(there’s too much to choose from, so follow #ACEP14)
Debating Clinical Policies: Implications for tPA and Beyond – Drs. David Newman, David Seaberg, and Edward Sloan
The ACEP clinical policy on TPA is hotly debated, as it gives Level A evidence to TPA in acute ischemic stroke. This policy is being reconsidered and big props to ACEP for doing this, most professional organizations aren’t that responsive.
TPA has a NNT of 8 and a NNH of 16. The TPA supporters typically reference NINDS, ignoring the other RCTs. They also reference large sets of registry data.
Evidence-Based Approach to the “Other” Stroke – Dr. Jon Edlow
Prothrombin complex concentrate (PCCs) are all the rage, particularly since the 4 factor PCC was approved last year in the United States. It improves patients numbers of coagulopathy, but not necessarily patient outcomes (Dr. Rory Spiegel on the topic).
Fresh frozen plasma, dosing is based on INR and the patient’s weight, it’s not an empiric “2 units.”
Blood pressure control may be safe in Intracerebral hemorrhage, but the studies such as INTERACT don’t show that it benefits patients (The SGEM).
Chest Pain in the ED: Is One Troponin Enough? – Dr. David Newman
The miss rate for MI is often quoted as 2%, but it’s more like 0.2% per the Pope et al study. So, we’re pretty good at this.
ACEP has a policy stating that a single troponin after 8 hours of chest pain is sufficient
States that have tort reform have shown fewer lawsuits and less money without compromising patient outcomes.
Clinical Pearls From the Recent Medical Literature – Drs. Jerome Hoffman and Richard Bukata (#hofkata)
Topical analgesia for corneal abrasions – the FOAM world has been buzzing with the notion of using tetracaine for corneal abrasions (Rebel EM, The SGEM). Hofkata reviewed this paper by Waldman et al that showed no difference in visual analog scores for normal saline compared with tetracaine for corneal abrasions. Tetracaine was perceived more effective so there may be a role for dilute proparacaine but we’ll need some more studies.
REBOA and ECMO are exciting and coming…but most of us don’t have them. Watch the literature.
“Normal” vital signs shouldn’t reassure us in trauma. Don’t wait for patients to become hypotensive (this is a danger of euboxia)
The Shock Index (Heart Rate/Systolic Blood Pressure) is one way to help detect badness amongst “normal” vital signs in these patients (See this post)
ACLS algorithms, they’re helpful for people who don’t specialize in resuscitation. Think about the individual patient and target interventions accordingly. Oh, and do good CPR.
The AHA supports this, for example, they recommend against the routine use of calcium and sodium bicarbonate [2010 Guidelines].
End of Life/Palliative Care – Dr. James Adams
Hospice and palliative care are INTENSIVE. Listen to Dr. Ashley Shreves on the EMCrit podcast if you’re not convinced of this (actually, listen regardless, it’s worth it).
A Do Not Resuscitate (DNR) order only speaks to whether or not a patient wants CPR if they die. No more, no less. But, for more on this, check out this blog post.
In general, physicians don’t broach end-of-life topics with patients. Dr. Adams quoted a statistic “Approximately 50% of doctors don’t know their patient’s resuscitation wishes.” The consensus in the room was that it really doesn’t take that much time to initiate these conversations but brief questions asking about a patient’s wishes, checking in to see if they have sufficient resources, or. (Lauren’s take on the topic).
FOAMcast is bringing you pearls from conferences we attend and, first up, the American College of Emergency Physicians annual meeting, ACEP14. Yesterday’s episode covered the council meetings.
Scientific Assembly Day 1 Pearls
Opening Session by Freakonomics hosts Steven Levitt and Stephen Dubner. Weird choice? It turns out that economists and physicians have a lot in common. What’s that? Probabilities. As physicians we like to think of ourselves as diagnosticians, but we’re more like probalisticians. We make predictions, hopefully based on the best evidence, our clinical expertise, and our patient’s values. People don’t remember the little stuff, like extra testing but they do tend to remember the more outlandish things, like the “amazing saves” or awful “misses.”
See this post by Dr. Simon Carley, in which he describes the ways in which physicians are really playing the odds and gambling.
Cardiology Pearls from Dr. Slovis.
Post cardiac arrest – targeted temperature management to 35-36 Celsius is the new 33 Celsius [Nielsen].
Many patients should probably go to the cath lab after arrest, but it’s still not clear exactly who benefits the most. STEMIs should probably go to the cath lab and, perhaps, non-STEMI ventricular fibrillation/tachycardia arrests. Apparently, 10-30% of these are actually STEMIs “on the inside” [More skeptical takes on this from Dr. Radecki here and here]
Infectious Disease Pearls from Dr. David Pigott – When someone returns from a developing nation, say, West Africa, the cause of their fever is not necessarily ebola. It’s probably an unknown, regular virus. It’s probably not ebola but it may be malaria which is quite common.
His thoughts on predictors of badness: Symptoms typically appear within 8-10 days although the “watch” period is 21 days. If a patient is in their second week of symptoms and are hemodynamically stable, then the patient has a pretty good shot.
Insulin bolus of 1 unit/kg followed by a drip of 1 unit/kg/h. Add dextrose at about 0.5 mg/kg/h, depending on their glucose.
Check glucose and potassium every 30 minutes, with the goal to keep the potassium 2.8-3.2, per Goldfrank.
Cyanide toxicity (discussed here) – if you’re thinking about it, please do NOT wait on a cyanide level, or any labs. Treat, with the current recommendation of intravenous hydroxocobalamin. There’s some discussion on the use of intramuscular cobinamide, which would be great in situations without IVs; however, this is largely untested in humans presently [Bebarta et al].
Dr. Scott Weingart – Catch the CO2 Wave (podcast). End tidal CO2 (ETCO2) – ETCO2 has become essential in monitoring patients in the ED. With anything we monitor, we really need to understand what we’re looking at as well as the interventions.
ETCO2 does NOT = PaCO2.
In most patients, the PaCO2 will be ~3-5 mmHg higher than their ETCO2.
This is because ETCO2 is really a measure of: PaCO2 (or production) but also cardiac output and alveolar ventilation. Thus, the ETCO2 may be falsely low in a patient with significant dead space, such as COPD, or with impaired cardiac output (heart failure).
FOAMcast is bringing you pearls from conferences we attend and, first up, the American College of Emergency Physicians annual meeting, ACEP14. However, Jeremy and I both worked overnights so we got into town a little late. Our friends and ACEP luminaries, Drs. Justin Hensley, Howie Mell, and Todd Slesinger.
Naloxone (Narcan) – The council approved resolutions in support of naloxone for everyone. There was also a resolution on developing a clinical policy for emergency physicians prescriptions of naloxone. Watch out for it.
Medical Marijuana – Apparently every year brings some bickering about medical marijuana….and every year, the council defeats the resolutions. This year was no different…no support for medical marijuana from ACEP.
Emergency Department Pharmacists – These folks are indispensable in the ED (and in the FOAM world), and ACEP recognized this with the passing of Resolution 44 (what this means, clinically, not sure). And if you haven’t work with them – you’re missing out. We’re huge fans of EMPharmD and, naturally, Bryan Hayes (@PharmERToxGuy)
There’s also a lot of politics that goes into these bills, for that part, we got Dr. Kevin Klauer, Council Speaker on FOAMcast to explain.
We review Dr. Scott Weingart’s episode 133 on pre-hospital REBOA (resuscitative endovascular balloon occlusion of the aorta). Weingart interviews Dr. Gareth Davies about the encounter, underscoring the increasing use of REBOA.
REBOA (Review of REBOA) – First described in 1954 in the Korean War, this is a form of hemorrhage control below the level of the chest without having to do a thoracotomy with aortic cross clamping, which has sparse mortality benefit and can be dangerous to providers. Most of the REBOA literature is from swine models and case-series, although there are currently larger trials underway.
Outline of procedure – Obtain arterial access through the common femoral artery, pass a vascular sheath, float a balloon catheter to the appropriate section of the aorta, and inflate the balloon to occlude blood flow. The aorta is divided into three zones so that balloon occlusion is performed in Zone 1 for abdominal injuries or Zone 3 for pelvic injuries, while Zone 2 is a proposed no-occlusion zone.
The Bread and Butter
Rosen’s Chapter 46, 134 and Tintinalli Chapter 260.
Answer: More than most appreciate. The spleen filters the blood, removing abnormal or old red blood cells (RBCs), debris, and antibody coated bacteria from the bloodstream. It also serves as a reservoir for RBCs and platelets and synthesizes antibodies, opsonins, etc.
Diagnosis – suspect spleen trauma clinically, with hypotension, left upper quadrant abdominal pain, or even minimal trauma, especially after infectious mononucleosis.
CT with IV contrast (hemodynamically stable patients). While FAST and DPL can detect peritoneal free fluid, they can’t detect subcapsular bleeds.
Unstable patients – operating room versus interventional radiology
Grading – 1 is 1 (<1 cm laceration depth), 3 is 3 (>3 cm laceration depth). Everything else is somewhere in between. Higher grades typically result in more aggressive interventions. Historically these get operative intervention
Grade 1: < 1 cm laceration depth or<10% subcapsular hematoma
Grade 2: 1-3 cm laceration or 10-50% subcapsular
Grade 3: > 3 cm laceration depth or >50% subcapsular hematoma
Grade 3 or higher should be considered for angiography with embolization (Level II, III – EAST)
Grade 4: partially devascularized spleen or contrast blush
Grade 5: a very battered, devascularized spleen
There’s slightly more to spleen grading, check out this post from Dr. McGonigal
Trivia: The punctate extravasation sometimes seen on angiogram after blunt trauma?
Answer: The Seurat Spleen (pubmed), named after the pointillist painter.
Unstable patients: Operating room or Angiographic Intervention (IR) (Level II – EAST)
Note: Board exam? Send the patient to the OR. In reality, there is some practice variation. Many would still argue the patient belongs in the OR, some places have combined OR/IR suites, and some opt for IR.
Post splenectomy patients will need immunizations for the encapsulated bacteria
Stable patients: Nonoperative management, which often comprises in-hospital monitoring, serial abdominal exams and hematocrits, etc is becoming increasingly common as first line for higher grade splenic injuries. The key here is that the team must be able to take the patient to the OR or IR should the situation change. Angioembolization has also gained momentum as management
Benefits: Preserved immune function of the spleen/patient may get to keep their spleen (Banerjee et al)
Post-Splenectomy Sepsis (Review)- Most common in the first years after splenectomy and in children.
Presentation – Patients may present with a vague flu-like illness or gastroenteritis but may go on to develop septic shock, DIC, and multiorgan dysfunction. In addition, meningitis without overwhelming infection or shock is a common presentation of pneumococcal infection in asplenic patients.
Etiology – encapsulated bacteria (Streptococcus pneumoniae, Haemophilus influenza, and Neisseria meningitidis), capnocytophaga canimorsus (dog bites), and parasites such as babesiosis (endemic in New England), malaria, and ehrlichiosis.
Question 2. A 23-year-old man presents with a stab wound to the abdomen. His vital signs are HR 132, BP 88/45. He has a positive FAST.
Chapter 46, 134. Rosen’s Emergency Medicine, 8e.
Chapter 260. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 7e. New York, NY: McGraw-Hill; 2011
1. C. Splenic artery aneurysms are the most common type of visceral arterial aneurysms, accounting for up to 60% of cases. Etiologies include arterial fibrodysplasia, portal hypertension, and increased splenic AV shunting in pregnancy. Clinical presentation is vague with left upper quadrant pain with radiation to the left shoulder or subscapular area. Most of the aneurysms are <2 cm in diameter; only 2% result in life-threatening rupture. Treatment is surgical resection if the patient is symptomatic. Otherwise, asymptomatic patients can undergo transcatheter embolization. Of those aneurysms that rupture, up to 95% occur in young pregnant women.
Hepatic artery aneurysms (A) represents 20% of visceral artery aneurysms and are caused by atherosclerosis, infection, and abdominal trauma. Clinical presentation can mimic cholecystitis. Inferior mesenteric artery aneurysms(B) are uncommon. Superior mesenteric artery aneurysms (D) are the 3rd-most common visceral aneurysms. IV drug abusers are at increased risk.
2. D. This patient presents with hemorrhagic shock from a penetrating abdominal trauma and should be immediately transferred to the operating room for an exploratory laparotomy. Stab wounds are the most common form of penetrating trauma. About 70% of anterior stab wounds penetrate the peritoneum. It is difficult to predict the specific organ injured based on the external location of the wound. Initial management should focus on securing the airway, assessing and supporting the patients breathing and circulation. IV access and supplemental oxygen should be provided. In hypotensive trauma patients, early blood transfusion should be initiated and consideration should be made for massive transfusion protocol. Concomitant with the primary and secondary survey, a Focused Assessment with Sonography for Trauma (FAST) exam should be performed. The speed and accuracy of the FAST has almost completely replaced the need for diagnostic peritoneal lavage. In a FAST exam, images are obtained of the splenorenal space, hepatorenal space (Morrison’s pouch), heart and bladder (pouch of Douglas). A FAST exam has high sensitivity in detecting as little as 100 ml of fluid. A FAST examination showing free fluid in any of the abdominal views in the presence of hypotension should lead to the patient being transported to the operating room for exploratory laparotomy according to the Advanced Trauma Life Support (ATLS) algorithm. Angiographic embolization (A) is useful in patients with pelvic fractures and bleeding from pelvic vessels. CT scan of the abdomen and pelvis (B) can be performed in trauma patients who are stable to further assess for injuries.Diagnostic peritoneal lavage (C) does not play a role in management of penetrating trauma patients with hypotension and positive FAST examination.
POUND- 4 criteria is very indicative of migraine (+LR 24), 3 criteria also likely (+LR 3), although most of this comes from the outpatient literature .
hOurs: headache lasts 4-72 h without medication
Disabling: disrupts daily activities
The Bread and Butter
We summarize some key topics from the following readings, Tintinalli (7e) Chapter 159 ; Rosen’s 8(e) Chapter 20, 103 – but, the point isn’t to just take our word for it. Go enrich your fundamental understanding yourself!
In Emergency Medicine, our job is to investigate and think about the life and limb threatening causes, even to mundane problems. Things such as intracranial bleeds, meningitis, masses – these are huge deals and are covered well and hammered into our heads. For FOAM core content on this, check out the St. Emlyn’s podcast. On this episode, we’re running a mini-ophthalmology headache special and focusing on headaches that treatment may render “sight saving.”
Temporal Arteritis – often in patients older than 50 years of age and more common in those with a history of polymyalgia rheumatica. May be accompanied by visual changes including the “classic” amaurosis fugax or “curtain” of unilateral vision loss. If not treated, these patient can lose vision permanently.
Unilateral or localized headache, often in the temporal or retro-orbital area
Jaw claudication (pain with chewing) – most specific sign
Decreased pulse in temporal artery or tenderness
Sedimentation Rate (ESR) >50
Prednisone 40-60 mg if thinking about diagnosis
Temporal artery biopsy within 48 hrs
Acute Angle Closure Glaucoma- Classically, these patients present with unilateral mid-dilated pupils and severe nausea, vomiting, and headaches. The history can, naturally, be less classic and more vague. Also, if not treated, this can lead to vision loss.
Elevated opening pressure (>20-25 cm H20) on lumbar puncture
Neuro follow up
Acetazolamide +/- furosemide
Therapeutic lumbar punctures
Cerebral Venous Sinus Thrombosis – may present as atypical headache with stroke like symptoms in patients without known vascular risk factors. The neurological findings may be transient. Often associated with post-partum patients, patients with hypercoaguable states (Factor V mutations, protein C or S deficiency, antithrombin III deficiency, etc), patients on OCPs.
Diagnosis – CTV or MRV (magnetic resonance venography) after CT scan, which may be normal.
Treatment – Anticoagulation, although this is somewhat controversial
Question 1. A 73-year-old woman with a history of hypertension presents with a unilateral headache for 3 weeks. She states that she has a throbbing pain at her right temple and has pain in her jaw with opening and closing. The vision in her right eye has worsened over the previous day. Her blood pressure is 173/100.
Question 2. A 71-year-old woman presents to the ED with daily headaches for 2 months. She describes the headache as a dull pain that is most intense in the morning and resolves by the afternoon. On exam you note 4/5 motor weakness of the left upper and lower extremity.
3.Chapter 159. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 7e. New York, NY: McGraw-Hill; 2011
1. D. This patient presents with a unilateral, subacute headache with associated jaw claudication and vision change; symptoms consistent with temporal arteritis. Temporal arteritis or giant cell arteritis is a systemic inflammatory process of small and medium-size arteries. The most commonly involved vessels are the ophthalmic vessels and the extracranial branches of the aortic arch. The disease typically affects patients over 70 years of age and is more common in women than in men. Patients present with a subacute headache that is throbbing in nature and may be present for weeks to months. Often, patients will have symptoms for more than 2 months. Patients may also report jaw claudication secondary to vascular insufficiency of the masseter and temporalis muscles. Physical examination may reveal tenderness over the temporal artery. Systemic symptoms may also be present including fever, joint pains, and weight loss. Diagnostic testing in the Emergency Department generally begins with an erythrocyte sedimentation rate (ESR) with a cutoff of 50 mm/hour although the level may be >100 mm/hour. However, the ESR will be normal in 10-25% of patients. The gold standard diagnostic test is a temporal artery biopsy. In patients with a high-clinical likelihood of temporal arteritis, treatment should be initiated regardless of initial diagnostic testing as delay can lead to permanent visual loss. Prednisone should be started at 60 – 120 mg/day.
Carbamazepine (A) is the treatment of choice for trigeminal neuralgia, not temporal arteritis. The patient does not present with symptoms consistent with hypertensive emergency requiring emergent antihypertensive treatment withlabetalol (B). A non-contrast head CT scan (C) is not helpful in temporal arteritis as the disease does not involve the intracranial contents.
2. B More than half of patients diagnosed with a brain tumor complain of headache. However, the headache associated with brain tumor is highly variable. Patients may describe it as continuous or intermittent, unilateral or bilateral, sharp or dull. It is associated with neurologic deficits less than 10% of the time. However, in the setting of aneurologic deficit and chronic headache (as in this scenario with motor weakness), a mass lesion should be strongly considered as the cause. Patients may also complain of nausea, vomiting, visual change, and gait disturbance. Headaches due to brain tumors are classically associated with pain that is worse in the morning (as in this case). However, this is rare.
Central venous thrombosis (A) results from hypercoagulable states and is associated with acute to subacute headaches with vomiting and sometimes seizures. Risk factors include the use of oral contraceptives, postpartum or postoperative states, and any hypercoagulable state such as factor V Leiden mutation, antithrombin III deficiency, protein S or C deficiency, or polycythemia. The diagnosis is usually made by MRI venogram. Migraine headache (C) is classified as a primary headache and can be quite variable in presentation. These headaches can be associated with nausea, vomiting, photophobia, and phonophobia. The headache may also be preceded or accompanied by an aura that develops gradually over minutes, usually lasts 60 minutes, and is reversible. Auras may include neurologic symptom but commonly include scintillating scotomas (dark spots) or flashing lights. Temporal arteritis (D) occurs almost exclusively in patients older than 50 years and is much more common in women. Headache is the most common symptom of temporal arteritis and usually occurs over the frontotemporal region. It is strongly associated with a history of polymyalgia rheumatic. It is not associated with focal neurologic deficits, but it can lead to vision loss due to ischemic optic neuritis.
In this tiny episode, Jeremy reviews his favorite pearl from each episode, loooking at episodes 4-14. Why the repetition? Well, it turns out we learn better when information is spaced in small aliquots over time (spaced repetition).
Strong Ion Difference (SID), which is the difference between the sums of concentrations of the strong cations and strong ions (typically Sodium minus Chloride). Small SID = acidic (example SID of 0.9% NaCl = 0)
The discriminatory zone is out. Get ultrasounds in pregnant patients, regardless of the quantitative beta-hCG. A certain beta-hCG level can not be used to rule in or rule out ectopic pregnancy or viable intrauterine pregnancy (IUP), get the ultrasound and ensure you identify the uterus.