Episode 53 – Intracranial Hemorrhage

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We cover a post by Dr. Rory Spiegel, EMNerd: The Case of Differing Perspectives, on the results of the ATACH-2 trial on blood pressure control in intracranial hemorrhage (ICH). This study sought to determine the safety and efficacy of the intensive blood pressure lowering.

Population: adults (>18 y/o) with ICH on CT scan, GCS ≥ 5 and <4.5 hours since symptom onset (changed mid-study)

Intervention: Reduce and maintain the hourly minimum systolic blood pressure in the range of 110 to 139 mm Hg throughout the period of 24 hours after randomization (“intensive treatment”). Preferred agents for blood pressure control in order of preference were 1. nicardipine 2. labetalol (diltiazem or urapidil if not available)

  • Mean minimum in hours 0-2: 128.9±16 mm Hg

Control: Reduce and maintain the hourly minimum systolic blood pressure in the range of 140 to 179 mm Hg throughout the period of 24 hours after randomization.

  • Mean minimum in hours 0-2: 141.1±14.8 mm Hg

Outcome: The primary outcome was the proportion of patients who had moderately severe or severe disability (modified Rankin scale score (mRS) 4-5) or those who had died (mRS 6; hereafter referred to as “death or disability”) at 3 months.

  • death or disability: Intensive treatment = 186 participants (38.7%) vs Standard treatment = 181 (37.7%)

Bottom Line:  INTENSIVE blood pressure lowering <140mmHg is not supported by the literature. AHA and Rosens/Tintinalli recommend goal of 160-180 mmHg or diastolic <130 mmHg.

We also discuss the history of blood pressure control in ICH and the pendulum swing on this in recent years, using an episode of the Skeptic’s Guide to Emergency Medicine, Episode 73. This episode covers the Interact-2 trial.

Core Content

We delve into core content on ICH using Rosen’s (8th ed) and Tintinalli (8th ed)

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The use of platelets in patients with ICH on antiplatelet agents (aspirin, clopidogrel, etc) has been controversial and both Rosen’s and Tintinalli acknowledge that there is no good quality evidence that platelets are beneficial in this population.   The PATCH trial, recently published in the Lancet, found no benefit to platelet transfusion in patients with ICH who had taken antiplatelet agents in the 7 days prior to their ICH. See this review from Dr. Salim Rezaie of Rebel EM.

Population: patients ≥18years of age with non-traumatic ICH confirmed by CT and GCS ≥ 8 who took antiplatelet agent for at least 7 days prior (excluded thrombocytopenia/known coagulopathy)

Intervention: platelet transfusion

Control: standard care without platelet confusion

Outcome: primary outcome was the difference in functional outcome at 3 months after randomisation scored with the mRS

  • Odds of a shift towards death or dependence at 3 months: adjusted OR 2.05 (95% CI 1·18–3·56; p = 0.0114). This favors the control group.
  • Secondary outcome of survival: 68% in platelet transfusion group vs 77% in standard group (p = 0.15)

Note:  Like many stroke trials, the planned statistical analysis plan changed after the data came in. Initially authors planned a fixed dichotomous analysis (yes or no, did they have an mRS of 4-6 at 3 months). They changed this to an ordinal logistic regression analysis of the shift of all categories of the mRS at 3 months as this has greater “statistical efficiency”.

Generously Donated Rosh Review Questions

Question 1.  A patient presents with nausea, vomiting, right-sided hemiplegia and non-occipital headache. His gaze is deviated to the left, but he denies loss of sensation. Thirty minutes later, he becomes stuporous and progresses into coma. The pupils are now fixed and dilated. Abnormal posturing is absent. A brain CT scan is ordered. You would expect to find intracerebral hemorrhage in which of the following sites

A. Left pons

B. Left putamen

C. Right cerebellum

D. Right thalamus

Answer

A large putamen hemorrhage results in a rapid progression of hemiplegia, nausea, vomiting and headache over 30 minutes, which is quickly followed by ipsilateral deviation of the eyes,stupor, coma and mydriatic pupils (“blown-pupil”, associated with brainstem compression and occulomotor nerve palsy). Acute management includes controlling intracranial pressure and hypertension. Surgical removal of clots is seldom successful, however, some neurologic function may be salvaged in those without coma or those with lobar clots.

Pontine hemorrhages (A) are characterized by total paralysis, rapid coma, decerebrate rigidity (abnormal posturing marked by shoulder adduction, elbow extension, wrist pronation and flexion, digit flexion, leg extension and plantarflexion) and small (miotic), not mydriatic, reactive pupils. Cerebellar insults (C) are evidenced by vomiting, occipital headache, inability to stand, vertigo, and eye deviation to the opposite side of the lesion. In this scenario, the eye deviation makes sense, but not the presenting symptoms.Thalamic lesions (D) are marked by complete hemisensory loss. Also common is hemiparesis (bleeding extension into the internal capsule) and aphasia.

Putamen Hemorrhage: Contralateral hemiparesis/hemiplegia, Contralateral sensory loss, Homonymous hemianopia

References:

  1. Qureshi AI, Palesch YY, Barsan WG, et al. Intensive Blood-Pressure Lowering in Patients with Acute Cerebral Hemorrhage. N Engl J Med [Internet] 2016;NEJMoa1603460. Available from: http://www.nejm.org/doi/10.1056/NEJMoa1603460
  2. Anderson C, Heeley E, Huang Y, et al. Rapid Blood-Pressure Lowering in Patients with Acute Intracerebral Hemorrhage. N Engl J Med [Internet] 2013;368(25):2355–65. Available from: http://www.nejm.org/doi/abs/10.1056/NEJMoa1214609
  3. “Spontaneous Subarachnoid and Intercerebral Hemorrhage.”  Chapter 166.  Tintialli’s Emergency Medicine: A Comprehensive Review. 8th ed.
  4. “Stroke.” Chapter 101. Rosen’s Emergency Medicine. 8th ed.
  5. Baharoglu MI, Cordonnier C, Salman RA-S, et al. Platelet transfusion versus standard care after acute stroke due to spontaneous cerebral haemorrhage associated with antiplatelet therapy (PATCH): a randomised, open-label, phase 3 trial. Lancet [Internet] 2016;6736(16):1–9. Available from: http://linkinghub.elsevier.com/retrieve/pii/S0140673616303920

Just In Time – A FOAM Resource Review

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Just in time for the new interns, we review our favorite resources to use on shift.

Free Open Access Medical Education (FOAM) exists in forms that are suitable for self-study or function as resources and those that are easy to use resources to consult on shift, Just In Time (JIT) Resources.

Our Favorite Free JIT Resources

ResourceWhat It IsOther
fri-post_aliem-logoSuccinct synopsis of presentation, workup, and treatment of a cornucopia of conditions seen in EM.Available on AgileMD application for smart phones.
556e4d7ce3105bb0e4d12e92811346cfA free app for smart phones that combines resources such as ALiEM PV cards, WikEM, Pediatric EM Resources, and a Toxicology Reference for off-line reference. Also, searchable.Free but requires account set-up.
Screen-Shot-2014-03-13-at-11.38.04-PMQuick outline of classic presentations, differential diagnosis, and treatment of many disease processes.Very brief, mostly outline oriented. Wiki structure, so not always clear how evidence based information is.
imgres1 minute review of commonly performed ultrasounds in the ED including technique and diagnosis.Not comprehensive - see the Emergency Ultrasound iBook or watch the full episodes of Ultrasound Podcast for detailed tutorials.
EMRA-Students-2016-PPTWell done procedural videos from a variety of resources (NEJM, Weingart, Mellick, etc)
urlExcellent, free, online calculator for everything from imaging decision aids, to HEART score, to free water deficit.Free iOS app currently available (7/1/16), may be paid at some point.

Episode 52 – The Esophagus

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The Free Open Access Medical Education (FOAM)

We cover a Scancrit post on the Back Up Head Elevated (BUHE) intubation position.  This post details a multicenter retrospective observational study by Khandelwal et al in Anesthesia & Analgesia

FullSizeRender (4)

Population: 528 adults undergoing emergent intubation

Intervention: Head up at least 30 degrees during intubation

Control: Supine intubation

Primary Outcome: Occurrence of intubation related complication (difficult intubation: >3 attempts or prolonged intubation, hypoxemia, esophageal intubation, or pulmonary aspiration) – 22.6% in supine group vs 9.3% in the head elevated position.  Absolute difference of 13.3%

Limitations: Did not look at emergency department intubation.  More experienced intubators used the BUHE positioning, which could confound the reduction in intubation related complications [1].

BUHE or Head Elevated Laryngoscopy Position (HELP) has also been found to

  • Improve laryngeal view [2,3]
  • Prolong safe apnea time [4]

Note: in patients with possible spinal injuries, one may use reverse trendelenberg (or forego the back up head elevated position)

Core Content

We delve into core content on the esophagus using Rosen’s (8th ed) Chapter 71 and Chapter 77 in Tintinalli (8th ed)

DYSPHAGIA

Emergent conditions may include stroke (most common cause), myasthenia/botulism/or other neuromuscular problems (may also have concomitant respiratory failure). Many causes do not need emergent workup.

@FOAMpodcast
@FOAMpodcast

ESOPHAGEAL FOOD BOLUS

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Generously Donated Rosh Review Questions

An 87-year-old woman presents to the ED after her caregiver witnessed the patient having difficulty swallowing over the past 2 days. The patient is having difficulty with both solids and liquids. She requires multiple swallowing attempts and occasionally has a mild choking episode. She has no other complaints. Your exam is unremarkable. Which of the following is the most likely cause of her condition?

A. Achalasia

B. Cerebrovascular accident

C. Esophageal neoplasm

D. Foreign body

Answer

B. Cerebrovascular accident.  Dysphagia can be divided into two categories: transfer and transport. Transfer dysphagia occurs early in swallowing and is often described by the patient as difficulty with initiation of swallowing. Transport dysphagia occurs due to impaired movement of the bolus down the esophagus and through the lower sphincter. This patient is experiencing a transfer dysphagia. This condition is most commonly due to neuromuscular disorders that result in misdirection of the food bolus and requires repeated swallowing attempts. A cerebrovascular accident (stroke)that causes muscle weakness of the oropharyngeal muscles is frequently the underlying cause. Achalasia (A) is the most common motility disorder producing dysphagia. It is typically seen in patients between 20 and 40 years of age and is associated with esophageal spasm, chest pain, and odynophagia. Esophageal neoplasm (C) usually leads to dysphagia over a period of months and progresses from symptoms with solids to liquids. It is also associated with weight loss and bleeding. Foreign bodies (D) such as a food bolus can lead to dysphagia, but patients are typically unable to tolerate secretions and are often observed drooling. These patients do not have difficulty in initiating swallowing.

A 33-year-old man presents with dysphagia to both solids and liquids, with solids being worse than liquids. He describes a sensation of the food getting stuck in his chest. Occasionally, he needs to raise his arms above his head to help food pass into his stomach. His primary care doctor has been treating him for GERD over the previous six months, but his symptoms are getting worse. Which of the following is the most likely diagnosis?

A. Achalasia

B. Diffuse esophageal spasm

C. Schatzki ring

D. Zenker’s diverticulum

Answer

Achalasia This patient most likely has achalasia, which is an esophageal dysmotility disorder due to failure of the lower esophageal sphincter to relax. Dysphagia is the most common symptom. While all patients have dysphagia to solids, only two-thirds have liquid dysphagia. By standing after eating, straightening one’s back, or raising the arms above the head, the esophageal pressure increases, which can help emptying into the stomach. Symptoms usually begin with mild dysphagia in patients who are 20 to 40 years old; symptoms are usually progressive. Diffuse esophageal spasm (B) is a hypermotility disorder causing strong, uncoordinated peristaltic contractions that do not propel food effectively to the stomach. Dysphagia, regurgitation of food, and chest pain are commonly present. The dysphagia is intermittent and does not progress over time. A Schatzki ring (C) is a fibrous band-like structure in the distal esophagus that is the most common cause of dysphagia with solids. Patients typically do not experience difficulty with liquids. Zenker’s diverticulum (D) is an acquired disease that is due to an out-pouching in the mucosa of the pharynx. It typically occurs in individuals older than 50 years and can cause regurgitation, cough, and halitosis from food that becomes stuck in the diverticulum.

What are three common treatments for achalasia?

Nitroglycerin to reduce lower esophageal sphincter tone, endoscopic injection of botulinum toxin into the muscle of the sphincter, and surgical myotomy.  Diffuse esophageal spasm (B) is a hypermotility disorder causing strong, uncoordinated peristaltic contractions that do not propel food effectively to the stomach. Dysphagia, regurgitation of food, and chest pain are commonly present. The dysphagia is intermittent and does not progress over time. A Schatzki ring (C) is a fibrous band-like structure in the distal esophagus that is the most common cause of dysphagia with solids. Patients typically do not experience difficulty with liquids. Zenker’s diverticulum (D) is an acquired disease that is due to an out-pouching in the mucosa of the pharynx. It typically occurs in individuals older than 50 years and can cause regurgitation, cough, and halitosis from food that becomes stuck in the diverticulum.

References

  1. Khandelwal et al. Head-elevated Patient Positioning Decreases Complications of Emergent Tracheal Intubation in the Ward and Intensive Care Unit. Anesthesia and Analgesia. Apr 2016.
  2. Lee et al. Laryngeal exposure during laryngoscopy is better in the 25 degree back-up position than in the supine position. British Journal of Anaesthesia. July 2007.
  3. Levitan RM, Mechem CC, Ochroch EA, Shofer FS, Hollander JE. Head-elevated laryngoscopy position: improving laryngeal exposure during laryngoscopy by increasing head elevation. Annals of emergency medicine. 41(3):322-30. 2003.
  4. Ramkumar V, Umesh G, Philip FA. Preoxygenation with 20º head-up tilt provides longer duration of non-hypoxic apnea than conventional preoxygenation in non-obese healthy adults. Journal of anesthesia. 25(2):189-94. 2011. [pubmed]
  5. Bodkin RP, Weant KA, Baker Justice S, Spencer MT, Acquisto NM. Effectiveness of glucagon in relieving esophageal foreign body impaction: a multicenter study. The American Journal of Emergency Medicine. 34(6):1049-1052. 2016.
  6. Weant KA, Weant MP. Safety and efficacy of glucagon for the relief of acute esophageal food impaction. American journal of health-system pharmacy : AJHP : official journal of the American Society of Health-System Pharmacists. 69(7):573-7. 2012
  7. ASGE Standards of Practice Committee, Ikenberry SO, Jue TL, Anderson MA, Appalaneni V, Banerjee S, Ben-Menachem T, Decker GA, Fanelli RD, Fisher LR, Fukami N, Harrison ME, et al. Management of ingested foreign bodies and food impactions. Gastrointest Endosc. 2011 Jun;73(6):1085-91

FOAMcastini – The Aorta and No Analgesia Will #!&?% You Up

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We cover pearls from smaccDUB (Social Media and Critical Care Conference in Dublin, Ireland), Day 3. We are here thanks to the Rosh Review.

Dr. Scott Weingart – “Post-Intubation Sedation

  • Analgesia first. Try a hydromorphone 1mg push while you’re waiting for the fentanyl drip. The endotracheal tube is uncomfortable.
  • Minimize sedation. There’s this principle: eCASH: early Comfort using Analgesia, minimal Sedatives and maximal Humane care [1]. 
  • Sedation: go for dexmedetomidine if you have it (but it’s expensive) or propofol. This is supported by the Society of Critical Care Medicine (SCCM) Pain, Agitation, and Delirium guidelines [2].
  • Be careful with rocuronium.  The long duration of rocuronium means that you can’t assess for pain or discomfort so you must be responsible and get these

Dr. David Carr – “The Aorta Will #!&?% You Up”

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Dr. Kathleen Thomas – “Oh Sh**! They’re bombing the hospital!”

We should not need a website entitled STOPBOMBINGHOSPITALS.ORG but, unfortunately, over the past 4 years, 400 hospitals have been bombed. This passionate, wrenching talk is a “must see” and “must listen” when the free talks are released on the SMACC podcast over the course of the next year.

References

  1. Vincent J, Shehabi Y, Walsh TS et al. Comfort and patient-centred care without excessive sedation: the eCASH concept. Intensive Care Med. 42(6):962-971. 2016. [article]
  2. Barr J, Fraser GL, Puntillo K et al. Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the Intensive Care Unit. Critical Care Medicine. 41(1):263-306. 2013. [article]
  3. Watt JM, Amini A, Traylor BR, Amini R, Sakles JC, Patanwala AE. Effect of paralytic type on time to post-intubation sedative use in the emergency department. Emergency medicine journal : EMJ. 30(11):893-5. 2013. [pubmed]
  4. Imamura H, Sekiguchi Y, Iwashita T et al. Painless Acute Aortic Dissection. Circ J. 75(1):59-66. 2011. [article]
  5. Diercks DB, et al. Clinical policy: critical issues in the evaluation and management of adult patients with suspected acute nontraumatic thoracic aortic dissection. Ann Emerg Med. 2015 Jan;65(1):32-42.e12. PMID: 25529153.
  6. Hagan PG, Nienaber CA, Isselbacher EM. The International Registry of Acute Aortic Dissection (IRAD): new insights into an old disease. JAMA. 283(7):897-903. 2000. [pubmed]

FOAMcastini – Undifferentiated Agitation and Cured Pork

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We cover pearls from smaccDUB (Social Media and Critical Care Conference in Dublin, Ireland), Day 2. We are here thanks to the Rosh Review.

Dr. Reuben Strayer (@emupdates) – “Disruption, Danger, and Droperidol: Emergency Management of the Agitated Patient”  

Dr. Strayer presented a brilliant talk on dealing with the quintessential Emergency Medicine patient – the undifferentiated acutely agitated patient. These patients are high risk and require emergent stabilization and resuscitation.  

Dr. Reuben Strayer's (@emupdates) algorithm for agitation in the ED
Dr. Reuben Strayer’s (@emupdates) algorithm for agitation in the ED
  • Oh, and, droperidol is not dangerous [1]. See this post on the controversial black box warning.

Dr. Haney Mallemat – “The PEA Paradox”

  • The typical way we think about PEA, the “H’s and T’s,” is overly complicated. Further, we are horrendous at pulse palpation (see this for more) [2,3], and so what we think is PEA may not actually be PEA.  Dr. Mallemat proposed something along the lines of the following the following.

Screen Shot 2016-06-15 at 6.43.52 PM

  • For some FOAM commentary on the limitations of this approach, see this post by Dr. Rory Spiegel [4].

Dr. Michele Dominico – “How Usual Resuscitative Maneuvers Can Kill Paediatric Cardiac Patients”

Interventions we jump to in sick patients – oxygenation, ventilation, vasopressors – these can kill pediatric patients with cardiac pathology. She gave examples of some high yield pearls in these already terrifying patients.

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EM Literature update by Drs. Ashley Shreves and Ryan Radecki

 Ridiculous Research Pearls from Drs. Ashley Shreves and Ryan Radecki

  • Perception of dyspnea and pulmonary function tests change with stress – and rollercoaster rides.  Rietveld S, van Beest I. Rollercoaster asthma: when positive emotional stress interferes with dyspnea perception. Behaviour research and therapy. 45(5):977-87. 2007. [pubmed]
  • Cured pork for epistaxis? Possibly. Researchers will try everything, especially if it involves bacon. Humphreys I, Saraiya S, Belenky W, Dworkin J. Nasal packing with strips of cured pork as treatment for uncontrollable epistaxis in a patient with Glanzmann thrombasthenia. The Annals of otology, rhinology, and laryngology. 120(11):732-6. 2011. [pubmed]

References:

  1. Calver L, Page CB, Downes MA et al. The Safety and Effectiveness of Droperidol for Sedation of Acute Behavioral Disturbance in the Emergency Department. Annals of Emergency Medicine. 66(3):230-238.e1. 2015. [article]
  2. Tibballs J, Weeranatna C. The influence of time on the accuracy of healthcare personnel to diagnose paediatric cardiac arrest by pulse palpation. Resuscitation. 81(6):671-5. 2010. [pubmed]
  3. Eberle B, Dick WF, Schneider T, Wisser G, Doetsch S, Tzanova I. Checking the carotid pulse check: diagnostic accuracy of first responders in patients with and without a pulse. Resuscitation. 33(2):107-16. 1996. [pubmed]
  4. Bergum D, Skjeflo GW, Nordseth T. ECG patterns in early pulseless electrical activity-Associations with aetiology and survival of in-hospital cardiac arrest. Resuscitation. 104:34-9. 2016.

Foamcastini – Do We Make Saves?

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We are at SMACC in Dublin – thanks to the Rosh Review, an excellent board review question bank.

Do We Make Saves?

Dr. Mervyn Singer “Is Survival Predetermined in the Critically  Ill?”

  • Many critical care studies are negative, but in some cases this may be because critically ill patients don’t have a uniform prognosis.
  • Dr. Singer argues that some people may be “destined to die” and some may be “destined to live.”  Interventions may be harmful or futile in one group but beneficial in the other.  For example, Dr. Singer references the CORTICUS trial of steroids in septic shock [1]. This was a negative trial.  Dr. Singer asserts that some evidence (of not great quality), purports that the sickest patients could benefit from steroids, while this same intervention could be deleterious in the healthier ones.
  • Problem: many of the studies that go back and re-analyze these groups looking at the sickest or least sick patients? They perform subgroup analyses, a form of data dredging that must be taken with a huge grain of salt.

Favorite Pearls

Dr. Suzanne Mason – “Acute Care of the Elderly”

  • Hospital admission may not benefit geriatric patients – interdisciplinary interventions involving nurses, consultants, pharmacists, physical therapy may be best.
  • If there is a single, free intervention that providers can do it’s assessing for polypharmacy. Polypharmacy in the elderly is a huge problem.  Check the patient’s medication list and beware adding new medications that may not be absolutely necessary.

Dr. Victoria Brazil – “So You Think You’re a Resuscitationist?”

  • The Dunning-Kruger effect is real in medicine and this is why we MUST have and provide feedback.  A review of the Dunning-Kruger effect can be found here.  Essentially, people tend to overestimate what they know (i.e. overly confident in their knowledge). The exception?  Masters tend to underestimate their knowledge.

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  • Our perception of reality is very skewed so, again, feedback is crucial. For example, Cemalovic and colleagues found that intubators underestimated the time they took to intubate: they estimated 23.5 seconds on average vs the 45.5 seconds intubation actually took. Additionally, they thought 13% of their patients desaturated during intubation but 23% actually desaturated [2].

Also, there was an excellent tribute to the late Dr. John Hinds, a reminder that by living profoundly, you can impact people across the world.

References

  1. Sprung CL, Annane D, Keh D et al. Hydrocortisone Therapy for Patients with Septic Shock. N Engl J Med. 358(2):111-124. 2008. [article]
  2. Cemalovic N, Scoccimarro A, Arslan A, Fraser R, Kanter M, Caputo N. Human factors in the emergency department: Is physician perception of time to intubation and desaturation rate accurate? Emergency medicine Australasia : EMA. 28(3):295-9. 2016. [pubmed]

Episode 51 – Ocular Trauma

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The Free Open Access Medical Education (FOAM)

We cover this short video from EMRAP on lateral canthotomies.  This is one of those rare procedures that is vision saving; hence, it is worthy of frequent review.

Lateral Canthotomy and Cantholysis

Indication:  Suspect orbital compartment syndrome -afferent pupillary defect (APD), “tense eye” with taught lids, and high intraocular pressure (IOP) ≥ 40 mmHg. The APD is really a critical feature, as it is your indicator that there is optic nerve compromise from the intraorbital pressure

Clinical presentation:  History of orbital trauma, often in the setting of orbital fractures with decreased visual acuity, proptosis, chemosis

Procedure: Call ophthalmology.

  • Analgesia – inject lidocaine with epinephrine into the area of the lateral canthus
  • Devascularize – use straight kelly clamps to crush the lateral canthus for 1-2 minutes
  • Incise – Use scissors to cut the lateral canthus 1-2 cm. Then,  find the inferior crus of the lateral canthus ligament (looks kind of like a wishbone from a turkey but you rarely are going to be able to see the tendon so you’re “strumming” it with the closed tips of your scissors inferomedially toward the nose) – cut the inferior crus of the ligament to release pressure (this is the key step).

Core Content

We delve into core content on eye trauma using Rosen’s (8th edition) Chapter 71 and Chapter 241 in Tintinalli (8th edition)

Orbital Fractures

Orbital Fractures

Note: entrapment is a clinical diagnosis.  A CT cannot comment on function, only structure.  Extraocular movements are a critical part of the fracture exam.

Pearl: young people are prone to “greenstick” fractures where the floor can actually pinch the muscle and trigger the oculocardiac reflex, which can be deadly.  They often have a “white eye” without too much impressive on exam but refuse to look in a certain direction due to nausea.

Hyphema

(and things confused with hyphema)

Hyphema

Burns

Ocular Burns

Pearl: An important thing to keep in mind is that a “white” eye after such an exposure is actually an ominous sign, as it implies ischemia of the limbal blood vessels, which portends a pretty bad prognosis.  People usually think that the more red an eye, the worse when, in truth, it’s often the other way around.

Generously Donated Rosh Review Questions

A 43-year-old construction worker presents with right eye pain. He states he was using a nail gun when he felt something hit his eye. Visual examination reveals a small nail penetrating the globe. What management should be pursued?

A. CT scan of the orbit and ophthalmology consultation

B. Measure intraocular pressure and consult ophthalmology

C. Perform lateral canthotomy and consult ophthalmology

D. Remove the foreign body, start topical antibiotics and send to ophthalmology for follow up

Answer

This patient presents with a globe injury and should have a protective shield placed, intravenous antibiotics started, CT scan of the orbit performed and ophthalmology consulted emergently. Foreign body penetration of the globe is often associated with hammering, drilling, mechanical grinding or sanding. Any patient who presents with a foreign body sensation after one of these activities should increase suspicion for a penetrating injury of the globe. CT scan, MRI and ultrasound can all be used for diagnosis but MRI should be avoided if the suspected foreign body is metal containing. Many of these patients will require operative management and should be kept NPO. A protective shield should be placed to protect the eye but patching should be avoided as it may increase pressure on the eye. Emergent ophthalmologic consultation should be obtained

A 23-year-old man presents after a fight. His eye is seen below. Physical examination reveals intact extraocular movements, normal fluorescein staining, normal intraocular pressure, and normal visual acuity.

content_image-_medial_lower_lid_laceration

What management is indicated?

A. Delayed closure

B.  Laceration repair by the Emergency Physician

C. Ophthalmology consultation for repair

D. Tissue adhesive for repair

Answer

C. Ophthalmology consultation for repair. This patient presents with a complex eyelid laceration possibly involving the canalicular system and should have a consultation with either ophthalmology or plastic surgery regarding repair. It is important to search for a penetrating globe injury in any patient with an eyelid laceration because of the proximity of structures. Simple horizontal and partial thickness lid lacerations can be repaired primarily by an Emergency Physician. However, more complicated lacerations should be considered for specialist repair because of the high likelihood of cosmetic or functional complications, or both. In general, lacerations through the orbital septum, lacerations with tissue loss, lacerations involving the lid margins, lacerations involving the levator or canthal tendons and those involving the canalicular system should be repaired by a skilled ophthalmologist or plastic surgeon. Injury to the canalicular system should be suspected in any laceration involving the medial lower eyelid. Tissue adhesive (D) is contraindicated this close to the eye and should not be used in an injury that requires precision alignment of tissue. Delayed closure (A) will likely lead to worse cosmetic outcomes. Primary repair by the Emergency Physician (B) is not recommended if the canalicular system may be involved.

 

Thanks to our peer reviewer, Michael Westafer, MD – Ophthalmologist and Glaucoma Fellow at Mayo Clinic

References

  1. “Eye Emergencies.”  Chapter 241.  Tintinalli’s Emergency Medicine: A Comprehensive Review. 8th edition.  
  2. Sharma R and Brunette D.  “Ophthalmology.”  Chapter 71.  Rosen’s Emergency Medicine.  8th edition, 909-930.

Episode 50 – Seizures

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The Free Open Access Medical Education (FOAM)

We cover Special Seizures from EMin5.com by Dr. Anna Pickens.  This is a short video summarizing important diagnoses to consider when a seizure doesn’t stop after the first or second round of benzodiazepines.

Female

Consider eclampsia, which typically occurs >20 weeks gestation to 6 weeks post-partum.  Magnesium 4-6 grams IV, followed by infusion. Watch for apnea, check reflexes. 

 

Possible history of alcohol abuse

Consider alcohol withdrawal seizure. These patients respond to benzodiazepines and will typically NOT respond to antiepileptics such as phenytoin. They just need larger doses of benzodiazepines, so ramp up the dosages of those (10-100 mg of diazepam) and may require phenobarbital or propofol. 

 

Possible isoniazid exposure

Isoniazid toxicity can cause seizures, coma, metabolic acidosis, often within only 30 minutes of ingestion. The treatment here is pyridoxine (vitamin B6). These patients will need large doses and many recommend empirically giving 5 GRAMS intravenously (note: this is takes many vials as the typical dose of this medication is 50-100 MILLIGRAMS). This is a great review by First10inEM 

 

Consider hyponatremia

Treat with 100 mL of 3% hypertonic saline over 10-15 minutes. Can repeat x 1.  Beware of rapidly correcting sodium in these patients due to central pontine myelinolysis/osmotic demyelination syndrome. 

Core Content

We delve into core content on seizures using Rosen’s (8th edition) Chapter 18 and Chapter 171 in Tintinalli (8th edition)

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Febrile Seizures AAP Guidelines

Febrile Seizures

Generously Donated Rosh Review Questions

A fifteen-year-old girl presents for evaluation and clearance for sports play. She has played team sports in the past, and would like to join the swim team this year. She was recently diagnosed with a seizure disorder. Her seizures are usually in the mornings, are generalized tonic-clonic seizures, and last for 1-2 minutes. They occur once per week. She is currently taking topiramate for seizure control. Her physical exam and vital signs are reassuring. Which of the following is the best recommendation for this patient?A. Allow participation in swimming as this is not a contact sport
B. Deny participation in all sports until seizures are better controlled
C. Permit patient to join the swim team as long as she has rectal diazepam with her at all times
D. Refuse participation in swimming as seizures are poorly controlled

Answer

D.  Refuse participation in swimming as seizures are poorly controlled.  Swimming (A) is a danger to children with poorly controlled seizures, as there is a risk that the child will have a seizure during the exercise and could suffer near-drowning or death. Some sporting events are safe for children with epilepsy (B), such as running. While the child participating in non-contact and non-aquatic sports may still have a seizure, the risk of morbidity and mortality to the child and other participants is low. Rectal diazepam (C) is a pharmacologic therapy that can stop seizures once they begin; however, the risk for morbidity and mortality remains high for children with poorly controlled seizures. 

A full-term 3-week-old girl is brought in by her parents who report that she has been “acting funny” for 2 hours. They noticed that she has been moving her lips nonstop. She was a full-term, normal, spontaneous vaginal delivery and has been feeding well with adequate wet diapers since hospital discharge. She is afebrile and vital signs are normal. The anterior fontanelle is flat, and red reflexes are present. Heart, lung, and abdominal exams are normal. Her neurologic exam is positive for root, suck, and Moro reflexes, upgoing Babinski reflexes, and rhythmic lip-smacking movements. What is the most appropriate next step to take with this baby?
A. Administer a benzodiazepine
B. Initiate EEG monitoring
C. Perform a CT scan of the brain
D. Provide reassurance that this is normal behavior

Answer

This baby is having neonatal seizures, which are often subtle and more likely to be focal than tonic clonic. The most common manifestations are lip smacking, eye deviation, staring, rhythmic blinking, and bicycling movements. The patient should receive a benzodiazepine, such as lorazepam, midazolam, or diazepam, to stop the seizure. This should be followed by a workup that is directed at finding the underlying cause because neonatal seizures are less likely to be idiopathic than seizures in older children. A full septic workup is mandated for neonates with seizures, whether or not they are febrile. This includes CBC, blood culture, chemistry, UA, urine culture, chest x-ray, and CSF analysis. The infant should receive antibiotics and acyclovir and should be admitted to the hospital for further evaluation. Trauma can also cause neonatal seizures. It is important to look for signs of trauma such as bruising, bulging fontanelles, and retinal hemorrhages; the history may also include poor feeding, lethargy, or vomiting. Any infant with suspected head trauma should have a CT scan (C) and undergo a full child-abuse workup. An EEG (B) can be considered after more life-threatening causes of seizures, such as infection or trauma, are ruled out. A newborn (< 1 month old) with abnormal behavior should never be sent home with parental reassurance (D) only. Many new parents mistake normal behaviors for abnormal ones, but any truly abnormal behavior needs further investigation.

 

References:

Kornegay JG.  Chapter 171: Seizures Tintinalli’s Emergency Medicine: A Comprehensive Review (8e).

McMullan JT, Davitt AM, Pollack CV.  “Seizures.” Rosen’s Emergency Medicine, Chapter 18, 156-161.e1

 

 

Episode 49 – The AAP BRUE (formerly ALTE) Guidelines

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The Free Open Access Medical Education (FOAM)

We review the American Academy of Pediatrics guideline on Brief Resolved Unexplained Events (Formerly Apparent Life-Threatening Events) and Evaluation of Lower-Risk Infants.

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Note: Some have voiced concerns that these guidelines potentially downplay the event. The concern is that the yield of these workups and admissions may be low, but possibly worthwhile.  At FOAMcast, we are not qualified to critique these guidelines but there are helpful tables and charts in them to realize that these recommendations really are only for specific events and children AFTER thorough history and physical.

Generously Donated Rosh Review Question

A 6-week-old boy is brought to the emergency room because of cyanosis. He was sleeping comfortably in a supine position right after a feeding when he suddenly choked, became limp and lips turned blue. The mother witnessed the event and blew to the face of the boy. The whole episode lasted for about two minutes. EMS was called and upon arrival at the house, the boy was back to his usual self. At the ER, he boy has normal vital signs with normal physical examination findings.

A. Admit for cardiorespiratory monitoring

B. Discharge after reassuring the parents

C. Observe for four hours in the ER

D. Request for complete blood count

Answer

A. Admit for cardiorespiratory monitoring. The boy in the vignette had an apparent life-threatening event (ALTE) which is not a specific diagnosis but a description of an acute, unexpected episode that is frightening to the caretaker. ALTE includes one or more of the following features: apnea, color change (may be cyanotic, pallid, erythematous or plethoric), marked change in muscle tone (limpness or rigidity) and choking or gagging. A specific cause for ALTE can be identified in over one-half of patients after a careful history, physical examination, and appropriate laboratory evaluation. The remaining cases are considered idiopathic if no cause can be identified after a thorough assessment. Common etiologies for ALTE include gastroesophageal reflux, neurologic problems (such as seizures), and respiratory infection. The history of an ALTE must be taken seriously, even if the infant appears entirely well by the time he or she is evaluated. In-hospital observation with cardiorespiratory monitoring is indicated for infants whose initial evaluation suggests physiologic compromise. Hospital admission may provide important clinical information where additional episodes may be witnessed by medical personnel during the observation period. In addition, serious underlying medical conditions may become apparent.  Discharging the patient after reassuring the parents (B) and observing the patient for four hours in the ER (C) are not appropriate management strategies for the infant in the vignette who needs admission for cardiorespiratory monitoring. Requesting for complete blood count (D) is not routinely done in the evaluation of an ALTE and would not aid in the management for the infant in the vignette.

References:

Tieder JS, Bonkowsky JL, Etzel RA, Franklin WH, Gremse DA, Herman B et al. Subcommittee on Apparent Life Threatening Events. Brief Resolved Unexplained Events (Formerly Apparent Life-Threatening Events) and Evaluation of Lower-Risk Infants: Executive Summary.  Pediatrics. In Press

Episode 48 – Urine Drug Screen, Cocaine, and PCP

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The Free Open Access Medical Education (FOAM)

We review a post by Dr. Seth Trueger (@MDaware) on false positives of common medications in the urine drug screen.  We delve into posts by Dr. Bryan Hayes (@PharmERToxGuy) on false negatives for benzodiazepines and opioids in the urine drug screen.

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Core Content

We delve into core content on cocaine and phencyclidine (PCP) using Rosen’s (8th edition), Chapter 154 and Tintinalli (8th edition)

Cocaine

Cocaine
Cocaine

Note: Beta-blockers are contra-indicated in cocaine induced hypertension and chest pain.  Much of the ischemia induced by cocaine is thought to be due to vasospasm, predominantly from alpha-1 receptor effects.  Beta-blockers block the relaxation provided by beta-2 stimulus on muscles, leaving alpha-1 constricting vessels, “unopposed.”  This is largely theoretical/based on canine literature as there are only two human studies on this, (a) 10 humans given propranolol + cocaine with vasospasm and (b) 9 humans given labetalol + cocaine without vasospasm [4,5]. However, recent papers attempting to dispel this teaching don’t quite prove the point. One retrospective chart review looked at cocaine positive urine screens in patients with chest pain and found no worsened troponins. Cocaine stays positive in the urine for 3 days so it is not clear that these were patients presenting with cocaine associated chest pain [6].

Generously Donated Rosh Review Questions

  1. An 18-year-old man is brought to the ED by the police after being found running around a parking lot, screaming at bystanders. He reportedly smoked phencyclidine (PCP) earlier that day. His vital signs are notable for a heart rate of 130 beats per minute and a blood pressure of 150/86 mm Hg. On physical exam, he is diaphoretic, with vertical nystagmus and equal pupils and appears acutely agitated.

A. Administer haloperidol for acute agitation

B. Administer IV fluids for presumed rhabdomyolysis and benzodiazepines for agitation

C. Apply physical restraints; this is adequate treatment for most cases

D. Monitor for traumatic injuries; they are the most common cause of morbidity and mortality with PCP use

E. Urinary acidification to increase PCP elimination

Answer

The most common cause of morbidity and mortality in patients with phencyclidine (PCP) intoxication is rhabdomyolysis. Fluid hydration with normal saline is the initial therapy for rhabdomyolysis. Creatinine kinase (CK) should be obtained in patients with PCP intoxication. If abnormal, serial levels should be obtained until a downward trend is noted. Serum creatinine should also be monitored for evidence of renal insufficiency. PCP is a dissociative anesthetic drug that works on the NMDA glutamate receptor. People who abuse PCP can have sensations of euphoria initially, but this can be followed by an emergence reaction that is characterized by dysphoria and psychosis. If initial calming measures such as placing the patient in a calm environment fail and chemical restraints are needed, benzodiazepines are the treatment of choice. Benzodiazepines are also the preferred medication for acute agitation. Haloperidol (A) may cause dysrhythmias and hypotension. It also lowers the seizure threshold and may precipitate PCP-induced movement disorders. PCP is a weak base and its excretion is increased in acidic urine. Physical restraints (C) may be required for patients with PCP intoxication, but they should be used in conjunction with chemical restraints (preferably benzodiazepines). An agitated patient fighting against physical restraints is at risk for worsening rhabdomyolysis, which, if unrecognized, can precipitate cardiac arrest. Traumatic injuries (D)frequently occur in PCP-intoxicated patients; however, rhabdomyolysis with subsequent renal insufficiency is the most common cause of associated morbidity and mortality. Patients with PCP intoxication should be evaluated for suspected trauma, and any injuries should be stabilized and treated. Acidification of the urine (E) can cause a metabolic acidosis, which is potentially harmful and has not demonstrated improved outcomes. For these reasons, urinary acidification is not routinely recommended.

2. A 39-year-old woman presents with chest pain and difficulty breathing that began shortly after smoking crack cocaine. Vital signs are BP 190/85 mm Hg, HR 105, RR 18, T 99.1℉. The ECG demonstrates ST segment depression and T wave inversions in the lateral leads.

A. Diazepam

B. Metoprolol

C. Morphine

D. Phenylephrine

Answer

Diazepam, a benzodiazepine, should be administered to this patient who is hyperadrenergic from cocaine intoxication. Signs and symptoms of cocaine intoxication include, dilated pupils, diaphoresis, tachycardia, hypertension and hyperthermia. Many patients experience euphoria, though some will develop acute psychosis. Benzodiazepines decrease the cocaine-induced hyperadrenergic state. Reduction of sympathetic tone induces coronary and peripheral vasodilation. Coronary artery dilation directly improves myocardial blood flow. Peripheral vasodilation reduces preload and afterload. Reductions in preload and afterload decrease blood pressure and improve myocardial oxygen demand. Several factors, including, excess sympathetic stimulation, dehydration, hyperthermia, and cocaine-induced cardiac sodium channel blockade, may cause patients with cocaine intoxication to develop dysrhythmias. These contributing factors should be treated with benzodiazepines, IV fluid resuscitation and temperature management. In some patients, cocaine-induced cardiac sodium channel blockade may cause wide complex tachycardia that should be treated with sodium bicarbonate. Hyperthermia should be managed aggressively with a target temperature of less than or equal to 102.0℉. Severe agitation, aggression or psychosis should be initially managed with benzodiazepines. Most antipsychotic agents have pronounced anticholinergic side effects. This may worsen dysrhythmias.and decrease sweating, further complicating temperature management

  1. Rao R, Hoffman RS.  Cocaine and other Sympathomimetics. Rosen’s Emergency Medicine (8e). Chapter 154, 1999-2006.e2
  2. “Cocaine and Amphetamines.” Tintinalli’s Emergency Medicine: A Comprehensive Study Guide (8e). Chapter 187
  3. “Prison Medicine.” Tintinalli’s Emergency Medicine: A Comprehensive Study Guide (8e). Chapter 301
  4. Lange RA, Cigarroa RG, Flores ED, et al. Potentiation of cocaine, induced coronary vasoconstriction by beta adrenergic blockade. Ann Intern Med. 1990;112:897–90
  5. Boehrer JD, Moliterno DJ, Willard JE, Hillis LD, Lange RA. Influence of labetalol on cocaine-induced coronary vasoconstriction in humans. Am J Med. 1993;94(6):608–610
  6. Ibrahim M, Maselli DJ, Hasan R, Hamilton A. Safety of β-blockers in the acute management of cocaine-associated chest pain. The American Journal of Emergency Medicine. 31(3):613-616.