Question
You are working in a clinic in Tanzania (or Baltimore, for that matter) when a 24 year old presents with this itchy rash on his feet. What's the diagnosis and what underlying systemic condition does it indicate?
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Coagulopathies in Critical Illness - DIC
- Disseminated intravascular coagulation (DIC) is an acquired syndrome of intravascular coagulation and is commonly encountered in critically ill patients.
- Think about DIC in the critically ill patient with oozing at vascular sites (or wounds) and the following lab abnormalities:
- Thrombocytopenia
- Prolonged PT and aPTT
- Decreased fibrinogen
- Elevated fibrin split products and D-dimer
- Guidelines for the management of DIC are primarily based on expert opinion and include:
- Treat the underlying condition (i.e., sepsis)
- Transfuse platelets if < 50,000 per mm3
- Transfuse FFP to maintain PT and aPTT < 1.5 times normal control
- Transfuse cryoprecipitate to maintain fibrinogen levels > 1.5 g/L
- The use of heparin remains controversial and cannot be routinely recommended.
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Question
25 year-old female presents with the following. It seems to have occurred spontaneously and spontaneously resolves during her ED evaluation.
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DeQuervain and Intersection Syndromes:
- DeQuervain's Syndrome (Tenosynovitis of the Abductor Pollicus Longus and Extensor Pollicus Brevis tendons) is a common disorder that has received a lot of press lately as BlackBerry Thumb or Gamer's Thumb.
- This condition can be diagnosised by the Finklestein test [Have the patient bend their thumb into the palm of their hand, and then make a fist. They should then ulnar deviate their wrist. Pain along the tendons secures the diagnosis.]
- The pain of DeQuervain's syndrome is typically along the distal end of the radius at the base of the thumb.
- Intersection syndrome is a less common disorder though closely related to DeQuervain's Syndrome
- The pain is usually felt on the top of the forearm about three inches proximal to the wrist.
- The pain from this condition is due to tenosynovitis of the Extensor carpi radialis longus and Extensor Carpi radialis brevis muscles/tendons caused by the intersection of them with the Extensor pollicus brevis and Abductor pollicus longus tendons.
- Occurs due to excessive wrist movements.
- Intersection syndrome can be seen in weight lifters, skiers, and can be seen in homeowners in the fall and winter when they rake a lot of leaves or shovel snow.
- Treatment is the similar for both conditions and consists of:
- NSAIDS
- Cortisone injections can be effective
- Thumb and wrist immobilization with a Thumb Spica Splint or Cock Up Wrist Splint
What are characteristics that increase the chance a patient is at risk for opioid-related death? A recent JAMA article begins to tackle this very issues. Baumblatt et al. found the following:
1) Patient with 4 or more prescribers had adjusted odds ratio 6.5 for opioid-related death
2) Patient with 4 or more pharmacies where they get their prescriptions aOR - 6.0
3) Patient with more than 100 mg of morphine equivalents mean per day aOR - 11.2
With the new Maryland Prescription Drug Monitoring program (PDMP) we can start looking at a patient's prescription drug use pattern. The recent JAMA article can help you identify patients at high risk to die an opioid-related death. Use the PDMP and be wary if a patient has more than 4 prescribers or pharmacies or has >100mg of morphine equivalents per day.
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Question
You are evaluating a 40 year old trauma victim and see this on pelvic xray. What are you worried about?
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Nitric Oxide appears to have NO role in ARDS
Background: The use of inhaled nitric oxide (iNO) in acute respiratory distress syndrome (ARDS) & severe hypoxemic respiratory failure has been thought to potentially improve oxygenation and clinical outcomes. It is estimated that iNO is used in up to 14% of patients, despite a lack of evidence to show improved outcomes.
Mechanism: Inhaled NO works as a selective pulmonary vasodilator which has been found to improve PaO2/FiO2 by 5-13%, but is costly ($1,500 - $3,000 per day) and increases risk of renal failure in the critically ill.
Study: A recent systematic review analyzed 9 different RCTs (N=1142) and compared mortality between those with severe (PaO2/FiO2 < 100) and less severe (PaO2/FiO2 > 100) ARDS and found that iNO does not reduce mortality in patients with ARDS, regardless of the severity of hypoxemia.
Bottom Line: Inhaled NO is an intriguing option for the treatment of refractory hypoxemic respiratory failure, however there does not appear to be a mortality benefit to justify it's high cost and potentially negative side effects. In the ED, it is important to focus on appropriate lung protective ventilation strategies (TV: 6-8 cc/kg IBW) and maintaining plateau pressures < 30 cm H2O in the initial stages of ARDS to prevent ventilator induced lung injury while awaiting ICU admission.
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The number of patients with left ventricular assist devices (LVADs) is increasing and development of optimal resuscitative strategies is becoming increasingly important. Despite a lack of evidence, many device manufacturers and hospitals have recommended against performing chest compressions because of fear of cannula dislodgment or damage to the outflow conduit.
A recent retrospective analysis of outcomes in LVAD patients who received chest compressions for cardiac arrest did not support the theory that LVADs would be harmed by conventional resuscitation algorithms.
The study was a limited case series of only 8 LVAD patients over a 4 year period. All patients received compressions and device integrity was subsequently assessed by blood flow data from the LVAD control monitor or by examination on autopsy. Although more research is necessary to determine the utility and effectiveness of compressions in this population, none of the patients in this study had cannula dislodgment and half of the patients had return of neurologic function.
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Ankle Syndesmosis Injuries are also called high ankle sprains as they involve trauma to the ligaments above the ankle joint
Most ankle sprains are lateral ankle sprains. High ankle sprains are relatively uncommon.
Usual mechanism: External rotation injuries
Exam: Tenderness at the syndesmosis and compression of the tib/fib at the mid calf level causing syndesmosis pain (squeeze test)
Median recovery time is almost 4 times as long as a lateral ankle sprain 62days vs. 15days
Emergency department care is similar tto that of other ankle sprains but the added benefit of patient education and advice may improve overall care and follow-up.
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Question
35yo M with history of rheumatic heart disease presents with fever. What disease process is suggested by the echo?
.JPG)
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In 2001, Rivers et al. published a landmark article demonstrating an early-goal directed protocol of resuscitation that reduced mortality in septic Emergency Department patients.
Many questions have arisen throughout the years with respect to that trial; critics have complained about the overwhelming change in clinical practice based on this one single-center randomized trial.
Challenging Rivers data are the ProCESS (Protocolized Care for Early Septic Shock) investigators, who released the results from a multi-center randomized control trial of 1351 septic Emergency Department patients; the primary end-point was 60-day mortality. Click here for NEJM article.
Patients in this trial were randomized to one of three groups:
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Protocol-based EGDT
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Protocol-based standard (did not require central lines, inotropes, or blood transfusions
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Usual care (no specific protocol; care was left to the bedside clinicians)
Bottom-line: The investigators did not find any difference in mortality between patients in the three groups and comment that the most important aspects of managing the septic patient may be prompt recognition and early treatment with IV fluids and antibiotics.
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Question
62 year-old male presents with weakness, chills, cough, and malaise. Recently, he had four teeth extracted but felt fine immediately after the extraction. Past medical history includes diabetes and hypertension; CXR is below. What’s the diagnosis?
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The HEART Score
Acute coronary syndrome defines a spectrum of diseases (unstable angina, NSTEMI, STEMI), without clear ECG abnormalities the diagnosis and disposition can be challenging
Several scoring systems have attempted to risk stratify patients: TIMI, PURSUIT, and GRACE
The TIMI & PURSUIT scores were designed to identify higher-risk patients and long-term mortality
A pilot/observational study has utilized a novel scoring system to risk stratify low to intermediate risk patients
The HEART (History, ECG, Age, Risk factors and Troponin) score:
- 0-3 points ~ 2.5% risk (data supporting discharge)
- 4-6 points ~20.3% risk (data supporting observation)
- ≥7points ~ 72.7% risk (data supporting early invasive strategies)
This scoring system is limited given the small study size and requires further study/validation, but may be an easy, quick, and reliable predictor of outcome in chest pain patients
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Carbon Monoxide Half-Life:
- Average elimination on room air: 5-6 hours
- 100% Oxygen: 70-130 minutes
- 100% Oxygen under hyperbaric conditions at 3 ATA: 23 minutes
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Question
35 year-old carpet-layer presents with swelling of the superior portion of his knee that has progressively gotten worse over one week. He has no fever and has full range of motion (although pain is worse with movement). The knee is not tender to touch and the area is not erythematous or warm. What's the diagnosis?
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In a collaborative effort between the Illinois Poison Center and the Illinois Hospital Association, a new study sought to determine a poison center's effect on hospital length of stay (LOS) and hospital charges.
While the methodology was understandably complex, the authors compared ~5,000 toxicology inpatients with poison center assistance to 5,000 toxicology inpatients without poison center assistance.
After adjusting for confounders, the LOS among patients with posion center assistance was 0.58 days shorter compared to that of patients without poison center assistance (CI 95%: -0.66, -0.51, p<0.001). Though hospital charges for poison center-assisted patients in the lower quintiles were significantly higher than patients without poison center-assistance (+$953; p<0.001), they were substantially lower in the most costly quintile of patients (-$4852; p<0.001).
Poison center assistance was associated with lower total charges only among the most expensive to treat. However, this outlier group is very important when discussing medical costs.
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- “B-Lines” can be seen in patients with pulmonary edema (see attached image below)
- A “B-line” is a reverberation artifact defined by Lichtenstein as having several properties:
1. A comet-tail artifact
2. Arising from the pleural line
3. Well defined
4. Hyperechoic
5. Long (does not fade)
6. Erases A lines
7. Moves with lung sliding
- A large amount of B-lines is pathologic
- These artifacts are also called “comet-tails” due to their appearance
- One or two B-lines can be seen in dependent lung zones in normal lungs
- AIS (Alveolar interstitial syndrome) describes a group of conditions including pulmonary edema, interstitial pneumonia, and pulmonary fibrosis that show similar findings on lung ultrasonography
- The most common presentation of this syndrome is from cardiogenic pulmonary edema and is characterized by B-lines in multiple lung zones
- B lines correspond with interlobular septal thickening on CT scans, which represent pulmonary vascular congestion
Technique
- B-mode is used with the micro-convex (cardiac) probe scanning in at least 8 lung zones
- Quantify the number of B-lines in each zone
- A lung zone is considered to be “positive” when three or more B-lines are present in a longitudinal plane between two ribs
- Two or more regions bilaterally are required to be defined as AIS
- Bilateral diffuse B-lines have a specificity of 95% and a sensitivity of 97% for the diagnosis of pulmonary edema
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Hot off the press! Pediatrics March 2014 just published results of a meta-analysis that compared 1 or 2 dose regimens of Dexamethasone versus 5 day course of Prednisone/Prednisolone for management of acute asthma exacerbations in pediatric patients. The results showed that Dexamethasone was as efficacious as the longer course of Prednisone. End points used were return trips to the emergency department and hospital admissions. On further review of the literature, parents tend to prefer the shorter duration of therapy with Dexamethasone. Also, there is less vomiting associated with Dexamethasone. There have been several articles published that show Dexamethasone is more cost-effective than Prednisone. Bottom line: consider giving single dose of Dexamethasone in the ER and then sending patient home with 1 additional dose.