We review a talk by Dr. Sara Gray from SMACC (Social Media and Critical Care) conference in June 2016, Resuscitative hysterotomy, which is the new name for perimortem c-section . In this talk she challenges the “4 minute” rule: if resuscitative efforts following maternal circulatory arrest are unsuccessful, cesarean delivery should be commenced at 4 minutes and completed by 5 minutes to optimize fetal outcome.
We delve into core content on pregnancy emergencies using Rosen’s Emergency Medicine (8th edition) Chapter 98and Tintinalli’s Emergency Medicine (8th edition) Chapter 178 as a guide.
Nausea and vomiting are very common in pregnancy, but few patients have hyperemesis gravidarum (~2%). Hyperemesis gravidarum is characterized by severe nausea and vomiting with starvation ketosis and significant weight loss and dehydration [2,3].
A 22-year-old woman presents complaining of vaginal bleeding and cramping for the last 4 hours. She is known to be 14-weeks pregnant. Her cervical os is dilated to 4 cm and she is actively bleeding. Pelvic ultrasound shows the gestational sac in the lower uterine segment near the cervix. Which of the following is the most likely diagnosis?
A. Complete abortion
B. Inevitable abortion
C. Missed abortion
D. Septic abortion
The patient is experiencing an inevitable abortion, which is characterized by an open cervical os and a gestational sac at the opening of the uterus on ultrasound. The case should be discussed with the patient’s obstetrician as the patient may ultimately require dilatation and curettage if all the products of conception (POC) do not pass spontaneously or the bleeding is not controlled. A complete abortion (A) occurs when the patient has passed all POC have passed. On examination, the cervix is closed and the uterus is firm and nontender. A missed abortion (C) occurs when a pregnant patient fails to pass the products of conception greater than two months after fetal demise. The pregnancy test will be negative, however ultrasound will show retained POC. A septic abortion (D) occurs when the patient develops foul-smelling discharge, vaginal bleeding, uterine tenderness and peritoneal signs following a spontaneous or induced abortion.
What is the most common cause of bleeding in the primigravid woman?
Rose CH, Faksh A, Traynor KD, Cabrera D, Arendt KW, Brost BC. Challenging the 4- to 5-minute rule: from perimortem cesarean to resuscitative hysterotomy. American journal of obstetrics and gynecology. 213(5):653-6, 653.e1. 2015. [pubmed]
Heaton, H. “Chapter 98: Ectopic Pregnancy and Emergencies in the First 20 Weeks of Pregnancy.” Tintinalli’s Emergency Medicine: A Comprehensive Review. 8th edition
“Chapter 178: Acute Complications of Pregnancy.” Rosen’s Emergency Medicine
The PESIT study in the New England Journal of Medicine stirred up controversy in the FOAM world earlier in October 2016. In this episode we cover the following posts on this article on pulmonary embolism in syncope:
An 83-year-old is being evaluated in the emergency department after an episode of syncope. The woman was preparing dinner when she felt her heart start to race. The next thing she remembers is waking up on the floor. She experienced a similar episode about three weeks ago. She has never had anything like this before. Her past medical history is remarkable for hypertension, hyperlipidemia and hypothyroidism. Her medications include lisinopril, atorvastatin and levothyroxine. On physical exam her blood pressure is 142/83, heart rate 76/min, and respiration rate 13/min. Cardiac auscultation reveals no murmur. The remainder of her physical exam is normal. Electrocardiogram reveals normal sinus rhythm with left axis deviation. No cardiac rhythm abnormalities are detected. What is the most likely etiology of this patient’s syncope?
A. Aortic stenosis
B. Cardiac dysrhythmia
C. Orthostatic hypotension
B. Cardiac dysrhythmia is the most likely cause of this woman’s syncope. Cardiac dysrhythmias are a common cause of syncope in the elderly population. It is characterized by a brief or absent prodrome and palpitations immediately preceding the event. Several episodes over a short period of time in someone with no history of syncope suggest a dysrhythmia. Given this patient’s short prodrome, palpitations and history of a previous similar event makes a cardiac dysrhythmia the most likely etiology.
Aortic stenosis (A) is unlikely the cause of her syncope. Aortic stenosis is associated with a crescendo-decrescendo systolic ejection murmur. Syncope related to aortic stenosis typically occurs during exertion and is associated with very severe disease. This patient’s syncopal episode occurred while stationary. Additionally, she has no systemic symptoms of aortic stenosis.Vasovagal (D) is the most common cause of syncope in the general population. It is usually triggered by provoking factors such a blood draw or an intense emotion. Prodromal symptoms include feeling warm, sweating, nausea, and pallor. This woman does not report any of these symptoms. Orthostatic hypotension (C) causes syncope upon assuming an upright position from supine or sitting. It is often caused by hypovolemia, medications or autonomic nervous system disorders. This woman was standing while preparing dinner making orthostatic hypotension unlikely.
An 18-year-old woman presents after having a syncopal episode. She is complaining of a 2-day history of lower abdominal pain and vaginal spotting. Her BP is 86/42, HR is 128, RR is 18 breaths, and oxygen saturation is 99% on room air. She is drowsy, but answers questions appropriately. What is the most appropriate next step in management?
A. Establish large-bore IV access and administer an IV fluid bolus
B. Initiate rapid sequence induction and orotracheal intubation
C. Perform a bedside urine pregnancy testing
D. Perform an ultrasound of the abdomen to assess for free fluid
A. The patient is hypotensive and tachycardic. She is suffering from hypovolemic shock secondary to a ruptured ectopic pregnancy. Therefore she requires immediate intravenous access and volume resuscitation with Lactated Ringer’s or normal saline. Emergency Department management of unstable patients includes rapid assessment of the ABC’s (Airway, Breathing, Circulation). This patient is phonating, has a respiratory rate of 18 breaths per minute and an oxygen saturation of 99% on room air. There is no concern that her airway or breathing is in immediate jeopardy, therefore she would not require immediate rapid sequence induction and orotracheal intubation (B). Although a bedside pregnancy test (C) and abdominal ultrasound (D) would help make a diagnosis of ruptured ectopic pregnancy, the next step would be to resuscitate the patient.
De Lorenzo RA. “Syncope.” Chapter 15. Rosen’s Emergency Medicine (8 ed). pp 131-145
Chapter 52. Tintinalli’s Emergency Medicine: A Comprehensive Review (8 ed).
Serrano LA, Hess EP, Bellolio MF et al. Accuracy and Quality of Clinical Decision Rules for Syncope in the Emergency Department: A Systematic Review and Meta-analysis. Annals of Emergency Medicine. 56(4):362-373.e1. 2010.
We are in Las Vegas at ACEP 2016 thanks to Annals of Emergency Medicine and ACEPnow and discuss high yield and cutting edge lectures each day.
Dr. Megan Osborn – Bell’s Palsy or Stroke?
Traditional teaching: we can differentiate Bell’s palsy (lower motor neuron) from a stroke (upper motor neuron by assessing forehead involvement. If the patient can wrinkle their forehead? Think stroke. Dr. Megan Osborn tackled the question: does this actually work all the time in her talk in the New Speakers Forum.
Llor C, Moragas A, Bayona C. Efficacy of anti-inflammatory or antibiotic treatment in patients with non-complicated acute bronchitis and discoloured sputum: randomised placebo controlled trial. BMJ (Clinical research ed.). 347:f5762. 2013. [pubmed]
Smith et al. Over-the-counter (OTC) medications for acute cough in children and adults in ambulatory settings. Cochrane Database of Systematic Reviews 2012, Issue 8. Art. No.: CD001831. DOI: 10.1002/14651858.CD001831.pub4.22895922
Dobson R. Cough medicines’ effect is mainly placebo. BMJ. 2006 Jan 7; 332(7532): 8. PMCID: PMC1325161
Cohen et al. Effect of Honey on Nocturnal Cough and Sleep Quality: A Double-blind, Randomized, Placebo-Controlled Study Pediatrics; originally published online August 6, 2012; PMID:22869830
Egerton-Warburton D, Meek R, Mee MJ, Braitberg G. Antiemetic use for nausea and vomiting in adult emergency department patients: randomized controlled trial comparing ondansetron, metoclopramide, and placebo. Annals of emergency medicine. 64(5):526-532.e1. 2014. [pubmed]
Furyk JS, Meek RA, Egerton-Warburton D. Drugs for the treatment of nausea and vomiting in adults in the emergency department setting. The Cochrane database of systematic reviews. 2015. [pubmed]
Beadle KL, Helbling AR, Love SL, April MD, Hunter CJ. Isopropyl Alcohol Nasal Inhalation for Nausea in the Emergency Department: A Randomized Controlled Trial. Annals of emergency medicine. 68(1):1-9.e1. 2016. [pubmed]
Friedman BW, Dym AA, Davitt M. Naproxen With Cyclobenzaprine, Oxycodone/Acetaminophen, or Placebo for Treating Acute Low Back Pain: A Randomized Clinical Trial. JAMA. 314(15):1572-80. 2015. [pubmed]
Derry S, Conaghan P, Da Silva JA, Wiffen PJ, Moore RA. Topical NSAIDs for chronic musculoskeletal pain in adults. The Cochrane database of systematic reviews. 4:CD007400. 2016. [pubmed]
We are in Las Vegas at ACEP 2016 and discuss high yield or cutting edge lectures each day.
Dr. Anne Daul – Emergency Care of the Transgender Patient
Most emergency medicine physicians and trainees lack training in caring for LGBTQ patients, let alone transgender patients . Many members of the LGBTQ community may have delays in medical care including 21% of transgender patients in a Canadian survey. Also, according to a 2010 task force, 19% of transgender patients report being denied care in some way .
Here is a video from SMACC Dublin from Thom O’Neill on caring for LGBT youth
2% of active shooter events take place in the health care setting.
Plan of Action in Active Shooter Scenario: AVOID DENY DEFEND TREAT
Avoid – stay away from the shooter.
Deny – deny them access to you or the area. Lock doors, block pathways, turn off the lights, make it more difficult for them.
Defend -.if necessary, defend yourself.
Treat – once you are safe, and the scene is safe, treat and care for your patients.
Dr. Kevin Klaur – Lawsuits
Documentation and discharge instructions repeatedly come up in lawsuits.
Documentation: If you document after the fact, particularly if there was a bad outcome – be straightforward that you are documenting after the fact. Do not document as though you do now know the outcome
Discharge – lawsuits often come up because discharge instructions or documentation were not sufficient. Klauer argues that it is not sufficient to state “patient improved, discharged home.” He urges us to document a repeat exam or show HOW they are improved.
Dr. Klauer also gave some general pearls on lawsuits – high numbers for orthopedics/missed fractures and administration of RhoGham. An additional pearl he gave was for cauda equina.
These patients often have small post void residuals because it’s a neurogenic problem, not a mechanical obstruction. Thus, if a patient has other features and has a post void residual of 100 cc, it’s not necessarily not cauda equina.
One ACEP16 lecturer talked about magnesium use in alcohol withdrawal – probably not ready for prime time, Cochrane agrees .
Moll J, Krieger P, Moreno-Walton L. The prevalence of lesbian, gay, bisexual, and transgender health education and training in emergency medicine residency programs: what do we know? Academic emergency medicine : official journal of the Society for Academic Emergency Medicine. 21(5):608-11. 2014. [pubmed]
Bauer GR, Scheim AI, Deutsch MB, Massarella C. Reported emergency department avoidance, use, and experiences of transgender persons in Ontario, Canada: results from a respondent-driven sampling survey. Annals of emergency medicine. 63(6):713-20.e1. 2014. [pubmed]
Eyes track movement in a non-voluntary way and results in pursuit, sacchade. Vision is at least 20/200 if they can do this
Stick out your hand as if to shake theirs
Often a habit to reflexively reach out
Have the patient touch their index fingers together in front of them.
This is a test of proprioception so if they are unable to do this, they either have a problem with proprioception or are faking.
Visual Field or Possible Neglect
Hold a pen horizontally in front of the patient's face and ask them to point to midline.
If the patient points off of midline, this suggests a visual field deficit
We previously reviewed eye trauma in this podcast. In this episode, we review ophthalmology basics using Tiintinalli’s Emergency Medicine Chapter 241.
When doing the pupillary exam, it is important to assess for an afferent pupillary defect (APD). Ophthalmologists will want “there is or is NOT an APD” when you consult them for essentially any reason. Normal pupils constrict when the light is shown in either pupil (direct and consensual constriction). To assess for an APD, perform the “swinging light test.”
A 72-year-old man presents with a painful red eye and visual loss worsening over the last 24 hours. He recently had cataract surgery. Examination of the eye reveals the image above. Which of the following is the most likely?
D. Vitreous hemorrhage
A. Endophthalmitis is an infection involving the anterior, posterior and vitreous chambers of the eye. It results from trauma (blunt globe rupture, penetrating injury, foreign bodies) and alsoiatrogenically after ocular surgery like cataract repair. Patients complain of severe pain in the eye and visual impairment or loss. Examination of the eye reveals decreased visual acuity, injected conjunctiva, chemosis and haziness of the infected chambers. Infections are treated with both systemic and intraocular antibiotics.
A hyphema (B) is blood in the anterior chamber usually caused by trauma. When the patient is in an upright position, blood will layer along the inferior aspect of the anterior chamber. As the hyphema increases in size, it elevates intraocular pressure. In some cases admission is warranted for patients with large hyphemas (>50%), decreased vision, sickle cell disease and elevated intraocular pressure. Treatment is aimed at decreasing pressure with topical (beta-blocker, alpha agonist or carbonic anhydrase inhibitors) and systemic therapy (carbonic anhydrase inhibitor, mannitol). Uveitis (C) occurs after blunt trauma in which the iris and ciliary body are inflamed causing ciliary spasm. Patients complain of significant photophobia with significant eye pain. Examination of the eye reveals perilimbal conjunctival injection (also called ciliary flush) and a small, poorly dilating pupil. Photophobia occurs with light shone on both the affected and unaffected eye. On slit lamp, cells (white and red) and flare (protein) are noted in the anterior chamber. Treatment is with a topical cycloplegic agent to minimize spasm. Vitreous hemorrhage (D) occurs as a result of injuries to the retina, uveal tract and their associated vascular structures. Common associated conditions include diabetic retinopathy, retinal vein occlusion and trauma. Patients complain of decreased visual acuity and floaters. The condition is not typically painful. Diagnosis is made with ocular ultrasound showing blood products in the posterior chamber.
What is a dependent pocket of pus seen in the anterior chamber called?
A 51-year-old man walks into a movie theater and experiences acute onset of right eye pain associated with nausea, vomiting, and cloudy vision. Which of the following is expected during the ophthalmologic exam?
A. Cherry-red spot in the macular area
B. Deep anterior chamber
C. Intraocular pressure >21 mm Hg
D. Miotic pupil
The patient has acute angle-closure glaucoma. This condition results in optic nerve damage from increased intraocular pressure. In patients with a narrow anterior chamber angle, reduced illumination (like entering a dark movie theater) causes mydriasis. Subsequently, folds of the peripheral iris can block the angle, which prevents aqueous humor outflow. This leads to a rapid elevation of intraocular pressure causing ocular pain, a hazy cornea, ciliary flush, a firm globe, and optic nerve damage if the pressure is not promptly relieved. An intraocular pressure >21 mm Hg is considered elevated. Pressures can elevate quickly to >60 mm Hg. The higher the pressure, the quicker damage occurs to the optic nerve and the poorer the prognosis. The diagnosis is often delayed due to the associated symptoms of nausea, vomiting, and abdominal pain. Treatment involves reducing aqueous humor production with IV acetazolamide, topical beta-blockers (timolol), and topical alpha-agonists (apraclonidine). Topical miotic agents (pilocarpine) are used to reverse the angle closure. Topical steroidshelp to reduce inflammation. Hyperosmotic agents (mannitol, glycerol) can also be administered for further reduction in intraocular pressure.
The funduscopic finding of a pale retina with a cherry-red spot in the macular area (A) is consistent with central retinal artery occlusion. This condition is associated with sudden unilateral vision loss that is painless. It is caused by a thrombotic plaque or embolus of the central retinal artery. A deep anterior chamber (B) is protective against acute angle-closure glaucoma. Individuals with a narrow chamber are at increased risk. The pupil in acute angle-closure glaucoma is most commonly fixed and mid-dilated, rather than miotic (D). Miotic pupils are associated with opiate use, cholinergic toxicity, and pontine strokes.
We cover a post from Dr. Josh Farkas on PULMcrit on lithium toxicity. The key message from the post is: a single serum lithium level doesn’t necessitate dialysis, despite a recommendation from the EXTRIP working group to initiate dialysis in patients with a lithium level > 5 mEq/L . Dr. Farkas advocates for aggressive management in asymptomatic patients with chronic lithium toxicity and patients without impaired renal function.
Lithium neurotoxicity does not correlate with serum lithium levels; it depends on the concentration in the CNS.
The argument is that the neurologic effects, among the most worrisome sequelae of lithium toxicity, results from lithium crossing the blood-brain-barrier (BBB) into the central nervous system (CNS). Thus, in an acute ingestion, patients may have a higher serum lithium level, but given the acuity, the lithium may not cross into the CNS. Conversely, a patient with chronic toxicity may have a mildly elevated serum lithium level but the lithium has had time to cross the BBB into the CNS so more neurotoxicity can result from lower serum lithium concentrations.
Differentiating between acute, chronic, and acute on chronic toxicity is important in management.
Acute – expect the levels will rise rapidly as the bolus of lithium is absorbed.
Chronic – expect the levels will not rise rapidly given a lack of lithium bolus.
Acute on chronic – again, expect levels to rise rapidly and may see more neurotoxicity as some lithium may have passed through the BBB into the CNS.
We review rhabdomyolysis using Rosen’s Emergency Medicine (8e) Chapter 160 and Tintinalli’s Emergency Medicine (8e), Chapter 181.
A 17-year-old man presents to the ED from a correctional facility complaining of general malaise with nausea and vomiting one day after a weightlifting competition. Vital signs are T 37.2°C, BP 100/65 mm Hg, HR 125, and RR 22. Physical exam reveals an uncomfortable, fatigued male who has diffuse muscle soreness. Urinalysis shows 3+ blood without red blood cells. What is the most important next test to direct the acute management of this patient?
A. Creatine kinase assay
C. Electrolyte panel with blood urea nitrogen and creatinine
B. Electrocardiogram. The patient presents with exercised-induced rhabdomyolysis. Although the causes of rhabdomyolysis are manifold, potential complications are independent of etiology. Of all the complications, hyperkalemia is the most concerning and, undiagnosed, can lead to sudden cardiac death. ECG changes indicative of hyperkalemia are thus critical to identify early in the course of management. Hyperkalemia results from impaired calcium transport with increased intracellular calcium accumulation, cellular necrosis, and expulsion of intracellular contents (including potassium) into the bloodstream. Rhabdomyolysis can also lead to acute tubular necrosis and kidney failure, which will exacerbate developing hyperkalemia by decreasing renal potassium clearance. Hyperkalemia is an immediate life-threatening condition that develops shortly after muscle injury. Absent point-of-care electrolyte analyzers, the most rapid way to screen for hyperkalemia is through an electrocardiogram.
Rhabdomyolysis is not defined by a specific creatine kinase (A) level. But, in general, a serum CK >5 times the upper limit of normal (a threshold that may differ by lab) is considered indicative of rhabdomyolysis. Although kidney injury can occur at any level, higher CKs correlate with an increased likelihood for the development of acute renal failure. In the absence of cerebral or myocardial infarction, a CK >5 times is diagnostic for serious muscle injury. Urinalysis (D) typically shows brownish discoloration with “large” blood on dipstick but few, if any, red blood cells on microscopic evaluation. This occurs because most dipstick tests cannot distinguish myoglobinuria from hematuria or hemoglobinuria. Protein, brown casts, and renal tubular epithelial cells may also be present. Measures of renal function and an electrolyte panel (C) should be obtained in all patients with suspected rhabdomyolysis. But, as mentioned, waiting for results may lead to a delay in the identification of life-threatening complications. In addition to hyperkalemia, hyperphosphatemia and hypocalcemia may also be seen. Additional (though less worrisome) laboratory abnormalities include elevated uric acid and low albumin.
One Step Further Question: What is the late complication of rhabdomyolysis associated with thrombocytopenia, hypofibrinogenemia, and an elevated D-dimer?
Disseminated intravascular coagulopathy may occur and is a result of muscle necrosis with liberation of activating substances from injured cells.
Increases in altitude are accompanied by decreases in pressure that cause the volume of gas to expand (Boyle’s law – pressure and gas volume are inversely associated). As such, gas filled spaces, such as a pneumothorax, may expand during ascent, particularly many thousand meters, as in is the case of aircraft.
British Thoracic Society (2011) – No commercial flights until full resolution of pneumothorax, confirmed by chest x-ray. They ideally recommend waiting 7 days after resolution of spontaneous pneumothorax and 14 days after resolution of traumatic pneumothorax. The risk of pneumothorax recurrence drops after one year .
An observational paper by Sacco and colleagues report the experience of patients flying after chest tube removal, but before the 7-14 day waiting period and found, in their experience, this was safe 
Tintinalli (8e) Ch 221, Rosen’s Emergency Medicine (8e) Ch 144.
Generously Donated Rosh Review Questions
A 20-year-old woman is climbing Mt. Kilimanjaro when she begins developing a headache followed by vomiting. As you begin to assess her, she has a grand mal seizure. Which of the following treatments should immediately be started?
A. Descent and acetazolamide
B. Ibuprofen and dexamethasone
C. Supplemental oxygen and acetazolamide
D. Supplemental oxygen, descent, and dexamethasone
This patient has developed high-altitude cerebral edema (HACE), a rare but potentially life-threatening form of high-altitude illness. Most cases of HACE are described in ascension past 12 000 feet although it may happen at altitudes as low as 8 200 feet. In HACE, mild altered mental status can rapidly progress to coma in as little as 12 hours. HACE is characterized by global cerebral dysfunction evidenced by headache, fatigue, vomiting, ataxia, confusion, generalized seizures, slurred speech, and focal neurologic deficits. It is a clinical diagnosis although imaging will show cerebral edema. Treatment should start with high-flow oxygen, dexamethasone, and immediate descent. Additionally, if hyperbaric treatment is available, it should be initiated. Ibuprofen (B) and other NSAIDs can be used for prophylaxis prior to ascent as can acetazolamide (A and C).
A 32-year-old man complains of dyspnea on exertion and a cough with clear, watery sputum. He has been climbing Mt. Kilimanjaro for 2 days. Other than descent, what treatment can be started immediately?
D. Portable hyperbaric chamber therapy
The patient is suffering from high-altitude pulmonary edema (HAPE) and should be treated with descent from altitude and hyperbaric oxygen therapy.HAPE is the most common fatal manifestation of high-altitude illness. It typically does not develop until the climber has passed 10,000 feet of elevation but it can happen at lower altitudes with heavy activity. The symptoms of HAPE usually begin 2-4 days after arrival at high altitude. Typically, patients experience marked dyspnea on exertion, fatigue with minimal effort, dry cough and difficulty with recovering from exertion. As HAPE progresses, patients will have a cough productive of copious clear secretions and have rales on examination. In severe cases, hemoptysis can develop. Although symptoms may mimic pneumonia or acute cardiogenic pulmonary edema, HAPE should be suspected in the correct clinical scenario. Rapid identification and management is central to preventing morbidity and mortality. The first and most important step in management is descent of the patient. Moderate decreases in altitude (1500 – 3000 feet) can rapidly resolve symptoms. If a hyperbaric chamber is available, it should be employed as simulated descent is just as effective and may be more logistically feasible.
Furosemide (C) is a loop diuretic, which decreases intravascular volume. There is a delay in onset of action and in recent years it has been replaced by pulmonary vasodilators like nifedipine. Additionally, the dehydration associated with furosemide makes it potentially dangerous in these patients. Moreover, HAPE is caused by hypoxia-induced pulmonary vasoconstriction and not from contractility problems of the heart. Acetazolamide (A) is a carbonic anhydrase inhibitor and can be used to treat mild altitude related symptoms like acute mountain sickness (AMS) or to prevent the development of high-altitude illnesses but it is not an appropriate treatment in HAPE. Albuterol (B) plays no role in the treatment of HAPE as bronchospasm is not the problem
Ahmedzai S, Balfour-Lynn IM, Bewick T et al. Managing passengers with stable respiratory disease planning air travel: British Thoracic Society recommendations. Thorax. 66(Suppl 1):i1-i30. 2011. [article]
Sacco F, Calero KR. Safety of early air travel after treatment of traumatic pneumothorax. Int J Circumpolar Health. 2014; 73.
Cheatham ML, Safcsak K. Air travel following traumatic pneumothorax: when is it safe? Am Surg 1999; 65:1160–1164
Yaron M, Paterson RD, Davis CB. “High Altitude Medicine.” Chapter 144. Rosen’s Emergency Medicine (8e).
Hackett PH, Davis CB. “High Altitude Disorders.” Chapter 221. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide.
Next, we dive into core content on platelet problems including problems caused by drugs, immune thrombocytopenic purpura (ITP/idiopathic thrombocytopenic purpura) and thrombotic thrombocytopenic purpura (TTP) using Tintinalli Chapter 233 (8th ed) and Rosen’s Chapter 122 (7th ed) as a guide.
A previously healthy 3-year-old boy presents to the emergency room with bruising to his arms, legs, trunk, and face. The mother reports that the boy was well appearing yesterday and noted the bruising upon waking up this morning. She also noticed that his gums were bleeding while brushing his teeth before coming to the hospital. Mom denies any trauma but notes her son had a viral illness three weeks ago that kept him out of daycare. A complete blood count is notable for a white blood cell count of 7,000, hemoglobin of 12, and platelets of 10,000. Which of the following is the most likely diagnosis?
A. Idiopathic thrombocytopenia purpura
C. Thrombotic thrombocytopenic purpura
D. Wiskott-Aldrich syndrome
A. Idiopathic thrombocytopenic purpura (ITP) is the most common cause of acute onset thrombocytopenia in an otherwise healthy child. It is most often seen in children aged 2-6 yearsand usually occurs 1 to 4 weeks after a viral illness. ITP is an autoimmune process where antibodies bind to the platelet surface. The platelet-antibody complex is then ingested by splenic macrophages and destroyed. The common physical exam findings are petechiae and purpura. If the child has hepatosplenomegaly, bone or joint pain, or lymphadenopathy, leukemia or other diagnoses should be suspected. In adolescents with new-onset ITP, systemic erythematous lupus should be suspected. Seventy to eighty percent of children will have spontaneous resolution of the symptoms. Treatment depends on the severity of the illness and includes such interventions as platelet transfusion for bleeding patients, steroids, and IVIG. Patients with ITP who have persistent or severe headache should undergo a head CT scan to rule out intracranial hemorrhage.
Leukemia (B) is rarely associated with thrombocytopenia alone and is typically seen with other cell lines being low with immature cells. In addition, physical examination may be remarkable for hepatosplenomegaly or lymphadenopathy. Children with leukemia often complain of bone pain. Leukemia is diagnosed by bone marrow biopsy and treated with chemotherapy. Thrombotic thrombocytopenic purpura (TTP)(C) is characterized by fever, micoangiopathic hemolytic anemia (MAHA), thrombocytopenia, abnormal renal function, and CNS changes. The microvascular thrombi are responsible for the clinical signs and symptoms. Lab findings associated with MAHA include anemia, schistocytes, spherocytes, and elevated reticulocytes. TTP is treated with plasmapheresis. Recurrent TTP is seen in patients with ADAMTS-13 deficiency. Wiskott-Aldrich syndrome (D) is an example of congenital thrombocytopenia. It is characterized by thrombocytopenia, small platelets, recurrent infections, and eczema. This disorder is X-linked.
A 9-year-old boy presents to the ED with bilateral knee pain, low-grade fever, nausea, vomiting, and diarrhea for the past 4 days. His vital signs are blood pressure of 116/80 mm Hg, heart rate of 98 beats per minute, respiratory rate of 14 breaths per minute, and a temperature of 38.1°C. On examination, you note the rash seen above. Urinalysis is positive for hematuria. Which of the following statements is the most accurate?
A. Despite plasma exchange, most patients progress to chronic renal impairment
B. Long-term prednisone therapy improves 5-year survival to greater than 50%
C. The disease is self-limited; most cases resolve within 6-8 weeks
D. Without treatment, the disease carries a mortality rate of 80% at one year
C. The patient has Henoch-Schönlein purpura (HSP). This small-vessel vasculitis predominantly occurs in small children.Most cases follow an upper respiratory tract infection. HSP classically presents with fever, abdominal pain, arthritis, hematuria, and a pathognomonic round, palpable, symmetrical rash that appears on the dependent areas of the legs and buttocks. NSAIDs, dapsone, and prednisone have all been shown to relieve symptoms. The course of disease is typically self-limited. Most cases resolve within 6 to 8 weeks, with a recurrence rate of up to 33%.
Plasma exchange (A) has been found to be successful in the treatment of microscopic polyangiitis. In HSP, most patients do not progress to chronic renal impairment. Prednisone (B) therapy has increased the 5-year survival rate to greater than 50% in Churg-Strauss Syndrome, which is typically associated with fever, weight loss, malaise, and pulmonary symptoms, but it does not affect survival in HSP. Granulomatosis with polyangiitis (D), not HSP, once carried a 1-year mortality rate of 80%, however, the combination of cyclophosphamide and corticosteroids has been successful in inducing remission in more than 90% of patients.
Historically, pericardiocentesis is taught using a landmark based method; however, use of ultrasound guidance may increase success. Experts recommend an approach wherever the largest pocket of fluid exists and each location has particular downsides to be aware of.
We delve into core content on the pericardium using Rosen’s (8th ed) Chapter 82 and Tintinalli (8th ed) Chapter 55.
1.A 25-year-old man presents to the ED with chest pain, shortness of breath, and fever. Vital signs include BP 98/50 mm Hg, HR 136 beats/minute, RR 26 breaths/minute, and T 102.4°F. On auscultation, you hear rales to the mid-thorax bilaterally. Bedside cardiac ultrasound shows global hypokinesis and a small pericardial effusion. Which of the following organisms is the most common cause of this condition worldwide?
A. Coxsackievirus B
B. Mycobacterium tuberculosis
C. Plasmodium falciparum
D. Trypanosoma cruzi
D. Trypanosoma cruz. This patient presents with signs and symptoms of myocarditis accompanied by pericarditis. Myocardial injury results from inflammation of the myocardium. The most common etiology worldwide is Chagas disease, caused by the protozoan Trypanosoma cruzi. The protozoan is spread by the reduviid bug, also known as the kissing bug as it feeds on the faces of those affected. Unfortunately, in many patients, the cause of myocarditis is idiopathic. Other noninfectious causes include connective tissue disorders such as scleroderma, toxins such as chemotherapy, cocaine, and heavy metals, and peripartum myocarditis. Symptoms often include a viral prodrome with fever, myalgias, and generalized weakness. Patients may present with chest pain, symptoms of acute heart failure, tachycardia, dysrhythmias, syncope, cardiogenic shock, or even sudden cardiac death. Diagnosis can be very difficult and patients often present to the ED multiple times prior to being diagnosed. An ECG may show global or segmental ST elevation, nonspecific ST segment and T wave changes, dysrhythmias, or conduction delays. Troponin and creatinine phosphokinase are often elevated. Echocardiography classically shows global hypokinesis. Management is primarily supportive; however, patients with new left bundle branch block or low ejection fraction may require a left ventricular assist device as a bridge to cardiac transplantation in some cases as these are poor prognostic indicators. The most common long-term sequelae of myocarditis is dilated cardiomyopathy.
2.A 56-year-old woman with a history of lymphoma presents to the Emergency Department at the recommendation of her primary care physician. During a routine visit, she had a chest X-ray that showed a “big heart.” She denies chest pain, shortness of breath, leg swelling, cough, orthopnea, or lightheadedness. Her vital signs include temperature 98.6 ºF, HR 88 beats/minute and regular, RR 14 breaths/minute, BP 121/89 mm Hg, and oxygen saturation 98% on room air. Her cardiac and neck exams are within normal limits. A bedside ultrasound reveals a small pericardial effusion. Which of the following is the next best step in management?
A.Lower extremity ultrasound
C. Reassurance and close follow up
D. Thoracic Surgery consultation
C. Reassurance and close follow up. The patient likely has a malignant pericardial effusion secondary to her known malignancy. Pericardial effusions are accumulations of fluid in the pericardial space that occur rapidly or gradually. Rapid accumulation of pericardial effusion can produce tamponade physiology and hypotension. This requires pericardiocentesis for emergent decompression of the effusion. Pericardial effusions that develop gradually often occur secondary to cancer (e.g. lymphoma, lung cancer, breast cancer, melanoma) or as the result of cancer treatment (e.g. radiation). Clinical signs or symptoms are determined by the rate of fluid accumulation. Asymptomatic pericardial effusions require no immediate treatment. Echocardiography is the diagnostic tool of choice. Chest X-ray may show a large cardiac silhouette indicating gradual fluid accumulation within a stretched pericardium. Malignant pericardial effusions can be managed in a variety of ways, including systemic or intrapericardial chemotherapy, or a pericardial window with pericardial resection. Lower extremity venous ultrasound (A) is an imaging modality to evaluating and diagnosing a deep venous thrombosis (DVT). This patient has no clinical features suggesting a DVT. Pericardiocentesis (B) is indicated in patients with symptomatic pericardial effusions or those who are experiencing tamponade physiology with hypotension. Thoracic surgery consultation (D) is not indicated since the patient is asymptomatic and hemodynamically stable.
3. A 4-year-old girl is brought to the ER by her parents due to lethargy. A week prior the girl had a cough and colds. Later symptoms progressed to include fever and malaise. She has been less active with decreased appetite. A few hours prior to arrival in the ER, she has been having difficulty of breathing. On exam, temperature is 38.3°C, respiratory rate of 35, heart rate of 126, blood pressure of 90/60, clear breath sounds, hepatomegaly, and poor pulses. Which of the following is the most likely diagnosis?
The girl demonstrates signs and symptoms that are suspicious for myocarditis which is a condition that results from inflammation of the heart muscle. Majority of children present with acute or fulminant disease. Myocarditis can be caused by infectious, toxic, or autoimmune conditions. Common causes of viral myocarditis include enterovirus (coxsackie group B), adenovirus, parvovirus B19, Epstein-Barr virus, cytomegalovirus, and human herpes 6 (HHV-6). The presentation of the disease is variable and patients can present with broad symptoms that range from subclinical disease to cardiogenic shock, arrhythmias, and sudden death. There is usually a history of a recent respiratory or gastrointestinal illness within the previous weeks. There is a prodrome of fever, myalgia, and malaise several days prior to the onset of symptoms of heart dysfunction. Then patients present with heart failure symptoms that include dyspnea at rest, exercise intolerance, syncope, tachypnea, tachycardia, and hepatomegaly. Testing is focused on determining the severity of cardiac dysfunction and these include electrocardiography (ECG), cardiac biomarkers, chest radiography, and echocardiography. Confirmation of myocarditis is generally made by cardiac magnetic resonance imaging or endomyocardial biopsy.
Dysrhythmia (B) usually presents with palpitations, syncope, chest pain. In the vignette, the girl’s symptoms are more consistent with a myocarditis. A primary dysrhythmia resulting in myocardial injury is differentiated from myocarditis by an endomyocardial biopsy. Bronchiolitis (A) is typically a disease in children younger than two years of age. It is diagnosed clinically with the characteristic findings of a viral upper respiratory prodrome followed by increased respiratory effort. Pneumonia (D) usually presents with respiratory complaints, particularly cough, tachypnea, retractions, and abnormal lung examination which were not present in the vignette.