Friday Board Review

Board Review with Dr. Edward Guo

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A ten year old male with no past medical history presents after a witnessed fall. He was attempting a kickflip on his skateboard when he fell backwards hitting his head. His friends state he lost consciousness for about two seconds immediately following the event. He was wearing a helmet. The patient reports feeling better now with only mild pain to palpation at his occiput. He denies vomiting. His vitals are normal for his age. Exam shows no obvious signs of injury, and he is neurologically intact, eating and ambulating without difficulty. According to the PECARN Pediatric Head CT rule, what is the appropriate management of this patient?

A: discharge now

B: observe for 2 hours and discharge if he remains asymptomatic

C: observe for 4 hours and discharge if he remains asymptomatic

D: obtain CT head

Answer: observe for 4 hours and discharge if he remains asymptomatic

The PECARN Pediatric Head CT rule is a widely accepted decision tool with sensitivities nearing 100% for detecting clinically important traumatic brain injury in children. This patient does not meet criteria for immediate CT imaging such as altered mental status, GCS < 15, or signs of basilar skull fracture. Due to the history of loss of consciousness, it is recommended to observe the patient in the ED for 4 to 6 hours for any signs of deterioration prior to discharge. It is important to distinguish length of LOC in age groups <2 and ≥2 years old.

http://127.0.0.1:49907/PECARN-head-injury-both-infographics-scaled.jpg

References:

Kuppermann, N., Holmes, J. F., Dayan, P. S., Hoyle, J. D., Jr, Atabaki, S. M., Holubkov, R., Nadel, F. M., Monroe, D., Stanley, R. M., Borgialli, D. A., Badawy, M. K., Schunk, J. E., Quayle, K. S., Mahajan, P., Lichenstein, R., Lillis, K. A., Tunik, M. G., Jacobs, E. S., Callahan, J. M., Gorelick, M. H., … Pediatric Emergency Care Applied Research Network (PECARN) (2009). Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet (London, England), 374(9696), 1160–1170. https://doi.org/10.1016/S0140-6736(09)61558-

Image from: https://www.aliem.com/pecarn-relevance-importance-pediatric-emergency-care/pecarn-head-injury-both-infographics/

Wednesday Image Review

From the EMDaily Archives: What’s the Diagnosis? By Dr. Jacob Martin

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A 40 year old male presents for right wrist pain. Onset was just before arrival when he was lifting at work, “felt a pop”, and had a sudden onset of pain. Exam reveals swelling and tenderness of the right wrist. Neurovascular exam is normal. A right wrist x-ray is performed and shown below. What’s the diagnosis?

Answer: Scapholunate Dissociation

  • Background
    • Scapholunate ligament is most commonly injured ligament in the wrist
    • SLD is part of a spectrum of traumatic carpal bone instabilities
  • Etiology
    • Most commonly occurs with FOOSH injury causing forceful wrist extension, rupturing the scapholunate interosseous ligament
    • Also associated with spastic paresis, rheumatoid arthritis, and congenital ligament laxity
  • Presentation
    • Wrist swelling and point tenderness over dorsal aspect of wrist
    • Pain with wrist extension, radial deviation, and “clicking” sensation with movement
  • Diagnosis
    • Obtain AP and lateral views (+/- grip compression view/wrist in ulnar deviation)
    • Radiographic signs:
      • Widening of the scapholunate joint space > 3mm (“Terry Thomas sign”)
      • Cortical ring sign – loss of ligamentous support results in rotary subluxation and palmar tilt of the scaphoid on AP radiograph 
    • MRI provides definitive diagnosis, rarely done in ED 
  • ED Management
    • Pain management
    • Radial gutter splint
    • Urgent referral to orthopedics/hand specialist 
  • Pearls and Pitfalls
    • Prompt recognition crucial
    • Delayed diagnosis is associated with chronic pain, joint instability, inflammatory arthritis, long-term degenerative changes

References:

Casey PD, Youngberg R.Scapholunate dissociation: a practical approach for the emergency physician.J EmergMed. 1993;11(6):701-707. doi:10.1016/0736-4679(93)90629-l

Long B, Koyfman A. Wrist Injuries. In: Tintinalli JE, Ma O, Yealy DM, Meckler GD, StapczynskiJ, Cline DM, ThomasSH. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw-Hill; Accessed September 29,2020.https://accessmedicine.mhmedical.com/content.aspx?bookid=2353&sectionid=222324635

Ramponi D, McSwigan T. ScapholunateDissociation.Adv Emerg Nurs J. 2016;38(1):10-14.doi:10.1097/TME.0000000000000094

Stevenson M, Levis JT. Image Diagnosis: Scapholunate Dissociation.Perm J. 2019;23:18-237. doi:10.7812/TPP/18-237

Tuesday Advanced Cases & Procedure Pearls

From the EMDaily Archives: Refractory Trigeminal Neuralgia by Dr. Richard Byrne

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A 34 year old female with a history of trigeminal neuralgia presented with a chief complaint of 5 days of severe, worsening paroxysms of pain in the left trigeminal nerve distribution. The pain was refractory to carbamazepine and gabapentin. Neurology was consulted and an unconventional therapy was recommended: 

  • Trigeminal neuralgia is a chronic facial pain syndrome characterized by paroxysms of severe, lancinating pain in the trigeminal nerve distribution: usually the maxillary or mandibular branches.
    • The pain is typically unbearable, having been described as “the worst pain a human can endure.” Before effective pharmacotherapy, patients would often resort to suicide.
  • First line therapy is carbamazepine at starting doses of 200 mg/day, titrated up as high as 1200 mg/day in divided doses.
  • Second line therapy is either gabapentin or lamotrigine. Baclofen has been used as an add-on medication in refractory cases.
  • Severe pain exacerbations will often prompt patients to seek care in the ED and require opiates for acute relief.
  • Several case reports and case series have suggested intravenous phenytoin or fosphenytoin for abortive therapy, usually reporting complete or near complete relief of pain after infusion.
  • The patient received 1,000 mg of phenytoin over a 1.5 hour infusion. Reported pain decreased from 9/10 to 1/10 nearly immediately. She was discharged on oral oxcarbamazepine and baclofen with neurology follow-up.
  • Conclusion: Consider intravenous phenytoin or fosphenytoin for acute pain crises in trigeminal neuralgia patients.
    • Remember to infuse phenytoin no faster than 25-50 mg/min to avoid hypotension and bradycardia.

References
1. Cheshire, William. Fosphenytoin: An Intravenous Option for the Management of Acute Trigeminal Neuralgia Crisis.  Journal of Pain and Symptom Management 2001; 21(6): 506-510.

Friday Board Review

Board Review with Dr. Edward Guo

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A thirty year old female with a history of poorly controlled type 1 diabetes and gastroparesis presents for 1 day of severe abdominal pain, nausea, and vomiting. The patient states that she cannot keep anything down including fluids and has been vomiting all day. Her last bowel movement was today. She denies missing any insulin doses. Vital signs are: Temp 98.2F, HR 98, BP 130/80, RR 18, SpO2 98% RA. POC glucose is 182. She appears to be in obvious discomfort and is pacing circles in the room as well as intermittently dry heaving into an emesis bag. Her abdomen is soft but she notes tenderness to palpation diffusely, worst over the epigastric area. Which of the following medications has been shown to decrease need for admission and additional analgesic administration for patients with this condition?

A: erythromycin

B: haloperidol

C: hydromorphone

D: metoclopramide

E: odansetron

Answer: haloperidol

Gastroparesis is a chronic disorder characterized by delayed gastric emptying without a mechanical obstruction. It is commonly associated with diabetes although a considerable percentage of cases are idiopathic. In a 2017 observational study, haloperidol was shown to have a significant decrease in the rate of admission and analgesia administration in patients with gastroparesis. Odansetron, metoclopramide, and erythromycin are anti-emetics and prokinetic agents for gastroparesis but have no proven benefit in admission rates and pain control. Hydromorphone is a potent analgesic but has no anti-emetic properties and has a common side effect of nausea. 

Management of Gastroparesis
IV fluids, electrolyte repletion
Anti-emetics: haloperidol, odansetron, metoclopramide
Prokinetics: metoclopramide, erythromycin
Glycemic control
Identifying triggers

References:

Ramirez, R., Stalcup, P., Croft, B., & Darracq, M. A. (2017). Haloperidol undermining gastroparesis symptoms (HUGS) in the emergency department. The American journal of emergency medicine, 35(8), 1118–1120. https://doi.org/10.1016/j.ajem.2017.03.015

Wednesday Image Review

What’s the Diagnosis? By Mona Moshet, MS4

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A 29 year old male with no past medical history presents with sudden onset, pleuritic chest pain radiating to right flank while swimming yesterday. He notes associated dyspnea, particularly with deep inspiration. Social history is notable for smoking tobacco and marijuana. Vital signs are: Temp 98.7F, HR 54, BP 125/76, RR 16, SpO2 98% RA. Exam shows a thin appearing male in no acute distress with clear bilateral lung sounds. A CXR is obtained and shown below. What’s the diagnosis?

Answer: Spontaneous Pneumothorax (see pleural line at apex of right lung)

  • Is there an association between smoking marijuana and spontaneous pneumothorax (PTX)?
    • A brief literature review showed multiple cases but no studies proved causality.2, 3 However, one case control study had evidence that patients with spontaneous PTX and marijuana smoking history were at higher risk for poorer outcomes such as having larger pneumothoraces, prolonged post-op stays, and recurrence.1
  • Treatment: Depends on clinical status and size of PTX
    • Tension PTX = immediate needle decompression followed by thoracostomy
    • Supplemental O2
    • Observation for small primary spontaneous PTX (<2 cm between lung margin and and chest wall) with no significant dyspnea OR asymptomatic patient with large primary spontaneous PTX (>2 cm) with serial CXRs
    • Chest tube insertion site: within the “triangle of safety” (see figure below)

References:

1. Stefani A, Aramini B, Baraldi C, Pellesi L, Della Casa G, Morandi U, Guerzoni S. Secondary spontaneous pneumothorax and bullous lung disease in cannabis and tobacco smokers: A case-control study. PLoS One. 2020 Mar 30;15(3):e0230419. doi: 10.1371/journal.pone.0230419. PMID: 32226050; PMCID: PMC7105102.

2. Manasrah N, Al Sbihi AF, Al Qasem S, Naik R, Hettiarachchi M. Recurrent Spontaneous Pneumothorax Associated With Marijuana Abuse: Case Report and Literature Review. Cureus. 2021 Feb 7;13(2):e13205. doi: 10.7759/cureus.13205. PMID: 33717745; PMCID: PMC7943398.

3. https://doi.org/10.1016/j.chest.2020.05.026

4. Dynamed, AMBOSS

Tuesday Advanced Cases & Procedure Pearls

Advanced Cases: Poor Appetite with Dr. Julia Shamis

Edward GuoLeave a comment

A 76 year old female with a history of advanced dementia is brought to the ED due to family concerns of poor PO intake for the last 7 days. Vitals are notable for a HR 109 and BP 70/40. On exam, she is cachectic, non-verbal, and somnolent. Point of care cardiac ultrasound demonstrates the following:

Diagnosis: Pericardial Tamponade

Teaching Pearls:

  • Presenting signs/symptoms
    • Most common symptoms: dyspnea, chest pain, syncope, and altered mental status
    • Exam may demonstrate: JVD, tachycardia, hypotension, muffled heart sounds, narrowed pulse pressure, and tachypnea
  • Point of care ultrasound findings:
    • Effusions can be visualized in all four traditional cardiac views
    • Tamponade occurs when the pericardial pressure > intracardiac pressures, resulting in RV collapse in diastole (most specific finding for tamponade)
    • Right atrial collapse in early diastole can be first sign of cardiac tamponade (more sensitive but not as specific)
    • LV ejection fraction is often high to compensate for decreased filling volume

Treatment:

  • IV fluid resuscitation
  • In hemodynamically stable patients, treat with pericardiocentesis under fluoroscopy with interventional cardiology or to the OR for pericardial window with cardiothoracic surgery
  • If hemodynamically unstable, bedside pericardiocentesis should be performed, ideally under direct ultrasound guidance

References

Franz, Taylor. “Pericardial Effusion and Cardiac Tamponade: Pearls and Pitfalls.” EmDOCs.net – Emergency Medicine Education, 4 Apr. 2022, www.emdocs.net/pericardial-effusion-and-cardiac-tamponade-pearls-and-pitfalls/. Accessed 12 July 2023.

Stashko E, Meer JM. Cardiac Tamponade. [Updated 2022 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK431090/

Farkas, Josh. “Pericardial Tamponade.” EMCrit Project, 10 Nov. 2021, emcrit.org/ibcc/tamponade/.

Alerhand S, Adrian RJ, Long B, Avila J. Pericardial tamponade: A comprehensive emergency medicine and echocardiography review. Am J Emerg Med. 2022;58:159-174. doi:10.1016/j.ajem.2022.05.001