11.15.18 Conference Summary

Clinicopathological Conference #4:

Drs. Janel Paukovits (PGY-2) and Dr. Colin McCloskey (Emergency Medicine Attending)

Case Presentation by Dr. Paukovits

  • 50 yo F w/ CC of headache, light sensitivity and dizziness and neck pain

  • VS show BP 90/72 and HR 56, otherwise WNL; weight: 136 kg

  • PMH: abdominal aortic dissection repair in 2016, COPD, HFpEF, HTN, hypothyroidism, fibromyalgia, GERD, CAD, anemia, anxiety

  • PSH: dissection repair in 2016, ABG in 1999

  • Social hx: former smoker and former ETOH use; currently homeless

  • Had a cardiac cath 4 months ago that was normal, having congestion, headache, R eye puffiness since then; she believes she has a sinus infection

  • Her L hand felt weak while in the shower this morning and the room felt like it was spinning

  • R hand feels numb and tingly since this AM

  • PE

    • Obese

    • Edema of bilateral eyelid

    • No meningismus; no rashes; neck appears unremarkable

    • L leg is edematous, erythematous and larger than R; soft systolic murmur

    • Negative HINTS exam

    • Weakness in L hand grip, numbness in R fingers

  • CXR with sternotomy wire and cardiomegaly

  • CT head WNL

  • CBC shows pancytopenia, BNP mildly elevated, otherwise labs unremarkable including Troponin, CMP, TSH; slightly elevated INR

  • EKG with sinus bradycardia, unchanged

And a diagnostic test was ordered…..


Reply by Dr. McCloskey

  • Must identify and pin down a timeline

  • Identify outliers

  • Is this one unifying diagnosis or multiple diagnoses coalescing?

  • 4 months of neck pain since medical procedure; 1 month of LE edema; 1 week of congestion and headache; 3 days of worsening neck pain; this AM, dizzy, lightheaded, dizzy, weak

  • VS: bradycardia and hypotensive

  • Outliers in this case: bradycardia with narrow pulse pressure, eyelid puffiness, temporal relationship with cardiac cath via R radial approach, neck pain, neuro symptoms

  • Bradycardia: could be normal?

    • Iatrogenic medications

    • Things Dr. McCloskey cares about: MI, tox, MOSF, hypothyroidism, increased ICP

  • Narrow pulse pressure?

    • Hypovolemia

    • Decreased contractility

    • Valvular problems

  • Eyelid puffiness?

    • Venous congestion

    • Angioedema

    • Carotid dissection

    • Hypothyroidism

  • Right trans-radial heart cath

    • Complications: hematoma, AV fistula, pseuodaneurysm, cerebral emboli (usually silent)

  • Neck pain?

    • Carotid artery injury

    • Mass lesions

    • Thrombophlebitis

    • Thyroiditis

  • Occam’s Razor?

    • One diagnosis explains every symptom

    • More common in otherwise healthy patients who present with new symptoms

  • Hicam’s Dictum?

    • Multiple diagnoses are at play that explain multiple symptoms

    • More common on chronically morbid patients

Diagnostic test of Choice by Dr. McCloskey: TSH with reflex to T4


Rebuttal by Dr. Paukovits

  • US placed on her bilateral neck where her pain was located and a clear carotid dissection with flap was identified

  • Bedside echo showed no pericardial effusion

Carotid Dissection with Intimal Flap

Carotid Dissection with Intimal Flap

  • Test of choice ordered: CTA head/neck/chest

    • Ascending aortic dissection with flap extending to proximal aortic valve and bilateral carotid arteries and L subclavian artery and L main coronary artery with aneurysm

  • PE not initially given:

    o    R radial pulse < L

    o    R arm BP 90/59

    o    L arm 127/70

  • ·Long operative course with CABG repair, aortic valve replacement, dissection repair into subclavian and carotid arteries

  • POCUS for Type A aortic dissection:

    • Sensitivity 59-83%

    • Specificity 63-93%

  • Take Home Points: Check your bias, keep your differential broad, Use POCUS to guide your testing and direct triage

The Changing Face of Procedural Sedation in Children: Dr. Anne Stormorken

Peds Sedation.jpg

Most common procedures requiring procedural sedation

  • Tongue lacerations

  • Lumbar puncture

  • Bronchoscopy

  • Procedural medication combos used in past in pediatric population

    • LP/Bone marrow biopsy:Demerol/phenergan/thorazine, midazolam, and fentanyl

    • Laceration/Abscess: local and papoose board

  • Conscious sedation: “a medically controlled state of depressed consciousness that allows the maintenance of normal, protective reflexes”

  • Sedation had been inconsistent in the 80s and 90s and adverse events were more common

  • The term “conscious sedation” was removed in 2002 and replaced with “minimal/moderate/deep/general anesthesia”

  • Minimal sedation: patient responds normal to verbal commands; cognitive function and coordination impaired, but lung and cardiac function unaffected

  • Moderate sedation: patient has a depressed level of consciousness but can respond to verbal commands either alone or by light touch; lung and cardiac function is unaffected

  • Deep sedation: patient cannot be easily aroused but responds purposefully to noxious stimulation; may require assistance to maintain airway patency

  • Serious adverse events associated with sedation

    • Airway obstruction

    • Aspiration

    • Cardiac arrest

    • Death

    • Laryngospasm

    • Unplanned admission

    • Unplanned intubation

  • Dexmedetomidine

    • Very effective with adverse event rate near 3%

  • Propofol is the most commonly used pediatric sedative and has the largest amount of research behind it

    • Higher AE rate than other agents primarily related to bradycardia and bradypnea

  • Ketamine

    • Most commonly used in pediatric population for short painful procedures

  • Pediatric literature supports NPO status for 4 hours prior to sedation as very low AE rate when this timeframe is met

  • Choice of sedative agents depend on a number of factors:

    • What are the desired effects?

    • How fast are the effects?

    • How long do the effects last?

    • Are there undesirable or contraindicated effects associated with the regimen?

  • Options?

    • Nitrous Oxide

      • Less often used in emergency situations today

      • Minimal risks and side effects as a single agent

      • Avoid with pneumothorax

    • Midazolam

      • Reliable sedation with effects that last ~5-20 min

      • Respiratory depression is a side effect

    • Ketamine

      • Dissociative sedation with amnestic effects

      • IV, IN, PO

      • Rapid onset and offset with IV bolus

      • Airway reflexes and cardiovascular stability is maintained

      • Emergence phenomenon and increased secretions

    • Etomidate

      • Rapid onset

      • Risk of adrenal suppression, particularly in patients with hx of adrenal insufficiency

    • Propofol

      • Sedative, hypnotic, and amnestic effects

      • No analgesia

      • Rapid onset and easily titratable

      • Better when longer sedation is required

      • Disadvantages: hypotension, respiratory depression

    • Dexmedetomidine

      • Sedative-hypnotic

      • Minimal respiratory depression; some bradycardia is possible due to AV nodal blockade

      • Less effective as a single agent

      • Slower onset and longer recovery

    • Pentobarbital

      • Rapid onset but very long half life with prolonged recovery

      • Emergence delirium, agitation and rage in up to 10% of children

    • Ketamine and propofol

      • 0.5 mg/kg each results in less total medication needed

EBM: Non-Pregnancy Vaginal Bleeding in the Emergency Department,

Dr. Elena Castleberry (PGY-3)

blood.jpg
  • Evaluation

    • Current bleeding, pain, odor, systemic symptoms, OB/GYN history, bleeding disorders, history of GYN family cancers or bleeding problems, smoking history, medication use (AED, hormones, herbal remedies)

    • Bleeding history: current pattern, amount, onset, duration, presence of clots, history of similar clots, presence of heavy bleeding (changing pads/tampons > Q3H, clot presence)

    • Use of anticoagulants, antidepressants, recent OCP use, tamoxifen, 1st generation anti-psychotics, herbs (ginseng, chasteberry, danshen)

  • Differential

    • PALM-COEIN pneumonic

      • Polyp

      • Adenomyosis

      • Leiomyoma

      • Malignancy

      • Coaglulopathy

      • Ovulatory

      • Endometrial

      • Iatrogenic

      • Not otherwise specified

  • Work-up

    • Pregnancy test, infection screening, ultrasound, Coag screen, thyroid studies

  • Management of stable patient

    • NSAIDs

      • Start day before menses begins and until bleeding stops

        • Naproxen 500 mg BID x 5 days

        • Ibuprofen 800 mg TID x 5 days

    • PO TXA

      • More effective than NSAIDs

      • Expensive ($60 Rx)

      • Does not treat pain

      • 1-1.3 g PO TID x 5 days

    • OCPs

      • Some combo of ethinyl estradiol and progrestone

      • No consensus on dosing

      • Some evidence for 35 mcg ethinyl estradiol TID for 7 days followed by completion of pack

        • 88% of women had cessation of bleeding by day 3

        • Associated with nausea and vomiting; consider prescribing anti-emetic with OCP

        • Options: Ortho-Cyclen, Sprintec, Previfem, MonoNessa

        • Contraindications: migraines with aura, smoking, hx of DVT or PE, obesity, SLE, AEDs, DM with complications, uncontrolled HTN, hx of malignancy

        • Patients can still get pregnant in the 1st 7 days!!!!

      • Progestin-Only

        • Better for women with contraindications to estrogen

        • Options: medroxyprogesterone, MPA, norethindrone

        • No consensus

        • Some evidence for 20 mg PO medroxyprogesterone TID x 7 days

        • Some evidence for norethindrone 5 mg 1-2x/day for 7 days

        • Contraindications: hepatic dysfunction, hx of breast cancer, hx of DVT or PE, hx of malabsorption

    • Overall recommendations:

      • For mild bleeding, consider NSAIDs if patient has no contraindications

      • Moderate/Failed NSAIDs

        • OCP: 1 pill TID x 7 days and finish pack

        • Progestin:

          • IM depot 150 mg and 3 days of 20 mg medroxyprogesterone

          • 20 mg medroxyprogesterone TID x 7 days

    • Patient counseling

      • STD risk

      • Take the pill every day, same time

      • Breakthrough bleeding is still a risk

      • Side effects: weight gain

  • Management of unstable patient

    • ABCs, resuscitate

      • Per ACOG guidelines, 2-4 units O- PRBCs

      • Per ACOG guidelines, 6:4:1 ratio of PRBCs: platelets: FFP

        • However, this trial was retrospective and done in the OR

      • PROPPR trial:

        • 1:1:1 trial in any patient with hemorrhagic shock

        • More applicable in the ED for shock associated with vaginal bleeding

      • 25 mg IV estrogen q4-6h x24h

      • TXA 1 g IV over 10 min

        • PE and DVT side effects no more significant than placebo

      • Foley catheter, Bakri balloon, or Rusch balloon also option until definitive management available

      • Endometrial ablation

      • Uterine artery embolization

      • Hysterectomy

Journal Club: Beyond the Patient in Front of You, Public Health in the ED;

discussion led by Dr. Justin Yax (EM Attending)

Pertussis Vaccination in Adults - Dr. Sara Pope

Yorkgitis et al. Surgery, 2015

  • Web based national survey sent to trauma centers requesting information about tetanus vaccination and which version given to trauma patients (tetanus/diphtheria (Td) vs tetanus/diphtheria/acellular pertussis (Tdap))

  • 61% completion rate of survey

  • Level 2 trauma centers had the highest rate of pertussis vaccination at 61%

  • Findings/Conclusions: There has been an increase in pertussis rates recently so giving the Tdap vaccine (as compared to the Td vaccine) can help significantly decrease the healthcare burden of this disease

HIV.jpg

Missed opportunities for HIV prophylaxis in the ED - Dr. Andrew Bloom

O’Donnell et al. Annals of Emergency Medicine, 2016

  • Retrospective database study used to determine what rate of occupational vs non-occupational patients that had a “blood or bodily fluid exposure” received HIV prophylaxis in the ED

  • Included patients from a single ED from 2007-2013

  • Findings/Conclusions: High risk non-occupational exposure patients were NOT given HIV prophylaxis at 2x rate of occupational exposure patients, with 1.9% of non-occupational exposure patients seroconverting at 6 months

Derivation and Validation of Denver HIV Score for Targeted Screening - Dr. Daniel Summers

Haukoos et al. American Journal of Epidemiology, 2011

  • Demographic information was collected in Denver from 1996-2008 to identify high risk patients for HIV infection

  • Multivariate logistic regression was used to develop a scoring system using 48 variables and 92,000 patients

  • Validation study was performed in Cincinnati, OH from 1998-2010 at an Urban ED including 22, 983 patients

  • Scoring system variables include age, gender, race, sex with a male, vaginal intercourse, anal receptive intercourse, IV drug use, and past HIV testing

  • Scores ranged from -14 to +81

  • Score <20 have HIV prevalence of 0.31%; score 20-29 have prevalence of 0.41%, scores 30-39 have prevalence of 0.99%, scores 40-49 have prevalence 1.59%, scores >50 have prevalence of 3.59%

  • Findings/Conclusions: The Denver HIV risk score accurately categorizes patients into groups with increasing probabilities of HIV infection

Prevalence of Diagnosed and Undiagnosed Hepatitis C in the ED - Dr. Laura Throckmorton

Lyons et al. Clinical Infectious Disease, 2016

  • Cross-sectional seroprevalence study using de-identified blood samples and self reported health information in ED patients aged 18-64 yo in single urban ED

  • Primary outcome: HCV antibody was detected in 128 of 924 of blood samples (14%); 103 had HCV RNA indicating active disease; 44 of these 128 samples (34%) had self reported HCV or unknown type hepatitis

  • Findings/Conclusions: HCV infection is highly prevalent in EDs and testing is worthwhile in high-risk patient populations