Monday Back to Basics

Measles Part 1: Identification with Drs. Edward Guo and Simon Sarkisian

While most cases of measles are mild and will self-resolve, the high infectivity of the virus is a public health hazard due to rare complications of the disease that can cause long-term morbidity and mortality. Particularly high risk populations include unvaccinated individuals, children < 5 years, adults > 20, pregnant women, and immunocompromised patients.  

Look forward to part 2 for more details on measles management, treatment, and complications! 

References: 

https://www.nj.gov/health/cd/topics/measles.shtml

https://www.cdc.gov/measles/hcp/index.html

Takhar SS, Moran GJ. Serious Viral Infections. In: Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw-Hill Education; 2020. 

Nguyen M, Dunn AL. Rashes in Infants and Children. In: Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw-Hill Education; 2020. 

Monday Back to Basics

Preeclampsia Management with Dr. Erica Westlake

Use these medications for aggressive blood pressure control

Load patients with magnesium early

Ultimate treatment is delivery – involve OB/NICU teams early, transfer patients if these teams are not available

Referneces:

Monday Back to Basics

From the Archives: Postpartum Hemorrhage with Dr. Oskutis

References:

1. Shakur H, Elbourne D, Gülmezoglu M, et al. The WOMAN Trial (World Maternal Antifibrinolytic Trial): tranexamic acid for the treatment of postpartum haemorrhage: an international randomised, double blind placebo controlled trial. Trials. 2010;11:40. doi:10.1186/1745-6215-11-40.

2. American College of Obstetricians and Gynecologists (ACOG). Postpartum hemorrhage: ACOG practice bulletin no. 183. Obstet Gynecol. 2017;130:168-186.

Tuesday Advanced Cases

Headaches with Dr. Harwood

Case: A 63 y.o. female with PMH of migraines and chiari malformation presents with headache. Patient reports that for the past 10 days, she has had a right-sided migraine that she describes as similar in quality to her prior migraines but longer-lasting. However, at 2 PM yesterday, she experienced an acute worsening of the severity of her headache – additionally, the pain became bilateral and occipital at this time. The patient reports dizziness, nausea, and photophobia, and her husband states that the patient has been slower to respond to questions for the past day. Denies vomiting, visual changes, or fever.

Vitals: BP: 133/90 | Pulse: 71 | Temp: 98.1F | Respiratory Rate: 18 | SpO2: 99%

Exam: Neuro exam is non-focal. Patient appears tired, but responds to questions appropriately. 

Clinical Course: Patient is given Tylenol, 10 mg IV Compazine, and 1 L lactated ringers with significant improvement in symptoms. Given change in headache quality from prior migraines and acute worsening of headache, CT Head without contrast ordered. 

CT revealed a large hemorrhagic neoplasm in the right frontal region with associated mass effect and 1.2 cm leftward midline shift resulting in obstructive hydrocephalus. Patient subsequently noted to be increasingly somnolent compared to initial presentation. Neurosurgery was consulted who recommended decadron, Keppra for seizure prophylaxis, and admission to the ICU.

Headache Pearls: The majority of headaches are due to primary headaches such as tension headache, migraine, or cluster headache. However, as 18% of patients with chief complaint of headache may be experiencing a secondary headache disorder. Many of these secondary headaches represent life-threatening emergencies such as intracranial bleeding or CNS infection. The SNOOP mnemonic is a helpful tool for remembering “red flag” headache symptoms to identify headache patients who warrant further imaging/laboratory work-up in the ED. Additionally, improvement in symptoms with medication does not decrease the likelihood of a secondary headache disorder.

Systemic: Systemic signs or conditions such as fever, weight loss, immunocompromised, HIV, cancer

Neuro: Neurologic findings including mental status changes, vision changes, seizure, confusion, or focal neuro findings on exam

Onset: Onset that is acute with progression to worst severity within minutes

Older: Older patient (50 y.o. or older) with new headache or a progressive headache

Previous: No history of previous headaches, or in a patient with history of headaches, a change in severity/symptoms/location from prior headaches

Pregnancy: Headache in pregnant or post-partum patient

References:

Ashenburg Nick, Marcolini Evadne, Hine Jason. Approach to Headache. In: Mattu A and Swadron S, ed. CorePendium. Burbank, CA: CorePendium, LLC. https://www.emrap.org/corependium/chapter/rec8eRzSrPsVUiMuV/Approach-to-Headache#h.pq7xksb5a2qy. Updated October 8, 2022. Accessed December 22, 2023.

Dodick DW. Clinical clues and clinical rules: primary vs secondary headache. Adv Stud Med 2003;3:87–92.

Do TP, Remmers A, Schytz HW, et al. Red and orange flags for secondary headaches in clinical practice: SNNOOP10 list. Neurology. 2019;92(3):134-144. doi:10.1212/WNL.0000000000006697

Monday Back to Basics

From the Archives: Baby, It’s Cold Outside: Death by Hypothermia with Dr. Kate Ginty

The Basics

  • On average, approximately 1300 Americans die of hypothermia each year 
  • These don’t all occur in cold mountain regions. Homelessness, mental illness and substance abuse are important risk factors, particularly in urban areas. 
  • Not all hypothermia cases are related to exposure! Other causes include hypoglycemia, hypothyroidism, hypoadrenalism, hypopituitarism, CNS dysfunction, drug intoxication, sepsis and dermal disease 
  • Hypothermia = core body temperature < 35 degrees C (95 degrees F) 
  • Mild hypothermia (32-35 degrees C): present with shivering, tachycardia, tachypnea and hypertension 
  • < 32 degrees C: shivering stops and HR and BP decrease; patients become confused, lethargic and then comatose; Reflexes are lost, RR increases; bronchorrea occurs; aspiration is common; cold diuresis and hemoconcentration occur 
  • As temp lowers, sinus bradycardia develops into atrial fibrillation with slow ventricular response to ventricular fibrillation to asystole. At temps < 30 degrees C, the risk for dysrhythmias increases

Rewarming and Management

  • Type of rewarming is based on cardiovascular status, NOT temperature 
  • Passive rewarming: removal from cold environment and wet clothes, insulation 
  • Active external rewarming: warm water immersion, heating blankets set at 40 degrees C, radiant heat, forced air 
  • Active core rewarming at 40 degrees C: Inhalation rewarming (warm air via the vent), heated IV fluids, GI tract lavage, bladder lavage, peritoneal lavage, pleural lavage, extracorporeal rewarming, mediastinal lavage by thoracotomy 
  • Remember to handle these patients gently to avoid precipitation of ventricular fibrillation!

ECMO in Hypothermic Arrest

  • The use of ECMO has been recommended as the rescue therapy of choice for hypothermic cardiac arrest for its ability to rapidly rewarm patients (8-12 degrees/hour) and provide complete cardiopulmonary support 
  • Studies have shown that patients with cardiac arrest have a rate of survival of 50% with the use of ECMO, whereas, at centers without ECMO, these same types of patients have a survival rate of only 10% 
  • Cases of survival with a good clinical outcome have been reported with core temperatures as low as 13 degrees Celsius and in cases requiring long transport with more than 5 hours of CPR!

Risk Factors for Poor Prognosis Despite Aggressive Therapy (ECMO, etc):

  • Clear history of cardiac arrest before cooling 
  • Obvious signs of irreversible death 
  • Core body temperature higher than 32 degrees Celsius with asystole 
  • Potassium greater than 12 mEq/L
Monday Back to Basics

Peritoneal Dialysis and Peritonitis with Dr. Carlos Cevallos

This image has an empty alt attribute; its file name is Peritoneal-Dialysis-and-Peritonitis-1024x1024.jpg

References:

Dialysis Related Emergencies | CorePendium (emrap.org)

ISPD peritonitis guideline recommendations: 2022 update on prevention and treatment – Philip Kam-Tao Li, Kai Ming Chow, Yeoungjee Cho, Stanley Fan, Ana E Figueiredo, Tess Harris, Talerngsak Kanjanabuch, Yong-Lim Kim, Magdalena Madero, Jolanta Malyszko, Rajnish Mehrotra, Ikechi G Okpechi, Jeff Perl, Beth Piraino, Naomi Runnegar, Isaac Teitelbaum, Jennifer Ka-Wah Wong, Xueqing Yu, David W Johnson, 2022 (sagepub.com)

Levine, Brian J. EMRA Antibiotic Guide. Emergency Medicine Residents’ Association, 2022.

Peritoneal Dialysis–Related Peritonitis: Towards Improving Evidence, Practices, and Outcomes – ClinicalKey

https://www.kidney.org/content/what-peritoneal-dialysis

Monday Back to Basics

Let’s talk about Rehab with Dr. Katie Selman

Many facilities may have multiple services – often, the same facility will offer subacute rehab and long-term care and memory care services

Instrumental Activities of Daily Living (IADLs) = managing house, finances, transport, medications, shopping

Activities of Daily Living (ADLs) = walking, toileting, bathing, feeding, transferring

  • Is this a rehab-able condition?
    • Rehab-able condition examples: stroke, hip fracture, deconditioning after serious illness
    • Potentially not rehab-able examples: any progressive, gradual degenerative disease in which the patient is expected to continue to decline
  • Why does this matter?
    • Insurance will stop paying for rehab if patient is not improving or making progress based on their PT/OT/ST notes
    • There is a daily copay for patients after 21 days in rehab and the full cost is on the patient after 100 days
      • PT is amazing but cannot fully reverse a months-long decline in 21 days!
  • Will the patient be able to physically and cognitively participate in rehab?
    • Acute inpatient rehab = 3 hours therapy/day
    • Subacute rehab = 3 hours/week
  • Patients are not rehabbed until they can go home safely – patients are rehabbed until they can safely live in a one-story home.
    • So what is the goal after rehab? What is the backup plan if they still can’t go home after 21 days? Will they still need help?

References:

https://www.genworth.com/aging-and-you/finances/cost-of-care.html

https://www.medicare.gov/care-compare/

https://www.aarp.org/caregiving/

Flint LA, David DJ, Smith AK. Rehabbed to Death. N Engl J Med. 2019;380(5):408-409. doi:10.1056/NEJMp1809354

Flint LA, David D, Lynn J, Smith AK. Rehabbed to Death: Breaking the Cycle. J Am Geriatr Soc. 2019;67(11):2398-2401. doi:10.1111/jgs.16128

Burke RE, Jones J, Lawrence E, et al. Evaluating the Quality of Patient Decision-Making Regarding Post-Acute Care. J Gen Intern Med. 2018;33(5):678-684. doi:10.1007/s11606-017-4298-1

Halifax E, Bui NM, Hunt LJ, Stephens CE. Transitioning to Life in a Nursing Home: The Potential Role of Palliative Care. J Palliat Care. 2021 Jan;36(1):61-65. doi: 10.1177/0825859720904802. Epub 2020 Feb 27. PMID: 32106767; PMCID: PMC8127871. 

Tuesday Advanced Cases

DIC with Dr. Alyssa Sinko

Case: 64 M with no PMH presenting with continuous oozing from mass in posterior pharynx. Vital signs significant for: T 98.5, HR 72, BP 130/84, RR 16, SPO2 98%. Patient also found to have petechia on lower extremities. IV access established, and it is noted that there is bleeding from the IV sites.

Pathophysiology of DIC:

Causes of DIC:
– Most common: Sepsis
– Carcinomas, leukemias, TBI, pancreatitis, snake bites, ARDS, transfusion reactions, transplant rejection, crush injuries, burns, fat embolism, liver disease
– Pregnancy associated: Placental Abruption, Amniotic Fluid Embolism, Septic Abortion, HELLP syndrome, Acute fatty liver of pregnancy

Laboratory Testing:

PT used for monitoring over course

Bleeding Differential Diagnosis:

Management:
– Treat to treat underlying trigger
– If purpura fulminans present, treat with protein C concentrate
– Consider heparin if thrombosis is primary symptom
– Repletion to be considered if significant bleeding or impending procedure

  • Fibrinogen < 100 = Cryoprecipitate
  • Platelets <50K with bleeding, <10K without bleeding = Platelets
  • PT/PTT over 1.5x normal limit = FFP
  • Vitamin K and Folate

References:

Tintinalli’s Emergency Medicine Manual, 8e Eds. Rita K. Cydulka, et al. McGraw Hill, 2018

Uptodate.com