Question
24 yo woman presents with syncope, abdominal pain, and normal menses 4 days prior. Urine HCG(+) and quantitative beta-HCG is 1300 with the transvaginal ultrasound seen below. Diagnosis?
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The long QT syndrome and causes of acquired long QT interval are well-known to most emergency physicians, but a short QT can be problematic as well. Short QT-syndrome is an inherited ion-channel disease that predisposes to ventricular dysrhythmias and sudden death. The QTc in these patients is generally < 340 msec. This condition is more common in children, and it should be considered in the differential diagnosis and evaluated on ECG in children presenting with syncope.
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Sever's disease ,aka calcaneal apophysitis, is a common overuse injury in the pediatric and adolescent population.
Occurs secondary to traction of the calcaneus that most often occurs in young athletes (8-12 yo)
-Avg. age of presentation is 11 years 10 months in boys & 8 years 8 months in girls
-Repetitive traction to the weaker apophysis, induced by the pull of the Achilles on its insertion
Hx: Heel pain that increases with activity (running, jumping).
-May involve one (40%) or both (60%) feet
PE: Tenderness of the posterior heel at the Achilles tendon insertion and ankle dorsiflexor weakness
Imaging: Radiography is often normal. When positive, show fragmentation and sclerosis of the calcaneal apophsis. NOTE: These findings are nonspecific and also are observed in asymptomatic feet.
http://t0.gstatic.com/images?q=tbn:ANd9GcQ9R-fx1iyhbhNJpNL2W72bWdK72_mRBLNX5DUDtcMfnDli-x7Ong
DDx: Includes osteomyelitis and tarsal coalition.
Tx: Rest from aggravating activities, NSAIDs, ice (both pre and post sport). When pain free a program of stretching (gastrocnemius-soleus), strengthening (dorsiflexors) and shoe inserts (heel cups, lifts, pads, or orthotics) can provide significant pain relief.
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- disorder in which the entire left side of the heart is underdeveloped
- the right side of the heart is dilated and hypertrophied, and supports both the systemic and pulmonary circulations via PDA
- accounts for nearly 1/4 of all cardiac deaths in the first year of life
- infants present within the first days or weeks of life acutely ill with signs of CHF
- PE often shows cyanosis and poor pulses but hyperdynamic cardiac impulses
- CXR shows cardiac enlargement and prominent pulmonary vasculature
- EKG shows RA and RV hypertrophy
- echo is diagnostic
- acute treatment is PGE1 to maintain the PDA.
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Continuing with the synthetic/designer drug theme. Last time we were discussing synthetic marijuana. Another old drug making a resurgence under the designer drug category is mephedrone.This amphetamine-like drug has been purportedly the active substance in "bath salts". It has also been sold as "plant food" - still trying to figure that one out.
Sold in head shops under the name Bliss or Cloud 9 - they have been reported to be available in Baltimore, MD recently. They can also be bought over the internet. Crushed, snorted or ingested, the effect is similiar to cocaine with a largely sympathomimetic toxidrome. Mephedrone has been labeled an entactogen with users behaving similiar to an MDMA ingestion. A Baltimore news station incorrectly called it "synthetic cocaine" - though the effect may be similiar, completely different molecular structure.
Treatment is cooling, check lytes (especially sodium), check for rhabdomyolysis and sedation with benzodiazepines. Below is one link from a Denver News Station. Attached is a picture of a bath salt product.
The latest and greatest on the street - synthetic marijuana and bath salts!
http://www.thedenverchannel.com/news/26567376/detail.html
Attachments
- A simple febrile seizure (SFS) is generalized, tonic-clonic in type, and occurs in children between the ages of 6 months and 6 years of age, lasting less than 15 minutes and NON-recurring in a 24 hour period.
- According to the 1996 guidelines of the American Academy of Pediatrics (AAP) and based on the consensus that seizure is a common presenting symptom of bacterial meningitis, the following indications should be used to determine whether lumbar puncture (LP) is performed in patients presenting with SFS:
-- 6 to 12 months > "strongly consider" LP
-- 12 to 18 months > "consider" LP
-- 18 months and up > LP not routinely necessary; may consider after clinical assessment
-- Any infant/child with recent antibiotic treatment plus SFS > "strongly consider" LP
- Despite these relatively outdated guidelines based largely on retrospective data, more recent literature suggests that serious bacterial infections such as meningitis are very rarely associated with simple febrile seizures, such that guidelines and practice paradigms may soon change.
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Hemodynamic Monitoring in the Ventilated Patient
- Consider pulse pressure variation (PPV) as a method to monitor volume responsiveness in your mechanically ventilated ED patients.
- The theory behind PPV:
- When a positive pressure breath is delivered via the ventilator, pleural pressure rises and causes a decrease in venous return, right heart filling, and right heart output.
- Simultaneously, the positive pressure breath causes an increase in left heart filling and a decrease in left heart afterload. This is reflected clinically as an increase in blood pressure.
- Within a few beats, the decreased right heart output is transmitted to the left heart resulting in a decrease in blood pressure during expiration.
- Patients who are volume depleted can have significant differences in blood pressure between inspiration and expiration - i.e. a large variation in pulse pressure.
- PPV values > 12% have been shown to identify patients who are volume responsive.
- Importantly, PPV works best in vented patients who have no spontaneous respiratory effort, are in sinus rhythm, and receiving 8 ml/kg tidal volumes.
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[Here's a nice simple pearl from Jeff Tabas, MD (Prof of EM at UCSF).]
3 causes of bradycardia to consider when the rhythm is not clearly sinus bradycardia:
1. Junctional bradycardia
2. Hyperkalemia
3. Digoxin toxicity
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Distal Radius Fractures
Typically distal radius fractures are treated with closed reduction and splinting in the ED, followed by operative repair. This is done because it is felt that patients will have the best functional outcomes if the bones are restored to their normal anatomic alignment. However, two studies published in 2010 suggest differently.
The study by Neidenbach showed that after one year there was no difference in functional outcomes between patients that were just splinted in the ED in the position the fracture was found versus those that had closed reduction with splinting.
The second study by Ego showed that there was no difference in outcomes between those that underwent conservative treatment with closed reduction and splinting versus those that underwent operative repair.
The take home point from these studies for the EM physician is that most distal radius fractures can be splinted in the position found with them following up with an orthopaedist. There is probably little advantage to performing a closed reduction in the ED knowing that this procedure can use a lot of valuable time and resources.
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Sold under the name of K2, Spice. Patients exposed to this will present with dry mouth, paranoia, tachycardia, hallucinations but will resolved rather quickly over several hours. Observation in the ED and supportive care is usually all that is needed. A little history about synthetic marijuana:
- JWH-018 is a synthetic cannabinoid (SC) that acts at cannabinoid receptors.
- Synthetic cannabinoids were created s in the 1960’s and continued to be developed as appetite stimulants (e.g., dronabinol).
- The JWH series of SCs are named for the chemist who first synthesized them, John W. Huffman, Ph.D. (thus the JWH prefix).
- SCs recently appeared for sale in smoke shops and other outlets (such as gas stations) as herbal incense.
- These products contain plant material that mimics smell and appearance of marijuana but is adulterated with one or more SCs.
Attachments
- Procedural sedation consists of administering sedatives (i.e. midazolam, etomidate, propofol) or dissociative agents (i.e. ketamine) with or without opioid analgesics such as morphine and fentanyl.
- The widespread use of ketamine for procedural sedation may be limited by physician concern about unpleasant, vivid dreaming, hallucinations, and reactions after its administration known as recovery agitation. This has been found to occur in 12 percent of cases and is seen less often in youth.
- In some instances, ketamine might be considered more ideal than other procedural sedation agents because it provides sedation, analgesia, and an amnestic-like dissociation between mind and body.
- Recent studies have shown that administering ketamine with a benzodiazepine such as midazolam significantly reduces the incidence of recovery agitation following procedural sedation; this alternative might therefore be considered when appropriate.
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- McConnell sign is right ventricular (RV) free wall hypokinesis with normal apical contraction on echocardiography.
- Finding McConnell sign has been associated with submassive and massive pulmonary embolism (PE) when moderate to high clinical suspicion exists. This is important if unstable patients are unable to tolerate other diagnostic studies.
- After its description, the specificity of McConnell sign’s for PE has been questioned, as other pathologies can produce it (e.g., RV infarction and severe pulmonary HTN).
- The paper referenced below retrospectively found that the sensitivity, specificity, positive predictive value, and negative predictive value of McConnell sign for diagnosing PE was 70, 33, 67, ad 36%, respectively.
- Bottom line: The McConnell sign must be used with caution if used alone to diagnose PE; especially if thrombolytics are being considered.
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Question
(Please note the prior version of this pearl was incorrect with respect to the images referenced. This version is corrected.)
Patient s/p blunt chest trauma. CXR (image 1) vs. lung ultrasound (image 2), do you see any inconsistencies?
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Is there a difference in the workup, etiologies, or prognosis between patients with syncope vs. near-syncope? Traditional teaching indicates that there is no difference, but that doesn't necessarily reflect common practice. Physicians sometimes are a bit less concerned about patients with near-syncope vs. patients with true, full-blown syncope; and many syncope studies exclude patients with near-syncope.
Grossman and colleagues recently published a useful reminder that patients with syncope and near-syncope have a similar 30-day rate of adverse outcome. However, they have a lower admission rate, reflecting the lower level of concern physicians have in their evaluation. Be wary of those patients with near-syncope. Don't be reassured just because they didn't hit the floor...yet!
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- normal mental status
- no loss of consciousness
- no vomiting
- non-severe injury mechanism
- no signs of basilar skull fracture
- no severe headache
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Many consider Paracelsus (1493–1541) as the father of modern toxicology.
- He was the first to emphasize the chemical nature of toxic agents.
- He stressed the need for proper observation and experimentation regarding the true response to chemicals.
- He underscored the need to differentiate between the therapeutic and toxic properties of chemicals when he stated in his Third Defense, "What is there that is not poison? All things are poison and nothing [is] without poison. Solely, the dose determines that a thing is not a poison."
The introduction of the dose–response concept might have been his most important contribution to toxicology, meaning that everything is toxic at the right dose (even oxygen and water).
- The benefit of IV alteplase (tPA) beyond the conventional window of 3 hours after onset of stroke symptoms was established by the randomized ECASS III Trial, which compared treating acute ischemic stroke with IV alteplase versus placebo, between 3 and 4.5 hours (median 4 hours).
- The study found a significantly more favorable outcome amongst participants who received alteplase (odds ratio 1.34, 95% CI 1.02 - 1.76). The overall number needed to treat was 14.
- The standard exclusion criteria used in this study differed from those of others, and these characteristics must be taken into account when deciding which patients are eligible for treatment at up to 4.5 hours.
- Therefore, data from ECASS III can not be used to support treating at up to 4.5 hours in the following types of patients:
-- Age > 80 years old
-- NIH Stroke Scale > 25
-- History of combination of previous stroke and diabetes
-- On anticoagulation medication, regardless of INR
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Acute LV Dysfunction in the Critically Ill
- Approximately one-third of critically ill hospitalized patients develop acute LV dysfunction, most often due to a stress-induced cardiomyopathy.
- In these patients, up to 25% develop an acute dynamic LV outflow tract obstruction.
- Consider acute LV outflow tract obstruction in hypotensive patients with a new systolic ejection murmur in the left parasternal area.
- Aggressive IVFs is central to the management of these patients with LV outflow tract obstruction.
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Great resource for teaching in the emergency department....
Here is a great new app that you can use when teaching residents and students in the ED. It's the NEJM app. Great pics, videos, audio, procedures, and articles. And, it's FREE.
Just go to the App store and search "NEJM"