This issue of "The Probe" covers chylothorax and pregabalin.
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This edition of "The Probe" covers all you need to know about intussception.
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This edition of "The Probe" covers a clinical case of tibial avulsion, and the management of meningitis in children.
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This edition of "The Probe" covers the use of inotropes and vasopressors. It also covers the management of acute rhinosinusitis.
This weeks edition of "The Probe" covers base of skull fractures, and analgesia in palliative care patients.
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Erythema infectiosum or Fifth disease is a viral infection caused by human parvovirus B19. It is also known as "Slapped Cheek Syndrome".
It is commonly seen in pre-schoolers and children of school age.
It presents with an erythematous rash of the face with perioral sparing. The rash progresses to the chest and limbs. It then undergoes central fading and develops a lacy pattern. The rash can last for up to 1-2 weeks. Onset of exanthem is approximately 17-18 days following innoculation.
Patients can also have fever and arthritis.
In patients with haemalytic anaemia's, an aplastic crisis may be precipitated.
The differential diagnosis includes measles, rubella, roseola and infectious mononucleosis. Bacterial infections (scarlet fever), drug reactions and skin conditions such as guttate psoriasis, papular urticaria, atopc dematitis and erythema multiforme should also be considered.
Once the rash has appeared the patient is NOT considered infectious.
Patients should avoid contact with pregnant women as this is the leading cause of hydrops fetalis, and can cause foetal death.
Abdominal pain is a commmon presentation in the ED. This well designed RCT looked at the effectiveness of paracetamol, hyoscine and a combination of the two.
Bottom line - paracetamol alone outperformed the other combinations, and should be used as a first line agent for mild to moderate abdominal pain. There is no benefit from adding in hyoscine.
Remington-Hobbs, Petts G, Harris T
Emergency department management of undifferentiated abdominal pain with hyoscine butylbromide and paracetamol: a randomised control trial.
Emerg Med J 2012;29:989-994 doi:10.1136/emermed-2011-200474
Objective; To compare the effectiveness of paracetamol, hyoscine butylbromide and the combination of paracetamol plus hyoscine butylbromide (paracetamol + hyoscine butylbromide) in the management of patients with acute undifferentiated abdominal pain attending the emergency department (ED).
Setting; A large teaching hospital with an annual ED census of 120 000 adult patients.
Methods; A prospective, randomised placebo controlled trial of a convenience sample of patients attending the ED. The trial compared the analgesic effect of intravenous hyoscine butylbromide, oral paracetamol and the combination of both drugs using a Visual Analogue Scale pain scoring tool. Rescue analgesia was administered when pain was inadequately controlled by trial medication.
Results; 132 patients were recruited to the trial. At 30 min, all analgesic combinations produced significant similar levels of pain relief. At 60 min after administration of the trial medication, mean reductions in pain scores for patients receiving paracetamol only were significantly greater than those receiving paracetamol + hyoscine butylbromide (ANCOVA model, p=0.0180). No relationship was seen between treatment arm and the need for rescue analgesia (χ2, p value=0.846).
Conclusion; The trial data suggest that oral paracetamol is at least as effective as intravenous hyoscine butylbromide and a combination of both drugs in the management of acute undifferentiated abdominal pain presenting to the ED. Based on these results and factors such as cost and tolerability, we recommend single agent paracetamol as the agent of choice for the management of acute mild to moderate undifferentiated abdominal pain.
A 30 year old male is brought into ED following an attempted hanging with a rope.
On examination, he has a hoarse voice and a ligature mark in zone 1 of the neck. Neurological examination is normal.
CT angiogram of the neck reveals a dissection of the carotid artery.
How should this injury be managed?
Right Carotid Artery Dissection with true lumen demonstrated with contrast.
- This is an injury which is more common than previously recognized, and is seen in up to 2% of patients screened for the disease.
- Screening is recommended for patients with severe cervical hyperextension/ rotation injury, basilar skull fracture, severe cervical spine fracture and facial fractures, DAI and GCS < 6 with focal neurological signs.
- Grading system; Grade 1 < 25% narrowing, Grade 2 > 25% narrowing, grade 3 pseudoaneurysm, grade 4 thrombosis, grade 5 transection with extravasation.
- Most patients are asymptomatic initially with development of symptoms on average 24 hours after injury.
- Mortality rates is 30%, survivors have a 60% morbidity related to stroke.
- Cothren et al demonstrated no ischaemic complications in patients who were anticoagulated, and a 49% stroke rate in patients who were not anticoagulated.
- High grade dissections or those with early neurological symptoms should be considered as candidates for open surgical repair or endovascular stenting.
OHCA is a condition with a poor prognosis, with the most common precipitant being IHD.
One of the major decisions in patients who have had ROSC following OHCA is whether to proceed to the cath lab for angiography. Traditionally, this decision has been based on ECG changes, but a new systematic review suggests that we should be more liberal in our interventions.
Larsen JM, Ravkilde J. Acute coronory angiography in patients resuscitated from out of hospital cardiac arrest - A systematic review and meta-analysis. Resuscitation. 2012; 83(12) 1427-1433.
Aim; To make a systematic review addressing the question: “In patients with return of spontaneous circulation following out-of-hospital cardiac arrest, does acute coronary angiography with coronary intervention improve survival compared to conventional treatment?”
Methods; Peer reviewed articles written in English with relevant prognostic data were included. Comparison studies on patients with and without acute coronary angiography were pooled in a meta-analysis.
Results; Thirty-two non-randomised studies were included of which 22 were case-series without patients with conservative treatment. Seven studies with specific efforts to control confounding had statistical evidence to support the use of acute coronary angiography following resuscitation from out-of-hospital cardiac arrest. The remaining 25 studies were considered neutral. Following acute coronary angiography, the survival to hospital discharge, 30 days or six months ranged from 23% to 86%. In patients without an obvious non-cardiac aetiology, the prevalence of significant coronary artery disease ranged from 59% to 71%. Electrocardiographic findings were unreliable for identifying angiographic findings of acute coronary syndrome. Ten comparison studies demonstrated a pooled unadjusted odds ratio for survival of 2.78 (1.89; 4.10) favouring acute coronary angiography.
Conclusion; No randomised studies exist on acute coronary angiography following out-of-hospital cardiac arrest. An increasing number of observational studies support feasibility and a possible survival benefit of an early invasive approach.
In patients without an obvious non-cardiac aetiology, acute coronary angiography should be strongly considered irrespective of electrocardiographic findings due to a high prevalence of coronary artery disease.
The utility of drugs in resuscitation of patients with OHCA remains unclear. There is an increasing amount of literature that does not show a survival benefit for drugs in all forms of cardiac arrest (VF/VT, Asystole, PEA).
This study, while it's main focus was on the variable drug use in OHCA also showed no survival benefit with lignocaine and amiodarone for VF / VT or atropine, sodium bicarbonate and adrenaline in asystole or PEA.
Wide variability in drug use in out-of-hospital cardiac arrest: A report from the resuscitation outcomes consortium
Benedict M. Glover, Siobhan P. Brown, Laurie Morrison, Daniel Davis, Peter J. Kudenchuk, Lois Van Ottingham, Christian Vaillancourt, Sheldon Cheskes, Dianne L. Atkins, Paul Dorian, the Resuscitation Outcomes Consortium Investigators. Resucitation. 2012; 83(11); 1324 - 1330
Background: Despite the publication and dissemination of the Advanced Cardiac Life Support guidelines, variability in the use of drugs during resuscitation from out-of-hospital cardiac arrest may exist between different Emergency Medical Services throughout North America. The purpose of this study was to characterize the use of such drugs and evaluate their relationship to cardiac arrest outcomes.
Methods and Results: The Resuscitation Outcomes Consortium Registry-Cardiac Arrest collects out-of-hospital cardiac arrest data from 264 Emergency Medical Services agencies in 11 geographical locations in the US and Canada. Multivariable logistic regression was used to assess the association between drug use, characteristics of the cardiac arrest and a pulse at emergency department arrival and survival to discharge. A total of 16,221 out-of-hospital cardiac arrests were attended by 74 Emergency Medical Services agencies. There was a considerable variability in the administration of amiodarone and lidocaine for the treatment of shock resistant ventricular tachycardia/ventricular fibrillation. For non-shockable rhythms, atropine use ranged from 29 to 95% and sodium bicarbonate use ranged from 0.2 to 73% across agencies in the 89% of agencies that used the drug. Epinephrine use ranged from 57 to 98% within agencies. Neither lidocaine nor amiodarone was associated with a survival benefit while there was an inverse relationship between the administration of epinephrine, atropine and sodium bicarbonate and survival to hospital discharge.
Conclusions: There is considerable variability among Emergency Medical Services agencies in their use of pharmacological therapy for out-of-hospital cardiac arrests which may be resolved by performing large randomized trials examining effects on survival.
CPR teaching has evolved recently with the new adage of "push hard, push fast" being expounded. However, we need to remember that we should not push too fast, A recent paper shows that increasing the rate of CPR leads to a reduced chest compression, and this in turn may lead to decreased cardiac output from the CPR.
Excessive chest compression rate is associated with insufficient compression depth in prehospital cardiac arrest
Koenraad G. Monsieurs, Melissa De Regge, Kristof Vansteelandt, Jeroen De Smet, Emmanuel Annaert, Sabine Lemoyne, Alain F. Kalmar, Paul A. Calle. Resuscitation. 2012; 83(11);1319-1323
Abstract: Background and goal of study: The relationship between chest compression rate and compression depth is unknown. In order to characterise this relationship, we performed an observational study in prehospital cardiac arrest patients. We hypothesised that faster compressions are associated with decreased depth.
Materials and methods: In patients undergoing prehospital cardiopulmonary resuscitation by health care professionals, chest compression rate and depth were recorded using an accelerometer (E-series monitor-defibrillator, Zoll, USA). Compression depth was compared for rates <80/min, 80–120/min and >120/min. A difference in compression depth ≥0.5cm was considered clinically significant. Mixed models with repeated measurements of chest compression depth and rate (level 1) nested within patients (level 2) were used with compression rate as a continuous and as a categorical predictor of depth. Results are reported as means and standard error (SE).
Results and discussion: One hundred and thirty-three consecutive patients were analysed (213,409 compressions). Of all compressions 2% were <80/min, 62% between 80 and 120/min and 36% >120/min, 36% were <4cm deep, 45% between 4 and 5cm, 19% >5cm. In 77 out of 133 (58%) patients a statistically significant lower depth was observed for rates >120/min compared to rates 80–120/min, in 40 out of 133 (30%) this difference was also clinically significant. The mixed models predicted that the deepest compression (4.5cm) occurred at a rate of 86/min, with progressively lower compression depths at higher rates. Rates >145/min would result in a depth <4cm. Predicted compression depth for rates 80–120/min was on average 4.5cm (SE 0.06) compared to 4.1cm (SE 0.06) for compressions >120/min (mean difference 0.4cm, P<0.001). Age and sex of the patient had no additional effect on depth.
Conclusions: This study showed an association between higher compression rates and lower compression depths. Avoiding excessive compression rates may lead to more compressions of sufficient depth.
A 48 year old female presents to the ED with a 5 day history of coryzal symptoms, increasing shortness of breath, dry cough and chest pain. She was seen in the ED the day before and diagnosed with acute bronchitis, but has represented as she is unable to walk due to her dyspnoea.
She is fit and well and is on no regular medications.
Physical examination is unremarkable.
Blood results show; WCC 7.4, Hb 126, Plt 241, Na 132, K 3.9, HCO3 21, Urea 5.8. Cr 72, ALP 206, GGT 221, ALT 315, AST 264.
hs Troponin is elevated at 36
ECG shows non-diagnostic ST-T changes.
Her CXR is below.
Cardiomegaly with globular heart. Mild interstitial infiltrate.
An urgent Echo was performed which showed global hypokinesis with a reduced EF.
A provisional diagnosis of viral myocarditis was made, and she was admitted under the cardiology team for further evaluation and treatment.
Sagar et al in a review on myocarditis propose a 3-tiered classification for acute myocarditis.
- Possible subclinical acute myocarditis- recent trigger such as a viral illness with an unexplained rise in troponin, ECG changes suggestive of myocardial injury or abnormal cardiac function on echocardiogram.
- Probable acute myocarditis - meets subclinical criteria with acute heart failure, chest pain, syncope or myopericarditis.
- Definite myocarditis - confirmed with endomyocardial biopsy.
CausesMyocarditis is most commonly caused by a wide spectrum of infectious agents including viruses, bacteria, chlamydia, rickettsia, fungi and protozoans. Non-infectious causes are uncommon and include systemic inflammatory conditions like SLE and RA, toxic causes such as alcohol, radiation, doxorubicin and hypersensitivity reactions to penicillins and sulphonamides.
- Troponins are elevated in 34% of patients with acute myocarditis.
- CRP, ESR and WCC are frequently elevated, but low specificity limits their usefulness.
- The ECG frequently shows non-specific changes. The presence of a widened QRS and Q waves are poor prognostic features.
- New regional or global wall motion abnormalities on echo, that are not associated with a coronary distribution are useful in the diagnosis.
- Cardiac MRI is an excellent non-invasive test for diagnosing myocarditis, with a sensitivity of 67% and specificity of 91%.
- The gold standard for diagnosing myocarditis is endomyocardial biopsy.
- Subclinical acute myocarditis - if ventricular function is normal, clinical assessment in 1-2 weeks.
- If there are symptoms of heart failure (LVEF < 40%), commence an ACE or ARA, and consider a beta-blocker.
- Immunosuppresive therapy with drugs such as azathioprine, cyclosporin and prednsione have not shown any benefit in improving ventricular function or transplant free survival except in non-infectious causes.
- Colchicine can improve the chest pain associated with myopericarditis.
- NSAID's should be reserved for patients with normal LV function as they can worsen myocarditis.
- Patients with syncope and arrhythmia's need admission to a monitored bed, and may need insertion of an implantable defibrillator or pacemaker.
- Sagar S et al. Myocarditis. Lancet; 2012; 379; 738-47
A 19 year old male presents to the ED with the following injury following a fall while playing Basketball.
Click here for the answers.
- What is the diagnosis?
- How would you manage this injury?
- What long term complications would you expect from this injury?