perspective of this NEJM study, Dr. Ryan Radecki gives his thoughts on his EM Lit of Note blog.

Show References

Background:

• Polio is a crippling and potentially fatal infectious disease
  • Can cause temporary or permanent acute flaccid paralysis
  • Fecal-oral or oral transmission
  • The majority of cases of polio infection are asymptomatic
  • The public/global health significance of polio has been discussed in previous UMEM Educational Pearls (See: 5/7/2014 and 12/18/2013).
• Caused by small, single-strand, positive-sense RNA virus of the genus Enterovirus

Enterovirus D68

• Recent widespread nationwide outbreak of this non-polio enterovirus
  • From mid-August 2014 to January 15, 2015, federal and state public health laboratories confirmed 1,153 people with infections
  • Usually seen in children
  • Usually causes mild to severe respiratory illness.
• Concurrent with the national outbreak of Enterovirus D68, there was a concurrent increase in children with acute flaccid myelitis

Is there a relationship between Enterovirus D68 and the outbreak of acute flaccid myelitis?

• Recent NIH funded research published in Lancet Infectious Disease analyzed the genomes of 48 patients with enterovirus infections
  • Phylogenetic analysis showed that all enterovirus D68 sequences associated with acute flaccid myelitis were part of the same clade B1 strain .
• These findings strengthen the possible relationship between enterovirus D68 and acute flaccid myelitis

Bottom Line

• Acute flaccid myelitis may rarely occur after Enterovirus D68 in susceptible hosts

Show References

Mechanical Ventilation in the ED

• Emergency physicians (EPs) intubate patients on a daily basis.  Due to prolonged lengths of stay for many of these patients, the EP must manage the ventilator during the crucial early hours of critical illness.
• Despite the marked increase in critically ill patients, emergency medicine residents receive very little training in mechanical ventilation (MV).¹
• In addition, recent literature has demonstrated some common themes regarding MV in the ED.^2,3
  • Use of higher than recommended tidal volumes
  • Infrequent use of lung protective ventilation strategies
  • Infrequent monitoring of plateau pressures
• Take Home Points
  • Pay attention to tidal volume
  • Monitor and maintain plateau pressures < 30 cm H2O

Show References

Question

35 year-old male presents with increasing difficulty swallowing and tenderness in the floor of him mouth. What's the diagnosis?

Show Answer

Show References