Friday Board Review

Board Review with Dr. Kat Kaminski

A 4-month old female born at full term otherwise healthy presents to the ED after parents observed her “turning blue” and “breathing funny” for less than a minute that spontaneously self-resolved. Parents report no recent fever or illness and say this has never happened before. Upon arrival to the ED patient appears to be well appearing and in no acute distress, afebrile and with reassuring vital signs and physical exam. Parents ask if they can take her home. What do you do?

A. Tell the parents the baby needs to be admitted to the pediatric floor

B. Monitor the baby on pulse oximetry for another 2 hours and then discuss possible discharge with the parents

C. Tell the parents the baby is fine and discharge to home

D. Tell the parents the baby needs to be admitted to the PICU

Answer: Monitor the baby on pulse oximetry for another 2 hours and then discuss possible discharge with the parents

This baby presents with a BRUE, a Brief Resolved Unexplained Event (formerly known as ALTE, Apparent Life-Threatening Event) as defined by:

  • Sudden, brief, and now resolved episode of one or more of the following in an infant < 1 year age:
    • Cyanosis or pallor
    • Absent, decreased, or irregular breathing
    • Marked change in tone (hyper- or hypotonia)
    • Altered responsiveness
    • No explanation for the event after full history and exam

And according to the most recent American Academy of Pediatrics guidelines, this patient is considered low risk according to the following criteria:

  • Age >60 days
  • Born >= 32 weeks’ gestation and corrected gestational age >=45 weeks
  • No CPR by trained medical provider
  • Event lasted <1 minute
  • First event

Therefore, this low risk patient may be safely discharged home with close pediatrician follow up after a period of observation and education provided to the parents about BRUEs. This is different than past practice where nearly all patients with BRUEs (then called ALTEs) were hospitalized. It should be noted that BRUEs can be related to a range of conditions both benign and more concerning. Possible etiologies include GERD, breath-holding spells, non-accidental trauma, and serious bacterial infection. The risk of a serious disorder presenting as a BRUE is unknown, therefore a thorough history and physical exam is essential.

References:

Joel S. Tieder, Joshua L. Bonkowsky, Ruth A. Etzel, Wayne H. Franklin, David A. Gremse, Bruce Herman, Eliot S. Katz, Leonard R. Krilov, J. Lawrence Merritt, Chuck Norlin, Jack Percelay, Robert E. Sapién, Richard N. Shiffman, Michael B.H. Smith, for the SUBCOMMITTEE ON APPARENT LIFE THREATENING EVENTS, Pediatrics May 2016, 137 (5) e20160590; DOI: 10.1542/peds.2016-0590

Wednesday Image Review

What’s the Diagnosis? By Dr. Chris Smith

A 31 yo male presents with left thumb pain after a dirt bike crash.  Patient is unable to move his left thumb and has tenderness at the base. An x-ray is shown below.  What’s the diagnosis?

Answer: Type I first metacarpal fracture (Bennett fracture)

  • Most commonly occurs in young males from forceful axial load against a fixed object (sports, bicycle accident, punching), presents with pain and swelling at thenar eminence, decreased range of motion at MCP/CMC joints
  • Diagnosis of first metacarpal fractures usually made by plain radiograph
  • Management with reduction (may be accomplished with longitudinal traction, abduction and extension of first MC), thumb spica splint, and prompt orthopedic follow up.  May require percutaneous pin fixation or open reduction and internal fixation.

Classification of first metacarpal base fractures

  1. Type I, Bennett fracture: intra-articular fracture-dislocation/subluxation at the CMC joint
  2. Type II, Rolando fracture: a comminuted Bennett fracture
  3. Type III, (no eponym): extra articular fracture
  4. Type IV, (no eponym): extra-articular pediatric fracture involving the proximal physis

References:

Stapczynski, J. Stephan,, and Judith E. Tintinalli. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 7th ed. New York, N.Y.: McGraw-Hill Education LLC., 2011.

Tuesday Advanced Cases & Procedure Pearls

Critical Cases – Acute Vision Loss!

by Edward Guo M.D.

HPI

A 70 year old male with a past medical history of hypertension, type 2 diabetes, and atrial fibrillation on warfarin presents for visual changes. He is accompanied by his daughter who states that about one hour ago, his vision on the right side became blurry. There is associated right facial numbness and headache. His daughter believes that he has become more confused over this time period. Fingerstick glucose is 220. An EKG is obtained which shows atrial fibrillation at a rate of 92.

Exam

BP 151/75, HR 92, T 97.8F, RR 18, SpO2 98%

Comfortable appearing in no acute distress. GCS E4 V4 M6. No facial droop. Decreased sensation to right side of face. 5/5 strength and sensation in all extremities. No difficulty with rapid alternating movements. Extraocular motion intact. Left gaze preference with right sided homonymous hemianopia.

Differential diagnosis: acute ischemic stroke, spontaneous intracranial hemorrhage, complex migraine, toxic-metabolic encephalopathy

Case continued: Neurology is emergently consulted and a stroke alert is activated. CT/CTA of the head and neck shows no acute intracranial hemorrhage and no large vessel occlusion. Labs are notable for an INR of 1.6. The decision is made in conjunction with neurology to administer thrombolytics, and the patient is admitted to neurology critical care. Repeat head CT 24 hours later demonstrates a left parieto-occiptal infarct.

Pearls:

– This patient’s neurologic deficits including right sided facial numbness, right homonymous hemianopsia, left sided gaze preference, and aphasia localize to a cortical distribution as noted above.

– Warfarin use alone is not a contraindication to thrombolytics for acute ischemic stroke. The INR must be > 1.7 in addition to be an exclusion criterion.

– This patient had multiple previous subtherapeutic outpatient INR levels which likely precipitated an embolic stroke.

– In patients without contraindications, the decision to administer thrombolytics for acute ischemic stroke should be clinical without waiting for results of laboratory testing with the exception of a point of care glucose and patients with suspected coagulopathy.

– Other common exclusion criteria to use of thrombolytics in acute ischemic stroke include previous head trauma or stroke within 3 months, any previous intracranial hemorrhage, SBP > 185 or DBP > 110, or known intracranial mass such as neoplasm or aneurysm.

References:

Go S, Kornegay J. Stroke Syndromes. 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.

Powers WJ, Rabinstein AA, Ackerson T, et al. 2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association [published correction appears in Stroke. 2018 Mar;49(3):e138] [published correction appears in Stroke. 2018 Apr 18;:]. Stroke.

Monday Back to Basics & Pharmacology

Pediatric Penile Pain with Dr. Edward Guo

​Differential Diagnosis​Clinical Findings​Management
​Balanoposthitis (cellulitis of glans or foreskin)​Glans, foreskin, or both are erythematous, tender, or edematous​Warm soaks +/- oral antibiotic or antifungal cream depending on etiology 
​Phimosis​Stenosis of distal foreskin preventing retraction of foreskin over the glans​Most uncircumcised infants have normal, physiologic phimosis that will spontaneously resolve by 5 years of age.
Rarely requires treatment other than daily hygiene.
Monitor for if foreskin completely seals off causing acute urinary retention – true emergency.
ParaphimosisEntrapped ring of foreskin retracted proximal to glans of penis causing pain, erythema, and swelling​Consult pediatric urology emergently!
In cases when urology is not immediately available or necrosis of penis is imminent, ED physician may attempt reduction.

References:
– Liu DR. Pediatric Urologic and Gynecologic Disorders. 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; 2020
https://www.uptodate.com/contents/balanitis-and-balanoposthitis-in-children-and-adolescents-management

Friday Board Review

Board Review by Dr. Edward Guo (Edited by Dr. Parikh)

A 40 year old female with a history of hyperlipidemia presents for abdominal pain. She has been having intermittent pain in her right upper quadrant after meals without vomiting or change in her bowel habits. Vital signs are within normal limits. She has mild tenderness to palpation to the right upper quadrant on exam with a negative Murphy’s sign. Point of care pregnancy test is negative. Her workup including CBC, BMP, LFTs, and lipase are unremarkable. A right upper quadrant ultrasound demonstrates numerous gallstones without evidence of cholecystitis. Which of the following is recommended for first line treatment of this patient’s suspected condition?

A: Acetaminophen

B: Gabapentin

C: Ketorolac

D: Morphine

Answer: Ketorolac

This patient is presenting with biliary colic which occurs by a gallstone causing periodic obstruction of the cystic duct. Management includes symptom control and outpatient surgical referral for cholecystectomy. NSAIDs are first line therapy. When administered parenterally, NSAIDs have similar analgesic effect compared to opioids for biliary colic. In addition, NSAIDs reduce the rate of short term complications such as acute cholecystitis. 

Acetaminophen is an antipyretic that has analgesic properties but is not first line for biliary colic. Gabepentin is typically used for neuropathic pain such as diabetic neuropathy or shingles. Opioids such as morphine are reserved for when NSAIDs are not effective in reducing pain but are not first line due to safety and side effects such as hypoventilation. It is known that opioids cause sphincter of Oddi spasm, but the clinical significance of this is unclear. 

References:

Besinger B, Stehman CR. Pancreatitis and Cholecystitis. 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.

Colli  A, Conte  D, Valle  SD, Sciola  V, Fraquelli  M: Meta-analysis: nonsteroidal anti-inflammatory drugs in biliary colic. Aliment Pharmacol Ther 35: 1370, 2012. [PubMed: 22540869]

Wednesday Image Review

What’s the Diagnosis? By Dr. Julie Calabrese

75 y/o M PMHx of ESRD on HD, pulmonary HTN, HLD presents to the ED with 1 week of progressive fatigue and SOB. Pt on 2L NC home O2 but requiring 4L NC in the ED to maintain saturation > 95%. On exam, pt with increased WOB and RR > 20. Lungs are CTA. Cardiac exam shows RRR with mild JVD, abdominal distention and +1 pitting edema B/L. POCUS was performed and is shown below. What is the diagnosis? 

Answer: Right Heart Strain from Pulmonary Hypertension 

  • Signs in POCUS that are indicative of R heart strain:
    • D-sign: septal flattening seen in the parasternal short orientation that is indicative of increased RV pressures 
    • McConnel’s Sign: seen in the apical 4 chamber view. R ventricular free wall akinesis with sparing of the apex (apical hyperkinesis) 
    • Increased RV:LV ratio, typically should be ⅓:⅔ 
    • Decreased TAPSE: measurement of the vertical motion of the tricuspid valve in the apical 4 chamber view (normal > 16 mm)
  • Causes of R- Heart Strain:
    • Pulmonary Embolism
    • Pulmonary hypertension 
    • Biventricular failure
    • R sided heart failure 
    • Valvular dysfunction (Acute TR) 
  • Pulmonary Hypertension:
    • Type 1: primary arterial pulmonary HTN 
    • Type 2: PH due to L heart failure
    • Type 3: PH due to lung disease 
    • Type 4: PH due to chronic thromboembolic disease 
    • Type 5: idiopathic PH 
  • Acute Treatment for PH includes
    • Optimize RV preload- patients typically euvolemic or hypervolemic and do not respond well to rapid shifts in fluid status (usually avoid fluids). If hypovolemia/sepsis consider small 250 ml boluses with frequent reassessments 
    • Improve cardiac output: consider early ionotropes 
    • Reduce RV afterload: avoid hypoxia, acidosis, hypercapnia 
    • Treat arrhythmias: most common is SVT followed by afib/flutter 

Resources: 

https://courses.coreultrasound.com/courses/take/fundamentals/lessons/18316427-right-heart-strain-5minsono

Tuesday Advanced Cases & Procedure Pearls

Critical Cases – Hypothermia Induced Arrhythmia!

Dr. Edward Guo

Hypothermia Arrhythmia by Dr. Edward Guo

HPI: A 29 year old male with a past medical history of polysubstance use presents to the ED in December via EMS for a suspected overdose. History is limited due to patient cooperation. EMS states that he was found outside in a puddle, minimally responsive. He was given 2mg IM naloxone by EMS and became acutely agitated and combative afterward, requiring 5mg IM midazolam and 5mg IM haloperidol upon arrival. Fingerstick glucose 226. ECG is obtained and shown below.

Exam: BP 182/84, HR 111, T 86.1F, RR 18, SpO2 100%

Disheveled appearing male in wet clothes, intermittently thrashing. Cold to touch. Pupils 5mm bilaterally. No signs of trauma. GCS E3 V2 M5. Moves all extremities equally. Heart rate is tachycardic and irregular

ECG interpretation: atrial fibrillation with Osborne waves

Differential diagnosis: polysubstance use, environmental cold exposure, severe sepsis, hypothyroidism

Case continued: Active rewarming is initiated by removing wet clothes, administering warmed IV fluids, and placing a bair hugger. Labs are notable for a creatinine kinase of 3966. The patient’s temperature, heart rate, and mental status significantly improve within 5 hours, and his repeat EKG shows normal sinus rhythm without Osborn waves. He is ultimately admitted to medicine.

Pearls:

– The cardiovascular response to cold is peripheral vasoconstriction and initial increase in heart rate and blood pressure. As core temperature drops below 32C, there is myocardial irritability and risk of cardiovascular collapse.

o Atrial fibrillation and flutter are common arrhythmias associated with hypothermia.

o Rescue collapse is a term to describe cardiac arrest that occurs during extrication or transport of a profoundly hypothermic patient due to profound myocardial irritability.

– Osborn waves are positive deflections at the end of the QRS complex that are non-specific but may occur in temperatures below 32C.

o Size of the wave correlates with the degree of hypothermia but has no prognostic value.

– As temperature continues to drop, EKG changes are variable but classically include bradycardia with prolonged PR, QRS, and QTc. Heart block or ventricular dysrhythmias may be encountered as well. Asystole is the common final dysrhythmia.

– Rewarming is the treatment of choice.

o Atrial dysrhythmias such as atrial fibrillation will often resolve with warming.

o Cardioversion for unstable arrhythmias should be attempted but may be refractory in severe hypothermia.

References:

Brown DA. Hypothermia. 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.

Hoek T. 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010. 122:5829-5861