EKGs and Chemistries: AMP Rapid Fire Case Conference Review, November 29, 2017

Welcome back to another week of rapid fire case conference review here at THE OSU EM Residency Program.

Leading off is Dr. Nicholson with his patient presenting from dialysis clinic with a chief complaint of “Problem with fistula site.” A quick duplex study with basic labs reveals an occluded outflow vein and a potassium of 7.3. Understanding the arrhythmogenic potential for hyperkalemia, he obtains the following EKG:

Screen Shot 2017-12-17 at 8.24.49 PM.pngRecognizing peaked t-waves as an early since of clinically significant hyperkalemia, he then initiates appropriate treatment (discussed later!).

He then asks, “What other changes might I see on an EKG in a patient with hyperkalemia?” and provides this helpful diagram.

Popular teaching suggest visualizing a hook progressively lifting at the T wave to the upper right as hyperkalemia progresses to help visualize the progressive EKG changes seen in hyperkalemia. First, a normal T becomes peaked; then P’s become flattened as the QRS widens. Finally, with severely elevated potassium comes the dreaded sine wave, V-fib or asystole.

Finally, treatment must be initiated for hyperkalemia with EKG changes. My favorite mnemonic is “C BIG K DROP.”

C – Calcium gluconate – membrane stabilization

B – Bicarb, B-agonists – Intracellular shift

IG – Insulin/glucose – intracellular shift

K – Kayaxelate – Excretion

D – Diuretics – Excretion (i.e., furosemide)

ROP – “Renal for dialysis Of Patient”

Screen Shot 2017-12-17 at 8.25.06 PM.pngDr. Faucher next brings us a case of abdominal pain and confusion in a 73-year-old male. Presentation, labs and imaging are consistent with a case of ascending cholangitis, caused by infection of the obstructed biliary tree. He reminds us of the constellation of signs and symptoms known as Charcot’s Triad, consisting of:

  • Fever
  • Abdominal pain
  • Jaundice (60-70% of patients)
  • Note this only occurs for bilirubin elevated >2.5-3 mg/dL and likely will be conjugated/direct as problem is post-hepatic obstruction

Add shock and altered mental status to the clinical picture to round out Reynold’s Pentad, especially in your elderly patients, in whom this might be their only presenting symptom.

Additional findings may include elevated liver enzymes, CBD dilation on ultrasound. Management involves broad-spectrum antibiotics in the acute setting with urgent ERCP.

Dr. Onders then presents her case of a 28-year-old female coming in after noticing one pupil was larger than the other. Realizing the causes of anisocoria range from the benign to the emergent, took a detailed history. It had started yesterday and she had only noticed it when changing her contacts. She denies any pain, eye redness or other associated symptoms. CTA of the brain was negative.

Dr. Onders came up with the following for her differential:

  • Physiologic: anisocoria equal or less than 1mm can be a normal variant. Hers was larger in this case.
  • Mechanical: damage to the iris can lead to anisocoria though this patient had no history of trauma and no pain
  • Argyll Robertson pupil: Seen in advanced syphilis, the “prostitute’s pupil” accommodates but doesn’t react, which was not the case in this patient
  • Oculomotor nerve palsy: This can be due to ischemia (spares pupil) or compressive due to aneurism (CTA negative)
  • Pharmacologic

As she ruled out items on her differential, Dr. Onders revisited the patient’s history. Recently, the patient’s mother had started using scopolamine patches, which the patient had handled. Exposing her eye to this anticholinergic prior to using her contacts likely resulted in her presentation.

Dr. Kosier then shares the case of a 51-year-old male who was found unresponsive. Found by EMS to be in V-fib arrest. On arrival, EKG was as below:

Screen Shot 2017-12-17 at 8.25.14 PM.pngA STEMI alert was called and the patient was taken to the cath lab where angioplasty and stent placement was performed for a 99% RCA occlusion.

With not all acute coronary syndromes presenting as textbook STEMIs, Dr. Kozier took this opportunity to remind us of the common STEMI equivalents.

Common STEMI Equivalents

  • De Winter ST/T complex – ST depressions with peaked t-waves in anterior leads
  • de Winters ST-T waves
  • Wellen’s syndrome – deeply inverted or biphasic t-waves in V2-V3
  • Wellen’s syndrome
  • ST elevation in aVR
  • LBBB with Sgarbossa criteria
  • Sgarbossa criteria
  • Isolated posterior MI
  • T waves upright in V1

 

It is Dr. Grantham up next to share the case of a worsening rash that developed hours of the patient received an injection of penicillin for his syphilis. The rash is maculopapular and does involve the palms and soles. It is accompanied by fevers and diffuse myalgias. Dr. Grantham first considers an allergic reaction as the possible cause but then remembers learning in medical school of the Jerish-Herxheimer reaction in a patient receiving treatment for syphilis.

Jerish-Herxhsimer reactions are self-limiting reaction experienced by patients within 24 hours of starting antitreponemal therapy. It may include worsening of the patient’s syphilitic rash, mylagias, fevers, nausea/vomiting. It is not an allergic reaction, but rather it is believed to be due to the rapid release of treponemal toxins and byproducts that occurs as the antibiotics begin to take effect. It does not pose an intrinsic harm to the patient and management should include antipyretics and symptom control.

Dr. Sanchez then provides the case of an 18F who was found unresponsive in bed after consuming a few wine coolers following a period of depressed mood. She was intubated, with no reaction to narcan or D50. She withdraws to painful stimuli but is otherwise unresponsive. An ingestion workup was initiated and significant for a bicarb of 5 with measured serum osmolality of 370 and calculated of 330 (corrected for alcohol of .038).

Her volatile alcohol panel whowed an ethylene glycol leve of 310 mg/dL.

Below you can find a reminder of how to calculate the osmorlar gap. Additionally, the following table can be helpful to determine expected osmolality changes with different volatile alcohols:

Screen Shot 2017-12-17 at 8.25.22 PM.pngShe then discusses the treatment for this dangerous ingestion.

Fompeizole – inhibitor of alcohol dehydrogenase inhibits conversion to dangerous intermediates

  • Consider when serum concentrations of methanol or ethylene glycol is > 20mg/dL
  • Start with confirmed or suspected methanol/ethylene glycol and two of the following:
    • Osmolar gap >10 mOsm, Arterial pH < 7.3, bicarb < 20 mmol/L, presence of urinary oxalate crystals

Sodium bicarbonate – consider with arterial pH < 7.3

Hemodialysis – consider in the presence of pH < 7.25-7.3, visual abnormalities, renal failure, electrolyte abnormalities, serum concentration > 50mg/dL

Screen Shot 2017-12-17 at 8.13.51 PM.png

Benzos, Bleeding, Burns. Case Conference Review, November 8, 2017

Welcome back to another edition of Case Conference Review here at Academic Medicine Pearls at THE Ohio State University! Old Man Adams starts us off with a 38-year-old male with known history of alcohol abuse presenting via EMS for suspected EtOH withdrawal. On walking into the room, Dr. Adams is greeted with choice expletives and the subsequently refuses any vitals or to participate in the examination. The patient then promptly starts to seize, sending Dr. Adams down his alcoholic withdrawal seizure pathway.

To treat the alcoholic withdrawal seizure, he recommends the following simple piece of advise: “Benzos, benzos, benzos.”

His initial treatment of choice is Ativan 4mg. If that doesn’t work, repeat it. Keep in mind that Ativan (and oxazepam) are also safe benzo choices for cirrhotic patients. Should the seizures be refractory to initial measures and status epilepticus is achieved, intubation may be necessary. RSI should be done using versed or propofol for their GABAnergic effects and your choice of paralytic. Dr. Aziz adds that you may require higher doses of versed than the standard 0.3mg/kg dosing given chronic alcohol abuse.

Other options for seizure control? Propofol and phenobarbital are both good options if benzos fail, with ketamine as a consideration as well. “What about phosphenytoin?” one resident asks. While this is a common secondary agent in any seizure algorithm, it will not be effective in the alcohol seizure. The reason for this lies in the neurotransmitters affected by chronic alcohol use. Withdrawal seizures are caused by reduced GABAnergic and increased glutaminergic activity, on which phenytoin will have no effect, but benzos and barbituates will.

Further workup for this patient should include a head CT and also an EEG if paralyzed. Dr. Rublee reminds us that if suspicious for Wernicke’s, the treatment dose of thiamine is 500mg TID for three days, which Dr. Aziz reminds us should be given IV if possible due to an absorption of only 50% orally.

Dr. Nagaraj then takes us to into procedure land with her patient presenting with headache, fever and maculopapular rash (Figure 1) suspicious for meningococcal meningitis. She asks the question, “When is a lumbar puncture safe in the anticoagulated patient?”

Unfortunately, clear guidelines are not available, though there does exist some information to help us make informed decisions.

When it comes to Coumadin, An INR > 1.4 is considered a relative contraindication. It is recommended to hold Coumadin for five days prior to performing an LP. What if you don’t have five days? Should we give PCC? Dr. Nagaraj comments on a retrospective study that addresses this. PCC can be safely used to reduce INR <1.5 within roughly two hours, creating a safe environment for LP from a bleeding standpoint. In this study, however, thromboembolic events occurred in 6% of patients who received PCC (PCC has 2% established acceptable thromboembolic event rate). While its use in hemorrhaging patients has long been established to be beneficial, its usage in nonemergent scenarios remains unclear.

Information on LPs in patients with NOACs is similarly unclear, with no guidelines in existence. LPs are commonly performed within 24h of a patient’s last dose of a NOAC. Anticoagulation is considered fully resolved after five half-lives have passed for a given drug

Half-lives for NOACs

  • Pradaxa – 3 days
  • Xarelto – 1.5 days
  • Eliquis – 2.25 days

What about low platelet counts? In one study of cancer patients, 199 LPs were performed on patients with platelet counts of 20,000/μL or less, and 742 LPs were performed with platelet counts between 21,000/μL and 50,00/μL, without any cases of major bleeding.

Bottom line: Consistent guidelines do not exist for LPs in patients at risk for bleeding. Use risks and benefit analysis to determine necessity of LP in these patients. Keep in mind that to date, there are only 35 case reports of iatrogenic spinal hematoma in the past 40 years.

Dr. Krystin Miller is up next, with a 33 year-old male who presents with burns to face and upper extremities after a can of PAM explodes after being set next to a hot grill. She started with IV, O2, monitor and ABCs, though had to use a lower extremity for her blood pressure cuff due to burns. She then walks us through standard management.

She reminds us that the first step is stabilization. She offers us the following tips:

  • Remember to check to oropharynx for any singed tissue or swelling. Also listen carefully for stridor, wheezing or any other signs of airway compromise. Intubation should be done early so as to decrease chance of a difficult airway due to swelling.
  • Don’t forget adequate pain control
  • For extremities, it is important to get a good neurovascular exam, especially in cases of circumferential burns that can lead to swelling and neurovascular compromise requiring
  • Cover the burns. Use saline moistened gauze (or dry with adaptic). Sterile drapes may be used for large burns
  • Update tetanus
  • Nutrition is important due to high protein losses with burns and large amount of tissue rebuilding that will take place.

Once stabilization has been completed, appropriate fluid administration must be initiated. The first step is calculating the total body surface area (TBSA) that sustained 2nd or 3rd degree burns. This is done using the “Rule of 9’s,” as seen in Figure 1.

Classification of burns goes according to the following scheme:

First degree: Superfiical, epidermis only. Think sunburns.

Second degree: Epidermis and part of the dermis. Blisters may be present and the wound is very painful.

Third degree: Entire epidermis and dermis are involved. Wound may appear charred, leathery and pale. This should be painless and nerve fibers in dermis have been destroyed.

Once you have the TBSA calculated, you can then use the Parkland Formula to determine fluid administration volumes.

Total fluid to be given within first 24 hours = TBSA x weight (kg) x 4mL

Recommendations are to give one half of this total within the first 8 hours and the rest during the subsequent 16 hours. Due to the large volume being administered, we recommend using lactated ringer’s instead of normal saline to prevent the development of hyperchloremic metabolic acidosis.

“Should You Find Yourself in Afghanistan.” A helpful tip from our Chief resident in this week’s Case Conference Summary

Conference moderator and forever resident Dr. Zach Adams leads off this week’s case conference with a 65-year-old female diabetic presenting with the always challenging chief complaint of a “room-spinning” dizziness, otherwise classified as vertigo. She describes it as worse with position, severe, and present intermittently for the past few days. Suspicious for peripheral vertigo, Dr. Adams performs the Dix-Hallpike maneuver (Figure 1). Seconds after placing the patient in the reclined position with head turned laterally, the patient displays strong rotary nystagmus and promptly vomits on Dr. Adams’ shoes. Confirming his suspicion for benign paroxysmal peripheral vertigo, Dr. Adams then successfully performs the Epley maneuver (Figure 2) to reposition the otoliths within the semicircular canal and relieve the patient’s vertigo.

Untitled

Figure 1: Dix-Hallpike Maneuver

 

Untitledepley

Figure 2: Epley Maneuver

 

However, what if this vertigo had not given a positive on the Dix-Hallpike test? Central vertigo needs to be ruled out.

 

This is done using the HINTS exam, or Head Impulse, Nystagmus, Test of Skew to diagnose, a beside examination that has been shown to be superior to early MRI in the detection of posterior strokes (Kattah et al., 2015).

 

Components

Head Impulse: Corrective saccade implies peripheral vertigo. Lack of corrective saccade means the vestibule-ocular reflex is intact, as you would find in central vertigo (or a person not actually suffering from vertigo at all, like you or me).

Nystagmus: unidirectional, horizontal nystagmus is suggestive of peripheral vertigo. If the nystagmus is bidirectional, torsional, or vertical, this is suggestive of a central cause

Test of Skew: Positive test is suggestive of central pathology

View the following video for instruction on how to correctly perform this maneuver!

https://www.youtube.com/watch?v=1q-VTKPweuk

Excellent article detailing the sensitivity of this test listed below. As Dr. Aziz pointed out, these tests were conducted by neuro-ophthalmologists, so be sure that you understand the tests themselves in order to be able to expect any sensitivity.

Kattah, J. C., Talkad, A. V., Wang, D. Z., Hsieh, Y.-H., & Newman-Toker, D. E. (October 26, 2009). HINTS to Diagnose Stroke in the Acute Vestibular Syndrome. Stroke, 40, 11, 3504-3510.

 

Dr. Yeh then shares the case of a schizophrenic gentleman, previously admitted the psych hospital, presenting back from psychiatry to the ED with the somewhat ironic chief complaint of altered mental status. Per report, he has had increasing fatigue and lethargy. His physical exam is significant for slow, one-word responses, slow gait without any focal neurologic deficits. A quick medication review revealed the recent addition of 1500mg of Depakote. His blood valproic acid level was found to be 130 mg/L, only slightly elevated, but given its recent addition to his medication list and coupled with the clinical scenario, the likely culprit in his altered mental status.

How to treat?

Discontinue the offending medication immediately. In order to treat hyperammonemia, lactulose should be given. How much you ask? “It should be given until the patient poops,” as Dr. Martinez reminds us. Additionally, in the case of severe toxicity where the patient is at risk for coma and death, dialysis should be considered. Dr. Rublee advises that this is most likely to be beneficial in the setting of high serum Depakote levels, as you can expect a high percentage of drug not already bound to serum protein.

 

Next up, is Dr. Schwab with a case of a friendly wrestling match gone wrong. Our patient comes in after feeling a “pop” sensation in his left arm while wrestling his roommate. His XR can be seen below:

postdisloc

Diagnosis? Posterior dislocation of the elbow without fracture. This needs to be reduced. But first, Dr. Schwab took a moment to discuss his sedation, which he accomplished with propofol.

 

He offers the following advice:

  • Ensure sedation is adequate. Do not be afraid to pause the reduction to do so.
  • When using propofol, start with a 1mg/kg bolus followed by 20mg ever 30s until desired sedation is achieved
  • Consider pre-medicating with fentanyl to decrease amount of propofol needed (though be wary of increased potential for adverse events from a respiratory standpoint)
  • Consider ketamine as adjunct – independent subdissociative doses vs ketofol

 

Once adequate sedation was ensured, reduction was accomplished using traction-counter-traction while applying firm pressure over the olecranon.

reduction

Video of proper reduction technique can be found here.

 

Dr. Rublee is up next with her case of a 29-year-old inmate whose face was on the receiving end of a flaming bowl of lit baby oil and chili powder. He presents in agonizing eye pain with concern for chemical and thermal damage to his eyes. Dr. Rublee quickly tested eye pH, finding it elevated (7-8 normal). Realizing the need for irrigation, she obtained a Morgan lens and began irrigation, choosing then to discuss its proper usage, as seen below.

  • Anesthetize with tetracaine, with care to ensure that pH has already been tested, as tetracaine may alter the pH.
  • Connect the Morgan lens to irrigation (LR preferred but normal saline works) and insert in a fashion similar to that of a contact lens
  • First irrigate under the upper eye lid for 30 minutes and then move to under the lower lid for an additional 30 minutes

 

When in doubt, the official instructions can be found on the manufacturer’s website:

 

morganlens

Dr. Carrol took this opportunity to remind us that this may not be a suitable option in young children as their eyes may be too small, in which case manual irrigation is the preferred option. Dr. Adams, before closing out the day, advises a quick and useful alternative to the Morgan lens, “should you find yourself in Afghanistan.” He recommends as a substitute placing the prongs of a nasal cannula on either side of the bridge of the nose. The NC can then be hooked up to a saline bag, providing continuous irrigation to both eyes.

This wraps up another week of AMP at The Ohio State University. Thanks for reading and check back next week!