Question

How many abnormalities can you find below?

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Imaging plays an important role in the evaluation of child abuse.

It aids in the identification, evaluation and in treatment.

Additionally, it is often the only objective evidence of abuse available to the courts.

It is often discovered through two means.

1) Injuries/fractures that are inconsistent with the alleged mechanism of injury.

2) Pathognomonic fracture patterns are found on routine radiographs

The ED physician should not attempt to precisely "date" the injury.

That said, soft tissue swelling resolves in 2-5 days. The periosteum becomes radiodense in 7 to 10 days. In subtle fractures this may be the only radiographic finding. If there is no evidence of bone healing (periosteal reaction), the fracture is less than 2 weeks old. Callus formation and resorption of the bone along the fracture line begins at 10 to 14 days. The callus is visible for up to 3 months. Bone remodeling continues for up to one year.

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• Pediatric forearm fractures are common, and on the rise due to increasing sporting activity and increasing BMI.
• The most common mechanism is falling on an outstretched hand, which often leads to rotational displacement. 
• If not properly reduced, it leads to reduced range of motion.
• The majority do well with closed reduction, if properly reduced.
• A recent study (Debrovsky, et al. Ann of Emerg Med), found  the accuracy of bedside ultrasonography to determine when pediatric forearm fractures have been adequately realigned was comparable to fluoroscopy. 
• Consider using US for post-reduction evaluation of pediatric forearm fractures to reduce radiation exposure, cost, and time.

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In the midst of an unprecedented opioid epidemic, there have been considerable efforts to expand access to naloxone (Doyon S, et al. J Med Toxicol 2014;10:431-4). If the situation arises when you need to write a prescription for it, here's how:

Option 1: Naloxone vial and needle traditional IM/SQ using 0.4 mg/mL injection vial and needles (least expensive $40, FDA approved)

Naloxone 0.4 mg/mL single dose vial and 3 cc, 23 g, 1 inch syringes, #2 each

SIG: Inject 1 mL intramuscularly upon signs of opioid overdose. May repeat X 1. Call 911.

Option 2: IMS/Amphastar 2 mg/2 mL prefilled syringe and mucosal atomization device ($95/kit, products FDA approved but intranasal administration is off-label)

Naloxone 2 mg/2 mL prefilled syringe and intranasal atomizer device, #2 each

SIG: Spray one-half of syringe (1 mL) into each nostril upon signs of opioid overdose. May repeat X 1. Call 911.

Option 3: Evzio Autoinjector ($200-700 per Rx though many insurances cover it and the company has vouchers available, FDA approved in 2014, evzio.com/hcp)

Evzio 0.4 mg, #1 two-pack

SIG: Use as directed upon signs of opioid overdose. May repeat X 1. Call 911.

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Cauda Equina Syndrome is a true neurologic and surgical emergency. Unfortunately, no constellation of symptoms or exam findings is 100% sensitive. In fact, no single symptoms predicts the radiographic finding of cauda equina syndrome with an accuracy greater than 65%.

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Transfusion in Major Trauma: The PROPPR Trial

What should we be transfusing in major trauma?

• Should we aim towards 1:1:1 ratios or is that unnecessary? Most trauma centers have gone towards a 1:1:1 ratio or a 1:1:2 ratio with a greater percentage of RBCs transfused in the latter
• Our strategy should be to avoid coagulopathy, acidosis, and hypothermia
• This trial looks at transfusion of Plasma, Platelets, and RBCs in a 1:1:1 vs a 1:1:2 ratio
• Is it safe to give 1:1:1 ratios?

The Trial

• RCT, Non-blinded
• 12 Trauma Centers in North America
• 15 years or older; highest level trauma activation
• Predicted to receive massive transfusion
• Transfusions stopped when clinically indicated

Results

• 24 hour or 30 day mortality no significant difference
• Post-hoc analysis: death by exsanguination (9% vs 15%) in the 1^st 24hrs was significantly decreased in the 1:1:1 group
• Achieved hemostatis (86% vs 78%; p = 0.006) greater in the 1:1:1 group

Conclusions

• Was not powered to detect a difference of less than 10% in mortality
• There was less mortality from exsanguination in the 1:1:1 ratio.
• Worth noting that platelets given first in 1:1:1 group (in control group 6 U and 3 FFP given prior to platelets)
• There was some "catch up" in the 1:1:2 group (after the initial transfusions, these patients got more than expected plasma and platelets based on INR/Plt counts)
• TEG was used in the majority of the patients and TXA was used in a majority of patients (but similar in both groups)

How does this affect my practice?

A 1:1:1 transfusion practice is safe and can decrease mortality from hemorrhage in major trauma

Other points: control bleeding, permissive hypotension, avoid crystalloids, use TEG to guide therapy (TXA etc)

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Question

35 year-old female presents with acute leg pain and swelling. What's the diagnosis?

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Afib Clinical Decision Aid: AFFORD

- Atrial fibrillation (AF) affects ~34 million people worldwide; the hospital admission rates vary with frequencies of 81%, 62%, and 24% in the US, Australia, and Canada respectively.

- Lack of a reproducible and accurate risk stratification/decision aid likely contributes to variability in ED disposition.

- AFFORD (Atrial fibrillation and flutter outcome risk determination) was the 1^st clinical decision aid (contains 17 variables) to predict 30-day adverse events in a prospective ED patient cohort with acute symptomatic AF.

- Vanderbilt University Medical Center's ED (2010-2013) derived and internal validated an ED based clinical decision aid for prediction of MACE within 30 days utilizing the AFFORD decision aid in hemodynamically stable patients whose AF reverted to sinus rhythm, either spontaneously or after cardioversion (pharmacologic or electrical), and those who are adequately rate controlled and candidates for outpatient management.

- Incorporating AFFORD with a shared decision model into ED practice may help identify patients at low risk and potentially reduce rate of hospitalizations. 

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Emergency Departments are increasingly searching for alternatives to opioids for acute pain management.

An urban trauma center in California retrospectively evaluated their use of low-dose ketamine for acute pain over a two-year period. [1]

• 530 patients
• Indications were separated in 7 broad categories such as abdominal pain, back pain, and musculoskeletal pain
• Ketamine dose: 10-15 mg (93% IV, 7% IM)
• No significant changes in heart rate or blood pressure
• 30 patients (6%) experienced adverse effects (psychomimetic/dysphoric reactions, transient hypoxia, emesis) - none were classified as severe based on authors' definitions

Application to Clinical Practice

There was no comparison group and there was no mention of what other pain medicines were given. Adverse events are often under-reported in retrospective studies. This study seems to demonstrate that low-dose ketamine administration for acute pain management in the ED is feasible with a low rate of adverse effects.

It's worth noting that a new review of 4 randomized controlled trials evaluating subdissociative-dose ketamine found no convincing evidence to support or refute its use in the ED. The 4 included trials had methodologic limitations. [2]

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Background: While much of international health focuses on communicable diseases, it is clear that noncommunicable diseases (NCDs), such as cardiovascular diseases, cancer and diabetes, causes substantial morbidity and mortality.

Epidemiology:

• NCDs kill 38 million people each year
  • Approximately 28 million of these deaths occur in low- and middle-income countries.
• Of the 38 million deaths, 16 million of these deaths occur in patients <70 years of age
  • 82% of these “premature” deaths occur in low- and middle-income countries
• Causes of NCD deaths
  • Cardiovascular diseases (heart attacks and strokes): 17.5 million
  • Cancers: 8.2 million
  • Chronic respiratory diseases (COPD and asthma): 4 million
  • Diabetes: 1.5 million

Bottom line: As in developed countries, risk factors for NCDs deaths include physical in activity, tobacco use, unhealthy diabetes, harmful use of alcohol.

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High-Flow Nasal Cannula for Apneic Oxygenation

• In recent years, much has been written about the use of apneic oxygenation for patients who require endotracheal intubation (ETI).
• Critically ill patients often have little cardiopulmonary reserve and can rapidly desaturate during ETI.
• High-flow nasal cannula (HFNC) devices can deliver heated, humidified O2 up to 60 L/min and can provide a modest amount of positive pressure.
• A recent study evaluated the use of a HFNC device for apneic oxygenation in ICU patients requiring ETI:
  • Prospective, quasi-experimental, before-after study
  • 101 patients in a single ICU in France
  • Compared NRB + nasal cannula to HFNC for preoxygenation/apneic oxygenation
  • Prevelance of severe hypoxemia (SpO2 < 80%) was significantly lower in the HFNC group
• Clinical Application: Consider using HFNC for apneic oxygenation in critically ill patients with mild-to-moderate hypoxemia who require ETI.

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Question

6 day-old child is brought in by parents with 1 day of reduced oral intake and 4 hours of rapid breathing. The child has no fever and no significant birth history. The child is tachycardic, hypotensive, and hypoxic. What’s the diagnosis? 

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Safety Risk? Digoxin in Atrial Fibrillation

- Digoxin is commonly utilize for atrial fibrillation/flutter with rapid ventricular response, though beta blockers and/or calcium channel blockers are a better 1^st line therapy given digoxin’s narrow therapeutic index and lack of mortality benefit.

- Digoxin in the acute setting is often favored given its ability to reduce the heart rate while maintaining or slightly augmenting blood pressure.

- 2014 AHA/ACC guidelines recommend digoxin, specifically for rate control in patients with heart failure and/or reduced ejection fraction.

- There have been 2 post hoc studies from the AFFIRM trial which showed conflicting results w/regards to digoxin and risk of mortality.

1.     Increased risk of mortality associated w/digoxin (on-treatment analytic strategy)

2.     No association w/mortality (intent-to-treat analytic strategy)

- A recent retrospective cohort examination of newly diagnosed afib patients without heart failure & no prior use of digoxin; digoxin was independently associated with a 71% higher risk of death & a 63% higher risk of hospitalization.

- Consistent and substantial increase in mortality and hospitalization risk was seen using both on-treatment and intent-to-treat analytic methods.

- Given other available rate control options, digoxin should be used with caution.

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Sesamoid Injuries

The first MTP joint contains the 2 sesamoid bones. They play a significant part in the proper functioning of the great toe. 30% of individuals have a bipartite medial or lateral sesamoid.

http://www.coreconcepts.com.sg/mcr/wp-content/uploads/2008/05/sesamoid_foot.jpg

Injury can occur from trauma, stress fracture or sprain of the sesamoid articulation or of the sesamoid metatarsal articulation. Overuse injuries tend to occur in sports with a great deal of forefoot loading (basketball/tennis).

SXs: Pain with weight bearing, pain with movement of first MTP, ambulation on lateral part of foot.

PE: Tenderness and swelling over medial or lateral sesamoid. Resisted plantar flexion (flexor hallucis) reveals pain and weakness.

Imaging: plain film with sesamoid view to assess for a sesamoid fracture. Stress fractures may take 3-4 weeks to show on plain film.

http://www.agoodgroup.com/running/Fracture002.jpg

Treatment for fractures and suspected stress fractures involve 4 to 6 weeks of non weight bearing.

Orthopedic Causes of Chest Pain

The first thing that pops into everybody’s mind when they hear a patient state they have chest pain radiating to the left arm is Acute Coronary Syndrome and specifically a Myocardial Infarction. However, there are a lot of orthopedic causes of chest pain that can also radiate to the left arm. It is estimate that up to 20% of patients with pectoral symptoms have an underlying orthopedic problem.

Some of them are:

• Herniated Disc
• Cervicothoracic tension syndrome
• Blockage of intervertebral or rib joints
• intercostal neuralgia

Some other less common causes are

• Arthritis of the shoulder
• Spondylocystitis
• Osteoporotic fractures
• Bone tumors

So instead of just ordering some troponin and admitting to medicine, consider that the cause can be orthopedic in origin.

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Question

Patient has the following Head CT, what is your differential diagnosis? There are only a few characteristic toxins that can cause this type of finding on CT.

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Neurologic causes of cardiac arrest have not been well described.  Two recent retrospective studies looked at the epidemiology and clinical features of these patients.

Hubner P. et al.

• Over 20 years, 154 patients suffered cardiac arrest from neurologic causes.
• Diagnoses were made by CT in 123 patients (80%), autopsy in 28 patients (18%), and by history and clinical presentation in 4 patients (3%).
• PEA was the presenting rhythm in 77 patients (50%).  Whereas 61 patients (40%) presented in asystole.
• Neurologic causes included subarachnoid hemorrhage in 74 patients (48%), intracerebral hemorrhage in 33 patients (21%), seizures in 23 patients (15%), and ischemic stroke in 11 patients (7%).

Arnaout M. et al.

• Over 13 years, 86 patients suffered out-of-hospital cardiac arrest from neurologic causes (2.3%).
• PEA was the presenting rhythm in 16 patients (19%).  Whereas 66 patients (77%) presented in asystole.
• After ROSC, 64% of cases had ECGs with possible ischemic abnormalities.
• Neurologic causes included subarachnoid hemorrhage in 73 patients (85%), intracerebral hemorrage in 5 patients (6%), ischemic strokes in 5 patients (6%).

Neurologic causes of cardiac arrest are uncommon presentations that may be difficult to distinguish from cardiac etiology of cardiac arrest.  If history and clinical presentation suggests a neurologic cause, obtain a non-contrast head CT for evaluation.

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The Role of the CVP in a Post- “7 Mares” Era
 

The role for using central venous pressure (CVP) as a measure of volume responsiveness has largely fallen out of favor over the years.¹ There are certainly better indices for fluid responsiveness, but don’t be fooled – the CVP isn’t a one trick pony.  In fact, a high or rapidly rising CVP should raise a significant concern for impending cardiovascular collapse.

Consider the following differential diagnosis in the patient with an abnormally high or rising CVP ( >10 cm H₂O).

• Excessive pressures outside of the heart or impediments to venous return (juxta-cardiac pressures)
  • Cardiac tamponade
  • Auto PEEP or breath stacking during mechanical ventilation
  • Tension pneumothorax
• Venous return that’s more than the right ventricle can handle
  • RV failure
  • Severe tricuspid valve disease
  • Massive increase in pulmonary vascular resistance (massive PE, pulmonary hypertension, ARDS, LV failure)

Bottom Line: In a time where the utility of the CVP has been largely dismissed, remember that an abnormal CVP offers great deal of information beyond a simple measure of volume status.

References

1. Marik PE, Baram M, Vahid B. Does central venous pressure predict fluid responsiveness? A systematic review of the literature and the tale of seven mares. Chest. 2008;134(1):172-8.
2. Berlin DA, Bakker J. Starling curves and central venous pressure. Critical Care. 2015;19(1):55.

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Question

45 year-old male complains of pleuritic chest pain following a "long" flight. What's the diagnosis and what's this sign called?

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This study is a case control study of the association of congenital heart disease (CHD) and stroke using a base population of 2.5 million Kaiser patients in California. 412 cases of stroke were identified and compared to 1236 controls. Of these stroke patients, 11/216 ischemic strokes and 4/196 hemorrhagic strokes were attributed to CHD (both cyanotic and acyanotic lesions). CHD was found in 7/1236 controls.

Children with CHD and history of cardiac surgery had the strongest risk of stroke (31 fold over the control group). Many of these children had strokes years after their surgery. Children with CHD who did not have cardiac surgery had a trend towards elevated stroke risk, but the confidence intervals included the null. More children without CHD history presented with headache.

Bottom line: Stroke risk (both hemorrhagic and ischemic) extend past the immediate postoperative period in patients with CHD.

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