Tuesday Advanced Cases

Critical Cases – Compartment Syndrome!

by Carlos Cevallos M.D.

Case:

A 60 year old male with a PMH of DM, HTN, HLD, MI presents to the ED after being found down with waxing and waning mentation. The patient complains of abdominal pain and diffuse myalgias.

BP 76/56, HR 92, Temp 98.4F, RR 22. 

Physical exam

Pressure wounds of the right rib cage, right side of his forehead

Right calf tenderness with a firm anterior compartment, cool/pale right lower extremity, dorsalis pedis and posterior tibial pulses were unable to be palpated.

ECG:

ECG interpretation: Peaked T waves, widened QRS concerning for hyperkalemia

Clinical course:

1L bolus of LR

IV calcium gluconate for possible hyperkalemia

Surgery was immediately consulted due to concern for compartment syndrome

Labs were notable for a potassium of 7.2, creatinine of 3.49, creatinine kinase of 188,760, a lactate of 4.0, and ALT/AST in the 3,000s/5,000s

Given intermittent hemodynamic instability a dialysis line was placed for definitive hyperkalemia management

Patient underwent emergent lower extremity fasciotomy with surgery

Compartment syndrome learning points:

·       Diagnosis is both clinical and by compartment pressure measurements

·       Compartment pressure >30mmHg or a delta pressure <30mmHg (diastolic BP – compartment pressure) is diagnostic

·       Clinical findings: 6Ps. Pain is the earliest and often only symptom, the rest are late findings.

o   Pain out of proportion to the exam (most common finding)

o   Pallor

o   Paresthesia

o   Paresis/paralysis

o   Pulselessness

o   Poikilothermia

·       Management: Immediate surgical consult for fasciotomy

Tuesday Advanced Cases

Critical Cases – Hypertensive Emergency!

by Dr. Sarah Perelman M.D.

Today’s case from the EM Daily archives involves one of the rare patients where you DO want to acutely treat elevated blood pressure with intravenous agents….

HPI

  • 48 year old male with PMH HTN presents with blurry vision for 2.5 hours 
  • Patient was using the computer tonight, could not see where the icons were on his desktop, could still see light/colors.
  • He has no pain in his eyes
  • Also reports dyspnea on exertion for 2 days. No headache, no chest pain, no abdominal pain
  • He has not had his anti-hypertensives (he reports he is on 5 different medications) for about 1.5 weeks

Physical Exam

T 98.3 BP 290/120, HR 118, RR 18, SpO2 99%

  • Patient is awake, alert, conversant, appears well and in no distress
  • Neuro: Visual acuity 20/200 OS, OD, OU Normal visual fields Normal pupillary exam Normal extraocular movements Otherwise normal cranial nerve exam Normal strenght in extremities , no pronator drift, normal finger to nose
  • Cardiac: tachycardic, normal S1/S1, no murmurs/rubs/gallops
  • Pulm: clear to auscultation bilaterally
  • Abdomen: soft, nontender, nondistended

Differential Diagnosis 

  • Hypertensive emergency with elevated BP and evidence of end organ damage (decreased visual acuity, evidence of pulmonary edema on bedside US) 
  • Sympathomimetic toxicity (hypertension, tachycardia), though patient reports no ingestions of medications or drugs
  • Thyrotoxicosis 
  • CVA given visual changes, however with no focal visual deficits (no visual field cut, decreased acuity is symmetric bilaterally) 

Initial ED Management 

  • Arterial line place – IV nicardipine started, with goal SBP 210s (25% reduction in the first hour)
  • Bedside lung US performed which demonstrates numerous B lines consistent with evolving pulmonary edema

Labs/Imaging –

  • Hb 6.1, PLT 142, WBC 5.92 – Na 147, K 3.7 – Cr 15.03 (last level in chart 3.95 7 years ago) – HS troponin 223 – pro-BNP 26,930
  • CT Head with 3 small, distinct areas of intraparenchymal hemorrhage

Further Management 

  • Repeat neurologic exam performed and is unchanged
  • Neurosurgery consulted, recommend BP goal under SBP 160
  • Repeat CTH in 4 hours: unchanged 
  • Patient admitted to ICU for IV nicardipine, continuous BP monitoring, and q1 hour neuro checks

Pearls 

  • Hypertensive emergency is acute SBP over 180 with evidence of organ dysfunction
  • Not every patient with SBP over 180 requires emergency BP control
  • In this patient: decreased visual acuity, pulmonary edema, elevated troponin and proBNP, renal failure, and intraparenchymal hemorrhage = hypertensive emergency
  • In managing hypertensive emergency, SBP should not be lowered by more than 25% in the first hour to prevent causing hypoperfusion and cerebral ischemia 
  • Continuous BP monitoring via arterial line is important to carefully titrate medications
  • Nicardepene is an easy to titrate CCB which may be the ideal agent for the treatment of hypertensive emergency
  • Indications for emergent dialysis (AEIOU – acidosis, electrolytes, intoxication, overload, uremia): critical metabolic acidosis, refractory or rapidly increasing hyperkalemia, life threatening intoxication with substance that is able to be removed with HD, volume overload, complications of uremia (pericarditis, neuropathy, encephalopathy)
Tuesday Advanced Cases

Critical Cases – The Red Eye!

By Stephanie Smith M.D.

HPI

  • 53 y/o male p/w complaints of L eyelid swelling and redness
  • Started 4 days PTA as small pimple which he popped, and slowly progressed to “softball” sized area of swelling with pus drainage
  • Subjective fevers

Physical Exam

  • BP 153/90, pulse 80, temp 98.6, RR 17
  • PERRL, EOMI
  • Extensive soft tissue erythema and edema of the L upper eyelid, 5×5 area of fluctuance with active pus draining from small laceration
  • Visual acuity: 20/40 R, 20/70 L
  • No corneal abrasions or ulceration on fluorescein staining 
  • IOP 21 bilaterally 

DDx

  • Preseptal / periorbital cellulitis
  • Orbital cellulitis
  • Abscess

Workup 

  • Labs: CBC, BMP, lactate, wound culture
  • Started empirically on broad spectrum abx: 2g vancomycin + 3g unasyn
  • CT orbits w/ contrast: significant soft tissue swelling of the L periorbital region consistent with inflammatory/infectious process, and involvement of the medial orbital wall along the lamina papyracea 

Clinical Course

  • Admission for continued IV antibiotics
  • Repeat CT orbits
  • Consults: OMFS, ophthalmology, ENT, ID 

Take home points

  • MUST differentiate orbital vs preseptal cellulitis given the increased morbidity and mortality a/w orbital (see table)
  • Confirm clinical suspicion with CT imaging
  • Orbital cellulitis complications: subperiosteal abscess, orbital abscess, vision loss, cavernous sinus thrombophlebitis, and/or brain abscess 
Tuesday Advanced Cases

Advanced Cases – Pericardial Tamponade as a Sequelae of Hypothyroidism!

By: Alexander Hilbmann MD

HPI:

52 year old female with pmhx of hypothyroidism who presents to Emergency Department with bilateral leg swelling and SOB with exertion. Reports swelling began one week ago and has progressively worsened. Denies any other symptoms. Patient has not seen a cardiologist/had an echo performed before. Reports she has not taken her prescribed levothyroxine for two years now.  

Physical Exam:

Vitals BP 128/82 HR 80 BPM Temp 92.8F Oral Resp 29 SpO2 99%

Abnormalities on physical Exam:

Periorbital Swelling of bilateral eyes

Rales present in bilateral lower lungs

Distension of abdomen

Bilateral lower extremities with non pitting edema

12 Lead ECG:

Interpretation: Sinus bradycardia, low voltage ECG

Bedside subxiphoid cardiac ultrasound:

Interpretation: Circumferential pericardia effusion, RV collapse consistent with pericardial tamponade physiology

For a FANTASTIC review of ultrasound guided emergency pericardiocentesis, check out the Ultrasound Podcast Youtube video HERE

Case continued:

  • Patient found to be hypoglycemic at 50 mg/dL, D10 administered
  • Patient found to be hyponatremic at 125, likely in setting of fluid overload
  • Cardiology consulted for cardiac tamponade, pericardiocentesis performed with 1.4 L drained. 
  • Ascites drained via paracentesis, other diagnoses ruled out with hypothyroidism most likely cause.
  • Patient restarted on levothyroxine and began liothyronine (T3)in hospital
  • Patient discharged home in stable condition after 10 days in hospital with levothyroxine, has not returned to hospital since

Pearls:

  • Consider hypothyroidism if patient has pmhx or classical physical exam findings: bradycardia, hypothermia, hypotension, lethargy, constipation, hair loss/thinning, facial swelling, coarse skin, pretibial myxedema(thickened, nonpitting edema), menstrual changes, decreased reflexes.
  • Hypothyroidism increases permeability in the blood vessels of the body and decreases drainage of lymphatic system, causing an accumulation of fluid outside of blood vessels and can present as pretibial myxedema, pericardial effusion, or pleural effusion.
  • Precipitating factors of hypothyroidism include medication nonadherence, infection, cold exposure, stroke, autoimmune disorders, thyroid radiation/surgery,  and medications (amiodarone, lithium).
  •  Management of hypothyroidism includes supportive, hydrocortisone(prevents adrenal crisis), levothyroxine (T4) and +/- Liothyronine (T3) supplementation.

References:

Chahine J, Ala CK, Gentry JL, et al Pericardial diseases in patients with hypothyroidism Heart 2019;105:1027-1033.

Patil N, Rehman A, Jialal I. Hypothyroidism. [Updated 2023 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK519536/

Tuesday Advanced Cases

Critical Cases – Fistula Hemorrhage Emergency!

Kane McKenzie M.D.

Dialysis Fistula Bleeding Aneurysm

HPI

69 year-old female with a past medical history of ESRD on HD, HIV, Pulmonary HTN, HFrEF (EF 25%), anemia, thrombocytopenia presents after dialysis with left upper extremity pain and swelling. The dialysis RN reports there was shiny skin present over the LUE AVF and they cannulated to avoid that area, the patient received one hour of treatment that was stopped due to pain. Patient reports the her arm above the AVF has been slowly enlarging

Vitals

BP: 98/54, HR: 78, RR 20, T: 97.6

Exam:

Alert and oriented, no acute distress, chronically-ill appearing

LUE with no external bleeding, fistula has a palpable thrill. Swelling and tenderness are present above the AVF, over the medial upper arm.

Cap refill >2 seconds

Rest of exam unremarkable

Clinical Course

-CTA upper extremity was obtained to assess for active bleeding – showed AV fistula with aneurysmal dilatation, large hematoma with upper arm approximating a volume of 1000cc. No evidence of active hemorrhage

-Direct pressure was held above and below the AVF.

-Repeat BP 58/24

-Central line placed, resuscitated with 2U PRBC, 1 platelets, 1 FFP. Required norepinephrine and vasopressin drip

-Taken level 0 to OR for Brachiocephalic fistula ligation and hematoma evacuation with 500cc hematoma removed

-The patient was stabilized and recovered after being treated for hemorrhagic shock

Pearls

-AVF aneurysms can develop from repeated ruptures, increased venous pressure, and immunosuppression. They are usually asymptomatic, rarely rupture. Aneurysm formation is present in 5-7% of AVF

-Skin changes, pain, high output heart failure, and thrombosis can result from aneurysms and are an indication for operative management.

-AVF pseudoaneurysms can develop from extravasation of blood from cannulation sites, are more prone to rupture, develop more quickly

-Aneurysms/pseudoaneurysms can be identified by their shiny, thin, atrophic skin. In more severe cases can present with necrosis.

-Apply pressure and/or tourniquet above and below the AVF if life threatening hemorrhage is suspected

-Emergent consultation with vascular surgery warranted for operative repair

References:

Pasklinsky G, Meisner RJ, Labropoulos N, Leon L, Gasparis AP, Landau D, Tassiopoulos AK, Pappas PJ. Management of true aneurysms of hemodialysis access fistulas. J Vasc Surg. 2011 May;53(5):1291-7. doi: 10.1016/j.jvs.2010.11.100. Epub 2011 Jan 26. PMID: 21276676.

Lok CE, Huber TS, Lee T, Shenoy S, Yevzlin AS, Abreo K, Allon M, Asif A, Astor BC, Glickman MH, Graham J, Moist LM, Rajan DK, Roberts C, Vachharajani TJ, Valentini RP; National Kidney Foundation. KDOQI Clinical Practice Guideline for Vascular Access: 2019 Update. Am J Kidney Dis. 2020 Apr;75(4 Suppl 2):S1-S164. doi: 10.1053/j.ajkd.2019.12.001. Epub 2020 Mar 12. Erratum in: Am J Kidney Dis. 2021 Apr;77(4):551. PMID: 32778223.

Saeed F, Kousar N, Sinnakirouchenan R, Ramalingam VS, Johnson PB, Holley JL. Blood Loss through AV Fistula: A Case Report and Literature Review. Int J Nephrol. 2011;2011:350870. doi: 10.4061/2011/350870. Epub 2011 May 30. PMID: 21716705; PMCID: PMC3118665.

Tuesday Advanced Cases

Advanced Cases – Complications of IBD!

Allison Cash M.D.

HPI

  • 42 year old male with history of Crohn’s
  • Presented with 5 days LLQ pain, fevers, chills, diarrhea
  • Denied hematochezia/melena, vomiting

Physical Exam

  • BP 136/82  | Pulse 77  | Temp 98.1 °F (36.7 °C) (Oral)  | Resp 16  | SpO2 98%
  • Exam: patient uncomfortable appearing, LLQ pain with no rebound or guarding

Work-up

  • CBC, BMP unremarkable
  • CT A/P with bowel wall thickening and multiple pericolonic abscesses

Hospital Course

  • Patient admitted to surgery and started on IV Zosyn
  • IR consulted for abscess drainage
  • Transitioned to oral Augmentin, diet advanced, discharge home

IBD complications pearls

References:

  1. Judith E. Tintinall, et al. (2020). Tintinalli’s Emergency Medicine : A Comprehensive Study Guide (Ninth Edition). New York: McGraw-Hill.
  2. Maaser C, Sturm, et al. European Crohn’s and Colitis Organisation [ECCO] and the European Society of Gastrointestinal and Abdominal Radiology [ESGAR] ECCO-ESGAR Guideline for Diagnostic Assessment in IBD Part 1: Initial diagnosis, monitoring of known IBD, detection of complications. J Crohns Colitis. 2019 Feb 01;13(2):144-164.
Tuesday Advanced Cases

Critical Cases – TCA Overdose!

by Daniel Petrosky M.D.

HPI

  • 31 y.o. female presents with acute change in mental status
  • Family found unresponsive 
  • EMS trialed one dose of naloxone without effect

PMHX

  • Multiple sclerosis, chronic pain, opioid use disorder, generalized anxiety disorder, and major depressive disorder,

Physical Exam

  • Markedly dry mucous membranes and cracked, dry lips 
  • Pt lethargic, localizes pain, mumbles, and does not follow commands
  • Afebrile

Work-up

  • ECG shows prolonged QT otherwise unremarkable
  • BMP, CBC, LFTs, acetaminophen, salicylate , UA all WNL
  • UDS positive for TCH, benzos, and amphetamines 
  • Bladder scan and subsequent bladder catheterization reveal over 1 L clear urine

Case Conclusion

  • Several hours later the pt was able to state that she overdosed on her amitriptyline and wrote a suicide note
  • Toxicology consulted did not recommend any acute interventions
  •  Psychiatry consulted for suicide attempt. 

TCA Overdose Pearls

  • Toxicity can vary in presentation and thorough review of medications as well as collateral from family can be very important
  • TCA overdose can be tricky as it can affect multiple organ systems and present with anti-cholinergic properties (see below), ECG changes such as QTc prolongation, QRS prolongation, and a “terminal r wave” in lead aVR , and seizures.
  • Symptoms typically occur 6 hours after ingestion and can be worse with con-ingestion of sedatives
  • Those with ECG changes should be monitored for 36-48 hrs
  • Treatment is aimed at overcoming cardiac sodium channel blockade with sodium bicarbonate or hypertonic saline, and is reserved for those patients with ECG changes
Classic Symptom DescriptionPhysical Exam Manifestation
“Mad as a Hatter”Acute encephalopathy
“Red as a Beet”Erythroderma (in fair skinned patients)
“Blind as a Bat”Dilated and unresponsive pupils
“Dry as a Bone”Dry, cracked mucous membranes, no sweating
“Tachy as a Leisure Suit”Sinus tachycardia
“Hot as Hell”Hyperthermia

References:

In: Tintinalli JE, Stapczynski J, Ma O, Yealy DM, Meckler GD, Cline DM. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e. McGraw Hill; 2016, 1194-1199.