Monday Back to Basics & Pharmacology

Everything Epinephrine with Dr. Sean Coulson

Erica WestlakeLeave a comment

References:

https://www.ncbi.nlm.nih.gov/books/NBK482160

https://cpr.heart.org/en/resuscitation-science/cpr-and-ecc-guidelines/algorithms

https://www.ncbi.nlm.nih.gov/books/NBK482124

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8139870

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5367766

https://www.emrap.org/corependium/drug/recLg1S2Jxb7XHuBZ/Epinephrine#h.isp1462n5h9n

https://www.uptodate.com/contents/advanced-cardiac-life-support-acls-in-adults?search=epinephrin%20code%20dose&source=search_result&selectedTitle=2%7E150&usage_type=default&display_rank=2#H3524182262

Wednesday Image Review

What is the Diagnosis?

Carlos CevallosLeave a comment

A 20 y.o patient presents to the ED after a motor vehicle accident after hitting a ditch. He is fully alert and oriented and is reporting generalized abdominal pain and myalgias. Physical exam is notable for diffuse abdominal tenderness, seatbelt sign with bruising to the right upper chest wall and right flank. VS: HR 70, BP 108/59, RR 18, SpO2 99%

A FAST exam is performed which demonstrates the following:

https://youtu.be/_GKdIG3aeFM

A CT scan was subsequently performed which confirmed large volume hemoperitoneum with a grade 2 liver laceration.

The patient was subsequently taken to the OR for an exploratory laparotomy. He was ultimately stabilized, and was able to be discharged from the hospital 2 weeks later. 

Focused Assessment with Sonography in Trauma: FAST

  • Indication: Blunt and/or penetrating abdominal and/or thoracic trauma with associated hypotension 
  • Focused question: Is there free fluid in the pericardium or abdomen?
  • Views: Right Upper quadrant, left upper quadrant, subxiphoid cardiac view, pelvic view
  • Sensitivity of 74% for detection of intra-abdominal fluid
  • Specificity of 98% for detection of intra-abdominal fluid

Resources:

Netherton, Stuart, et al. “Diagnostic accuracy of Efast in the trauma patient: A systematic review and meta-analysis.” CJEM, vol. 21, no. 6, 18 July 2019, pp. 727–738, https://doi.org/10.1017/cem.2019.381.

Wednesday Image Review

What is the diagnosis? By Dr. Westlake

Carlos CevallosLeave a comment

65 year old M presents with significant swelling, discoloration and pain to the right scrotum and penis after inguinal hernia repair 2 days prior. On exam, patient with ecchymosis and erythema of the right testicle and shaft of the penis. There is significant swelling in the inguinal canal, which is not compressible or reducible. You take the ultrasound to bedside to see: 

What is the diagnosis? 

Answer: Scrotal hematoma 

Differentials for this patient include hematoma, hydrocele, scrotal abscess or infection, failure of mesh causing strangulated or incarcerated hernia.

On imaging, you see mixed echogenic fluid collection with no vascular flow noted. This extends from the right groin into the scrotum, with hypoechogenic fluid tracking around bilateral testicles. This is consistent with a scrotal hematoma. There is no bowel noted, ruling out strangulated or incarcerated hernia. There is no “swirl” sign which would be more consistent with scrotal abscess/infection. The mixed echogenic fluid is most consistent with hematoma rather than hydrocele. 

Pearls for the bedside scrotal ultrasound: 

  • Use the linear probe
  • Place the patient supine, place a towel under the scrotum and drape the patient appropriately
  • Obtain imaging of the unaffected side first for landmarks and comparison
  • Compare to the affected side, noting echogenicity and landmarks
  • Visualize both testicles in the same view 
  • Can utilize doppler to assess for flow in concerns for torsion 

References: 

CT and radiology ultrasound imaging from case are below: 

Tuesday Advanced Cases & Procedure Pearls

Advanced Cases: Adrenal Crisis

Sean CoulsonLeave a comment

Pt is a 55 y/o F w/ hx of SLE who presents to the ED for hypotension. Pt is altered and not providing any information. Pt arrives with family who notes she has had progressively worsening mental status and abdominal pain w/ vomiting non bilious material x 3 days. Not compliant with medications during this time 2/2 vomiting. Unclear what medications she takes.

HR 119, BP 71/48, Temp 94F, RR 20, Acc Check 51

Physical Exam:
GCS 11, arousable to gentle stimuli 

Extremities warm w/o pitting edema

Abdomen soft and nontender

Lungs CTA b/l

Heart rate tachycardia and regular

POCUS unremarkable

Pertinent Labs:

CBC: WBC 15k w/ increased lymphocytosis

BMP: Na 128, K 5.8, AG 18, Cr 2.1

Differential diagnosis: Distributive shock 2/2 sepsis w/ unclear source vs adrenal insufficiency, hypovolemia, myxedema coma etc.

Physiology

  • Primary adrenal insufficiency (Addisons) – direct loss of glucocorticoids (cortisol) and mineralocorticoid (aldosterone)
  • Secondary adrenal insufficiency – loss of ACTH / CRH
    • More common secondary to chronic steroid therapy – leads to loss of glucocorticoids
    • Aldosterone is largely unaffected because its regulated by RAAS so typical electrolyte abnormalities are not as common / pronounced and hypotension is less severe

When to consider

  • Shock refractory to fluid resuscitation / vasopressors
  • Typical lab findings: HypoNa, HyperK, HypoGlycemia, HypoThermia, HypoTension, AMS
  • Azotemia
  • If leukocytosis -> likely eosinophilia w/ lymphocytosis > neutrocytosis
  • Fever of unexplained origin

High Risk Groups

  • Included in the ddx for shock refractory to pressors / volume resuscitation
  • Pts on long term steroids
  • Autoimmune disorders
  • HIV and TB
  • Head trauma, tumors and pituitary apoplexy (sheehan syndrome)
  • Bacterial meningitis
  • Neonates w/ congenital adrenal hyperplasia
  • Infiltrative disorders
  • Chronic opioid use and withdraw can suppress the HPA axis as well

Diagnosis

  • In the ED, its a clinical diagnosis. Suspect? = Treat!
  • Cortisol < 20 ug/dl is highly suggestive however not definitive
  • Confirm w/ cosyntropin test (to be done on floor/ICU)


Management

  • Hydrocortisone 100mg IV then 50mg q6: 1st line as it has glucocorticoid and mineralocorticoid effects – however it will affect the cosyntropin test. Can consider adding fludrocortisone for added mineralocorticoid benefits but not typically recommended.
    • If affecting the cosyntropin test is a large concern – consider starting dexamethasone 6mg IV (glucocorticoid). Must rx fludrocortisone as well (mineralocorticoid)
  • Low threshold for empiric levothyroxine as well
  • If pt truly has adrenal crisis – pt should have some clinical improvement within a few hours after receiving the above steroids

Prevention

  • Patients on chronic steroids who present w/ acute illness – take at home steroid dose and triple – this is their new maintenance dose for the next 1-3 days or until their acute presentation improves.


References:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6566489
https://pubmed.ncbi.nlm.nih.gov/26760044
https://www.ncbi.nlm.nih.gov/pmc/articles/pmid/36958832
https://www.uptodate.com/contents/treatment-of-adrenal-insufficiency-in-adults?search=adrenal%20crisis&source=search_result&selectedTitle=1%7E73&usage_type=default&display_rank=1
https://www.emrap.org/corependium/chapter/reckrn64vrSS1Zsfa/Adrenal-Insufficiency
Wednesday Image Review

What is the diagnosis? By Dr. Cevallos

Carlos CevallosLeave a comment

A 38 year old male presents to the ED with a chief complaint of right wrist pain that began after a fall off a motorcycle the day prior. On exam, the patient is noted to have tenderness along his right distal radius, snuffbox tenderness, wrist swelling, and is unable to flex/extend the wrist. Normal pulses and sensation is present.

Wrist X-rays demonstrate the following:

What is the diagnosis?

Perilunate dislocation, scaphoid fracture, radial styloid fracture

Perilunate Dislocation:

  • Occur due to a high energy traumatic injury
  • Multiple wrist ligaments are injured with resultant dislocation of the capitate dorsally
  • Often associated with fractures of the radius, ulnar, or carpal bones
  • Imaging:
    • Lunate stays in place, dislocated bone is actually the capitate!
    • AP/PA XR may demonstrate “piece-of-pie” sign: triangular appearance of the lunate (yellow arrow)
    • Lateral XR: Proximal and dorsal displacement of the capitate (yellow arrow) with volar displacement of the lunate (green arrow).
      • The lunate remains articulated with the radius differentiating it from a lunate dislocation (lunate dislocation would have a “spilled-teacup” sign)
  • Management:
    • Emergent closed reduction is indicated to minimize complications such as: median nerve injury, cartilage damage, wrist function issues
    • Sugar-tong splint
    • Urgent orthopedic follow-up as most will require surgical fixation

References: 

Cheffers M. Wrist Reduction Techniques. In: Johnson W, Nordt S, Mattu A and Swadron S, eds. CorePendium. Burbank, CA: CorePendium, LLC. https://www.emrap.org/corependium/chapter/recoPqKOBgkCSHesR/Wrist-Reduction-Techniques#h.493xci6kkby6. Updated December 21, 2022. Accessed August 15, 2024.

Mark Karadsheh. “Lunate Dislocation (Perilunate Dissociation).” Orthobullets, 5 Nov. 2022, www.orthobullets.com/hand/6045/lunate-dislocation-perilunate-dissociation. “Solution to Unknown Case #30 – Perilunate Dislocation.” RADIOLOGYPICS.COM, 6 Jan. 2014, radiologypics.com/2013/03/28/perilunate-dislocation/.