11.8.18 Conference Summary

Clinicopathological Conference #3: Drs. Christopher Peluso (PGY-2) and Dr. Riley Grosso (Emergency Medicine Attending)

Case presentation by Dr. Peluso

  • 17 yo F with PMH of depression on Fluoxetine presented for researching ways to harm herself. Otherwise denies complaints. Sexually active x1 2 years ago

  • Physical exam: thin appearing with sunken temporal spaces and cheeks; 2/6 early systolic murmur; otherwise unremarkable

  • CBC, EKG, UA, tox screen, and EKG unremarkable aside from low bicarb and K 3.1; microcytic anemia with H/H 10.5/31

  • Mom went home; patient began eating and drinking and was sleeping

  • At around 25h into hospital stay, nurse reports patient is now unresponsive and somnolent

  • HR 45 Sat 90%, RR 8, BP 100/72

  • General: ill appearing; pupils sluggish; Abdomen: soft but diffuse TTP; Neuro: globally weak with GCS 7

  • Narcan given, suctioned with residual emesis; patient was emergently intubated with RSI for expected clinical course, BG 117

  • A single test result then prompted the diagnosis of…

Rebuttal by Dr. Grosso

  • Fix imminently pressing issues: airway, breathing, circulation, stop seizures

  • Work up revealed metabolic alkalosis, hypokalemia, microcytic anemia, and mild thrombocytopenia

  • DDx: aortic dissection, ICH, stroke, encephalitis, hepatitis, refeeding syndrome, posterior fossa tumor, tox (benzo OD, ETOH, APAP OD, Iron OD, Lead, TCA OD), bulimia, anorexia, vitamin B6 deficiency, thiamine deficiency, hypercalcemia, hypothyroidism, seizure

  • Test ordered: phosphate level

  • Diagnosis: bulimia causing hypophosphatemia that was exacerbated by refeeding syndrome

Response by Dr. Peluso

  • TSH, urine and blood tox screens negative

  • ABG: hypercapnic resp failure

  • Phosphate 0.5

  • REFEEDING SYNDROME!!!! (She was researching how to kill herself without anyone understanding how she did it)

  • She stopped eating 4 days prior to arrival and began binging while in the department

  • Refeeding syndrome is caused by prolonged starvation leading to depletion of ATP; when you try to eat again, your body cannot make ATP from ADP fast enough so you become metabolically challenged; her HR and RR decreased

  • Signs of refeeding syndrome: signs of malnutrition, anemia, resp comprmoise, hyperglycemia, hypo Mg/K/Ca

  • Her CXR showed a bilateral white out consistent with ARDS (caused by decreased myocardial contractility and diaphragm weakness)

  • HEADS-ED questionnaire (helps predict suicidality in pediatric population)

    • Home, Education, Activities, Drugs/ETOH, Suicide/Sex, Emotions/Behavior, Discharge/Current Resources

    • Score >7 = SI factor of 2

  • Don’t dismiss cries for psychiatric help as non-medical

A Flaring Scaly Rash in the ED: Drs. Timmie Sharma and Robert Rothbaum (Dermatology)

  • 35 yo F with hx of chronic plaque psoriasis previously on MTX and cyclosporine but lost to follow up now presenting with new numerous scaly spots

  • No joint pain/stiffness, sore throat

  • Some urinary frequency frequency and bladder fullness; generalized malaise

  • PE: numerous circular scaling erythematous plaques and papules involving whole body including palms and soles of feet, worse on the R side

  • Papulosquamous (raised and scaling) eruptions DDx:

    • secondary syphilis

    • Reiter’s syndrome (reactive arthritis)

    • pityriasis rosea

    • guttate psoriasis (often preceded by strep pharyngitis)

  • Work up: ASO, GC/Chlamydia, Syphilis IgG , HIV Ag/AB screen

    • Syphilis IgG positive and ASO slightly elevated

  • Dx: Secondary Syphilis

  • Confirmatory testing with RPR or VDRL

    • False negative testing of RPR or VDRL can be seen with the “Prozone Phenomenon” (syphilis antibodies are in excess and are not forming Ag/Ab complexes so complexes are not being detected, which is what RPR and VDRL is testing for)

    • Needs serial dilutions to get accurate result

  • Treatment: single dose of 2.4 million unit of PenG IM is curative for primary or secondary syphilis; if PCN allergic, consider desensitizing and treating with PCN

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Community Emergency Medicine, STEMI without a Cath Lab: Dr. Cody Pollack, PGY-3

  • Only 1 in 3 hospitals in the US are PCI capable

  • Acute STEMI with no cath lab: transfer to PCI capable hospital vs TPA?

    • Mortality benefit if transfer for PCI if symptoms less than 12 hours

  • If you find yourself <120 minutes from PCI hospital, give DAPT with ASA and ticagrelor, heparin and transfer

  • Mortality benefit at 5 weeks s/p TPA

  • If giving TPA at community ED, consider giving clopidogrel instead of ticagrelor

  • Choice of fibrinolytic?

    • Tenecteplase is considered standard of care and has mortality benefit over Streptokinase

  • Complications after fibrinolytics

    • Bleeding (primarily GI-related)

    • Stroke (1% risk)

  • Fibrinolysis failure?

    • Persistent ischemic EKG findings

    • Transfer to PCI facility emergently

  • Fibrinolysis success?

    • EKG shows improving ischemia

    • PCI should be performed within 6 hours after tenecteplase or TPA

  • Overall PCI > Fibrinolysis

  • PCI should be ideally performed within 120 minutes (door to balloon time)

  • Fibrinolysis is best within 30 min door to needle time and within 6 hours of symptom onset

  • Most common arrhythmia after fibrinolysis: accelerated idioventricular rhythm (AIVR)

    • Benign and does not require treatment

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EM/Trauma Collaborative Lecture Series, Trauma in Pregnancy: Dr. Justin Lappen

  • Caveat in OB and trauma research: all studies thus far are retrospective in nature, so utility is questionable

  • Physiologic changes in pregnancy

    • Increased blood volume/Preload (increased plamsa primarily, leading to functional anemia)

    • Increased TV, but no change in RR

    • Increased HR (~10 beats/minute)

    • Chronic hyperventilation from increased TV leading to chronic respiratory alkalosis and compensatory metabolic bicarb wasting in the kidneys

    • Blood gases vary by gestational age

    • Increased oxygen demand

    • Compression of IVC after 20 weeks leading to decreased venous return

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  • Patters of injury in pregnancy

    • More abdominal trauma as gestational age increases

    • Less head and chest trauma

    • “Uterine shield” leads to less abdominal organ injuries

  • Pregnancy specific injuries:

    • SAB

    • Placental abruption

    • Uterine rupture

    • PPROM

    • IFUD

    • Red cell alloimmunization

    • Amniotic fluid embolism (not really an embolus; more of a anaphylactic maternal reaction to fetal RBCs)

  • Placental abruptions can be common and severe even without severe traumatic mechanism or outward injuries

    • May be delayed several hours after injury

  • Minor trauma is not inconsequential

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  • Evaluation and management of traumatic pregnant patients

    • Prehospital care is similar to non-pregnant patients

    • Avoid hypotension and hypoxia as much as possible

    • Lower threshold for intubation

    • Keep 30 degree tilt of abdomen to the left

    • If performing chest compressions, can manually displace uterus to the left with hands

    • OB assessment should come after secondary survey

    • Primary cause of fetal death is maternal death

    • Work up: CBC, BMP, type and screen, fibrinogen (best predictor of massive transfusion requirement), coag panel, KB test (helps determine amount of RhoGam necessary to prevent

    • Maternal imaging studies should not be deferred over concerns for fetus if necessary for adequate for maternal assessment

    • Exposure in pregnancy should be kept to <5 rad

  • Stratification by Gestational Age

    • Prior to 22-23 weeks: resuscitation aimed at mother

    • >23-24 weeks, consider as two patients; must monitor and support both

  • “4 Minute” Rule

    • If CPR ineffective at 4 min (with no ROSC), perform C-section

    • Maternal/fetal survival benefit

    • Maternal hemodynamics are improved and increased chance of ROSC

    • Irreversible maternal CNS damage at 5-6 min

  • Indications for delivery:

    • Obvious uterine injury

    • Abruption with coagulopathy

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Ultrasound Lecture Series: Musculoskeletal: Dr. Ben Boswell (Departments of Emergency Medicine and Sports Medicine)

  • Musculoskeletal ultrasound: aim small, miss small

  • Normal appearance on ultrasound:

    • Muscle: relatively hypoechoic, separated by hyperechoic fibrotic bands or septa

    • Tendons: hyperechoic bands

    • Ligaments: look like tendons, but more compact compared to tendons

    • Bone: very hyperechoic with posterior acoustic shadowing and possibly reverberations

  • Muscle tear vs Muscle scar: tears will look more hypoechoic and scars more hyperechoic

Muscle Scar

Muscle Scar

Muscle Tear

Muscle Tear

  • Tendonitis: fluid around tendon due to inflammatory changes

  • Bone Fractures: break in periosteum will be hyperechoic

  • Moral Lavallee Lesion: sheering of fascial tissue resulting in fluid collection

    • Commonly occurs from cleats in sports-related injuries

  • Rotator cuff tears: supraspinatus is most commonly injured

  • Proximal biceps tendon tear will be pulled out of bicipital groove

  • Ganglion cysts will appear as circular hypoechoic fluid collections that are mobile

  • Patellar tendon rupture will show large hematoma and high riding patella

Normal Patellar Tendon

Normal Patellar Tendon

Patellar tendon rupture

Patellar tendon rupture

  • Maisonneuve fracture: injury of distal deltoid ligament and proximal fibula fracture; unstable and requires urgent orthopedic follow up and possible operative fixation

  • Medial gastrocnemius tear (aka tennis leg) can feel similar to achilles tendon tear but is more proximal


Tox Series: House Fires, Dr. Blain Tesfaye, PGY-1

Carbon Monoxide

  • Carbon monoxide is an odorless, colorless gas that dissociates oxygen from hemoglobin with high affinity and shifts dissociation curve to the left

    • Sources: clogged chimney, car running in garage, space heater, house fires, “mud bogging”, gasoline generator, wood burning fireplace

  • Symptoms: headache, ataxia, dizziness, fatigue, confusion, tachycardia, cherry red skin

  • SpO2 is usually normal (pulse oximeter mistakes CO for O2 and cannot differentiate between the two)

  • Carboxyhemoglobin is diagnostic test of choice

  • Other labs: ABG (respiratory alkalosis, metabolic acidosis), lactate, blood glucose level, EKG, troponin, CK, BNP, echo, +- CT/MRI

  • Treatment: 100% O2 via NRB, fluids or inotropes for hypotension

  • Indications for hyperbaric treatment

    • Syncope, LOC, seizure, COOX >25% in non-pregnant and >20% in pregnancy, prolonged exposure


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Hydrogen Cyanide

  • Pungent gas that smells of bitter almonds

  • Sources: suicide attempt, sodium nitroprusside at high doses, burning wool/silk/rubber, cassava

  • Labs to consider: ABG, lactate, RFP, whole blood CN concentration (takes >24 hours to return)

  • Lactate out of proportion to pH

  • Treatment: hydroxocobalamin 5g IV over 15 minutes (Cyanokit)

    • Side effects of antidote: hypertension, red urine (chromaturia), pink skin

Hydrogen Sulfide

  • Pungent gas that smells of rotten eggs

  • Found in waste and excrement as a by-product

  • Classic case is an environmental worker without protective mask that goes into an underground well and suddenly passes out

  • Symptoms: lacrimation, rhinorrhea, SOB, tachypnea, palpitations, pulmonary edema

  • Antidote: sodium nitrite (induces methemoglobinemia)

Supertrack Series: Approach to Headache, Dr. Zac Rasmussen, PGY-1

  • Headaches account for 3% of all ED visits

  • Red Flags as a clue to life-threatening pathologies

    • Change in headache compared to baseline

      • Tumor

    • Fever

      • Meningitis, Encephalitis

    • Age >50

    • Trauma (particularly if on anti-platelets or anti-coagulants)

    • Abrupt Onset

      • Coitus, Posterior Reversible Vasoconstriction Syndrome, SAH

    • Exertional

      • Temporal Arteritis, ICH

    • Pregnancy

      • Pre-eclampsia vs Eclampsia

    • Multiple patients

      • Concerning for CO (must eval for source)

    • Focal neurologic deficits

  • Benign causes of headaches:

    • Migraine: unilateral, pulsating, n/v, photophobia and phonophobia, 4-72 hours in duration

    • Tension headache: bilateral, pressure-like, starts with trigger, lasts 30 min-7 days

    • Cluster headache: unilateral, near eye or temple, associated with lacrimation/rhinorrhea/sweating, lasts 15 min-3 hours

      • Treatment: HFNC

  • Treatment Options:

    • Antidopaminergic

      • Prochlorperazine (Compazine)

      • Metoclopramide (Reglan)

        • Studies show these are superior for headache relief compared to other treatment options

    • Antihistamines

      • Diphenhydramine (Benadryl)

        • Used to decrease akathisia associated with antidopaminergic agents

    • IV fluids

      • Beneficial if dehydration is a possible component

    • NSAIDS/Acetaminophen

      • Ketorolac (Toradol)

        • Beneficial for pain relief

        • 15 mg IV is as effective as 30 mg IV with fewer side effects

      • Naproxen and acetaminophen

    • Other options

      • Dexamethasone

        • 8-16 mg IV given to reduce recurrence

        • NNT = 9

      • Sumatriptan

        • Primarily used in outpatient settings

        • Contraindications: hx of ischemic heart disease

      • Valproic acid

        • Contraindicated in pregnancy

      • Magnesium

        • Mixed results in terms of pain relief

      • Haloperidol 5 mg IV

      • Propofol

      • Ketamine

      • Occipital or Sphenopalatine Nerve blocks

  • Opiates should NOT be used for the acute treatment of headaches as they have no significant effectiveness on pain relief and may make treatment more difficult in the future

  • Large single doses are more effective than multiple lower doses