UMEM Educational Pearls

Neutropenic Fever

A few pearls about neutropenic fever:

• Usually occurs a few weeks after chemotherapy (14-21 days)
• Defined as a fever in the setting of rapidly declining neutrophil count
• Patients who report fever at home but who are not febrile in the ED should be treated as if they are neutropenic
• ANC=absolute neutrophil count. Calculated by adding neutrophils and bands together
• Classification of neutropenia, use the ANC to calculate:  Mild: 1000-1500 cells/mm³, Moderate 500-1000 cells/mm³, and Severe Less than 500 cells/mm³.
• Mortality rate increases as the ANC drops to below 500 and the duration of neutropenia. These people die of overhwhelming bacterial infections/sepsis.
• Treatment: #1 Consider the diagnosis, #2 Broad spectrum antibiotic coverage: Imipenem, or Pip/Tazo, or Cefipime. Consider adding Vanc if the patient has a line, looks ill or is hypotensive, or if the patient has been on a fluoroquinolone.

#1 Pitfall:

• Not initiating broad spectrum antibiotic coverage fast enough. These patients can crash very rapidly.
• Patients do not have to be febrile in the ED to be diagnosed with this. Their report of fever is enough.
• Mortality rates drop the faster big gun antibiotics are given. Don't be skimpy and give Unasyn. Use the big bad boys like single agent Pip/Tazo (4.5 grams, not 3.375), Cefipime, etc. Have a low threshold for adding Vancomycin.

IDSA Guidelines on Neutropenic Fever, 2002. New Guidelines coming Summer 2008!

 

Clinical Presentation of SVC Syndrome

SVC syndrome (caused either by tumor or thrombosis of the SVC) classically presents with facial swelling, arm swelling, and dilated chest wall veins. The problem in the real world is that often times the manifestaions are a bit more subtle.

Some SVC syndrome pearls:

• Consider the diagnosis in patients with a generalized complaint of facial swelling or "fullness," particularly if they have an indwelling catheter in place.
• Consider in patients who complain there face is swollen or red (plethoric) in the morning, or who notice this when their arms are raised (Pemberton's sign)
• The diagnosis is usually established by CT.
• Patients with SVC syndrome and the complaint of hoarseness or headache should make you nervous, as these symptoms may indicate laryngeal and cerebral edema.
• The importance of examining the neck and chest in ED patients cannot be overemphasized. Often the one clue that leads to the diagnosis is prominent and asymetric neck, upper chest, or shoulder veins.
• Treatment: For tumor related SVC syndrome-head elevation, possibly steroids, radiation therapy (along with biopsy if no cancer diagnosis established); For thrombotic-related SVC syndrome-anticoagulation, Interventional Radiology consult for lytics/stent

 

The insurance companies are always trying to down code our visits so that they can save money, and unless we diagnosis the patients with the appropriate jargon it can cost us a lot of money.  Here are some coding suggestions as written by Sharon Nicks, President and CEO of Nicks & Associates in EP Monthly .

 

Diagnosis	Consider Diagnosising  It this, if the condition fits
Esophagitis	Acute Chest Pain
U.R.I.	Acute febrille illness with cough Acute tracheobronchitis
Gastroenteritis	Acute severe abdominal pain Acute dehydration (volume depletion) secondary to nausea/vomiting Electrolyte imbalance
Flu/Viral Ilness	Acute viremia Acute febrile illness
Musculoskeletal Pain	Acute cervical pain Acute chest wall syndrome Acute strain or pain to a specific (i.e: lumbar) due to a MVA or fall
Otitis Media	Acute febrile illness secondary to acute otitis media Otalagia

 

The moral of this pearl is try to use words like Acute, Severe, Sudden, Serious, Distress, Pain, or Fever so that it is clearer to the insurance companies that the patient warranted a visit to a physician (i.e.: an ED) before their PCP could see them in a week.

I have made some improvements to the educational pearl interface. This required recoding several sections to change the text formatting from plain text to html...

Why do you care?
Well, many email clients will block html, or messages that have lots of capitals, decorations, etc...

Our first priority is to get you the information and beat anti-spam auto-filtering. If you notice that you are not getting the educational emails. 

• Add admin@umem.org  and umem.org to your safe senders list

Notes to authors Do not use a lot of colors like this post Do not use allcaps, lots of bolding, etc...

thanks
dan

Medical Management of Ureteral Stones Tamsulosin (Flomax ) has been shown to help increase the passage of ureteral calculi. According to a metaanalysis compared to patients receiving conservative therapy only, patients receiving conservative therapy plus α -blockers were 44% more likely to spontaneously expel the stones (RR 1.44, 95% CI 1.31 to 1.59, p0.001), and stone expulsion incidence increased significantly (RD 0.28, 95% CI 0.22 to 0.34, p0.001). Mechanism of action: Alpha blockage results in ureteral smooth muscle relaxtion and subsequent inhibition of ureteral spasms and dilatation of the ureteral lumen. Erturhan S. Erbagci A. Yagci F. Celik M. Solakhan M. Sarica K. Comparative evaluation of efficacy of use of tamsulosin and/or tolterodine for medical treatment of distal ureteral stones. [Comparative Study. Journal Article. Randomized Controlled Trial] Urology. 69(4):633-6, 2007 Apr. Parsons JK. Hergan LA. Sakamoto K. Lakin C. Efficacy of alpha-blockers for the treatment of ureteral stones. [Journal Article. Meta-Analysis] Journal of Urology. 177(3):983-7; discussion 987, 2007 Mar.

I am redesigning the way the educational pearls are sent. You will still receive them via email to the education list. This will not change. What will change, is that a record will be available for review on the website in the residency --> pearls section. Currently you can browse the posts as the come in. In the very near future, you will be able to search by keywords and review several pearls at once. This should serve as a really handy review tool. Please bear with me as I test the email system to ensure it comes across ok. thanks dan