Podcast Episode 25: Pediatric Appendicitis

In what two age groups is perforated appendicitis most common?  If you said the very young and the very old, you would be correct.  As we all know, the workup and diagnosis of appendicitis in kids can be extremely difficult.  There are communication barriers, distractors, and mimickers.  So how do we tease out the right history and get to the correct conclusion?

In this episode, we discuss many of the more difficult and important aspects of the workup for a child with possible appendicitis.  Can physical exam change your pretest probability?  Can you do labs without imaging, or is it an all or nothing workup?  what about documentation and follow up?  How do you handle the indeterminate ultrasound?  Do you use oral contrast if CT is needed, or IV only?  

In this conference, we have a panel of five of our best and brightest attendings discussing these issues and more.  You’ll hear from:

  • Dan Kaminstein, MD: You’ve heard him before, international medicine and ultrasound expert
  • Tom Kehrl, MD: From the Airway tips and tricks episode, and our EUS fellowship director
  • Andy Kepner, MD: Emergency Physician with a surgical background and director of our sim center
  • Erik Kochert, MD: Also a frequenter of the EM Res podcast, APD and Research director
  • Jess Riley, MD: Emergency physician with both academic and community experience
  • Bob Stuntz, MD: You know me

This episode does run longer than the typical episode, but it is chock full of good pearls.  Let us know what you think in the comments below, or head over to the Google Community to discuss this episode.

References:  

  1. Bundy DG1, Byerley JS, Liles EA, Perrin EM, Katznelson J, Rice HE.  Does this child have appendicitis?  JAMA. 2007 Jul 25;298(4):438-51.
  2. Ebell MH1, Shinholser J2.  What Are the Most Clinically Useful Cutoffs for the Alvarado and Pediatric Appendicitis Scores? A Systematic Review.  Ann Emerg Med. 2014 Apr 11.
  3. Ohle R1, O’Reilly F, O’Brien KK, Fahey T, Dimitrov BD.  The Alvarado score for predicting acute appendicitis: a systematic review.  BMC Med. 2011 Dec 28;9:139.
  4. Meltzer AC1, Baumann BM, Chen EH, Shofer FS, Mills AM.  Poor sensitivity of a modified Alvarado score in adults with suspected appendicitis.  Ann Emerg Med. 2013 Aug;62(2):126-31.
  5. Ross MJ1, Liu H, Netherton SJ, Eccles R, Chen PW, Boag G, Morrison E, Thompson GC.  Outcomes of children with suspected appendicitis and incompletely visualized appendix on ultrasound.  Acad Emerg Med. 2014 May;21(5):538-42.
  6. Estey A1, Poonai N, Lim R.  Appendix not seen: the predictive value of secondary inflammatory sonographic signs.  Pediatr Emerg Care. 2013 Apr;29(4):435-9.
  7. Bachur RG1, Dayan PS, Bajaj L, Macias CG, Mittal MK, Stevenson MD, Dudley NC, Sinclair K, Bennett J, Monuteaux MC, Kharbanda AB; Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics.  The effect of abdominal pain duration on the accuracy of diagnostic imaging for pediatric appendicitis.  Ann Emerg Med. 2012 Nov;60(5):582-590.
  8. Leeuwenburgh MM1, Stockmann HB, Bouma WH, Houdijk AP, Verhagen MF, Vrouenraets B, Cobben LP, Bossuyt PM, Stoker J, Boermeester MA; OPTIMAP Study Group.  A simple clinical decision rule to rule out appendicitis in patients with nondiagnostic ultrasound results. Acad Emerg Med. 2014 May;21(5):488-96.
  9. Elikashvili I1, Tay ET, Tsung JW.  The effect of point-of-care ultrasonography on emergency department length of stay and computed tomography utilization in children with suspected appendicitis.  Acad Emerg Med. 2014 Feb;21(2):163-70.
  10. Yu CW1, Juan LI, Wu MH, Shen CJ, Wu JY, Lee CC.  Systematic review and meta-analysis of the diagnostic accuracy of procalcitonin, C-reactive protein and white blood cell count for suspected acute appendicitis.  Br J Surg. 2013 Feb;100(3):322-9.
  11. Kwan KY1, Nager AL.  Diagnosing pediatric appendicitis: usefulness of laboratory markers.  Am J Emerg Med. 2010 Nov;28(9):1009-15.

Either click here to listen to the podcast, or check out the episode embedded below:


Asynchronous learning quiz: Coming Soon!

A Young woman with chest pain: The Conclusion

Let’s welcome Dr. Shafer back to the blog.  Between being a chief resident and being accepted in to a critical care fellowship, she has another interesting case presentation for you.  Some really interesting learning points on this one.  Here is a link to the original post in case you missed it, and here is the answer…

-Bob

Diagnosis: Spontaneous LAD dissection

This is an unusual diagnosis that is mainly described as case reports in the literature.  In 1996 only 100 cases in the world had been identified (2). Of these reported cases, 75% were diagnosed at autopsy and the rest were diagnosed with coronary angiography (1). The majority of these cases (approximately 75%) were in women, and of these cases, 32% of the patients were pregnant, post-partum, or taking oral contraceptives (2). One study in 2009 observed that one out of ten women under the age of 50 who clinically presented with ACS instead had a coronary dissection on coronary angiography (3). 

LAD dissection is considered especially disastrous and results in malignant arrhythmias, severe CHF, extensive infarct and sudden death (2). The clinical presentation of coronary dissection is similar to that of a patient having an acute MI, but they are usually younger and without the cardiac risk factors.  It is important to note that spontaneous coronary dissection can be recurrent. The etiology of this disease is unclear, but some autopsies have demonstrated an eosinophilic penetration of the tunica adventitia and it is postulated that this subsequently causes damage to the collagen, elastin and smooth muscle wall (2). Treatment options for these patients include medical management only versus stenting versus bypass surgery. There is no treatment standard at this time and the prognosis of these patients who survive is unknown. However, the case reports overall seem to demonstrate that at least one year post-event survival rate is quite high. 

For our case presentation, the patient was emergently taken to the cath lab where her diagnosis of spontaneous LAD dissection was made. She was stented at this time and started on Aspirin, Metoprolol, and Effient.  She had a complicated hospital course, developing pericarditis, a small pericardial effusion,  and a new apical thrombus. Ultimately, however, after a week her symptoms had dramatically improved and she was discharged home. 

Spontaneous coronary dissection is a rare but rapidly fatal diagnosis that should be considered in the differential diagnosis of young patients who present with symptoms of ACS; it can be both diagnosed and treated in the cath lab.  Remember that diffuse ST segment elevation in the younger patient with chest pain will not always equate to a diagnosis of pericarditis.

  1. Spontaneous Coronary Artery Dissection, Aneurysms, and Pseudoaneurysms: A Review. Echocardiography. 2004: 21(2), 175-182.
  2. Zampieri et al. Follow up after spontaneous coronary artery dissection: a report of five case series; Heart.1996: 75, 206-209.
  3. Vanzetto, et al. Prevalence, therapeutic management and medium-term prognosis of spontaneous coronary artery dissection: results from a database of 11,605 patients. European Journal of Cardio-thoracic Surgery. 2008: 35 (3), 205-254. 

A young woman with chest pain

Let’s welcome Dr. Shafer back to the blog.  Between being a chief resident and being accepted in to a critical care fellowship, she has another interesting case presentation for you.  Some really interesting learning points on this one.  Stay tuned for the answer! 

-Bob

Dr. Shafer: 

    A 28 year old female presents to the ED with a chief complaint of chest pain that started acutely at 3am this morning and awoke her from sleep. She reports that pain is in the center of her chest and is constant, nothing makes it better or worse, and it is not positional.  She woke up vomiting this morning and additionally feels short of breath and is diaphoretic. She states that she feels weak all over and has bilateral arm numbness. She has not had any recent URI symptoms. She does not abuse alcohol but she does use marijuana occasionally. She smokes ½ pack of cigarettes per day. There is no family history of cardiac disease or of sudden deaths. She has no prior past medical history and takes no medications. 

    Vital signs are as follows: HR 108, BP 165/98, RR 18, Oral Temp 98.6F, oxygen saturation is 100%. On exam she pale, diaphoretic, is leaning forward clutching her chest and appears uncomfortable. Lungs are clear to auscultation bilaterally, heart is normal rate and rhythm without murmurs/rubs/gallops. She has normal strength and sensation to light touch in bilateral upper and lower extremities, cranial nerves are intact, and has 2+ radial pulses bilaterally. 

    Her EKG is shown below. Cardiology was immediately consulted due to the patient’s appearance; they evaluated the patient at the bedside and diagnosed the patient with pericarditis. CT thorax was obtained which revealed no dissection or PE.  A bedside echocardiogram reveals a normal EF with concerns for apical wall motion abnormalities.  Pertinent labs revealed a white count of 18.8, troponin 3.15, lactic acid 3.6, and a normal BNP.



What is on your differential at this point?

What further testing could be done to evaluate the patient?  

Have a diagnosis in mind?

Episode 24.5: “EBM is crap…”

While making Episode 24, we had a little aside talking about the pitfalls of evidence based medicine.  It did not really fit in with the full episode, so here it is in all its half episode glory.  Dr. Kaminstein makes his feelings known, and we talk about those feelings.  Some great points are raised and debated regarding the art and practice of our specialty, and how EBM fits in.  What do you think?  Let us know in the comments below.  

Episode 24: What do I read, and how do I do it?

In Episode 24, EM Res vets Drs. Kaminstein and Kochert return with Dr. Becker’s debut to talk about how residents should approach reading medical research articles.  Do you need to read everything?  What should you read?  How do you do it?  All this and more in the first of a series on reading original research for residents.  

The first thing you need to know is that if you are an intern, and maybe even a second year, it is ok if you are not keeping up to date on the latest and greatest in original EM research.  The most important thing you can do during this time is to cover the basics.  Develop your basic knowledge and skills in EM.  

Once you do delve into research, pick one or two journals to start out with.  Annals of EM and Journal of EM come to mind (full disclosure: I am on the Annals Social Media team, and on the AAEM YPS board).  Once you have a journal or two, skim the titles and see what interests you.  If you see an interesting title, read the abstract and see if the full article is worth your time.  

Remember, once you start reading, the discussion is the writer’s chance to slant their results as they see fit.  There is a reason this section is last - it should be the least important part of your analysis.  

Think about articles in PICO format.  

P: What type of patient are they looking at/what is the patient population?

I: What is the intervention?

C: What is the control?

O: What are the outcomes?

This should give you the foundation to start.  This is the first in a series of podcasts where we will cover more advanced topics so that you too can be able to critically read and appraise the medical literature by the time you are done with your EM residency.  

Here are some great resources cited during our discussion:

The Skeptics Guide to EM

Emergency Medicine Abstracts

EMCrit

EM Literature of Note

EM Nerd

EM Journal Watch

EM:RAP paper chase

SMART:EM

A few announcements:

  1. I have been away for the last month working on Emergency Board Review!  Go check it out.  Check out our latest review lecture on nervous system disorders.  Find the lectures on our podcast on iTunes, or any podcast software.  Check out the revamped website, rate the board review resources, and get involved.  Are you an upper level resident and want to help out with the Emergency Board Review project?  Get in touch with me at bobstuntzmd@gmail.com, or use the website contact form if you are interested in any of the open topics
  2. Want to write for the EM Res Blog?  Have an idea for an article, or even a series (US of the week, Image of the week…)?  Want to help with podcast episodes?  I want to expand the EM Res Blog and Podcast, but I need your help to do it.  Residents, educators, anyone anywhere - send your ideas to me at bobstuntzmd@gmail.com or @BobStuntz, and let’s see if we can make this thing even better!
  3. Please go join our Google Community.  The goal is to have this be a place that EM residents and educators (you can help answer resident questions) can get together to discuss resident issues and questions, both clinical and non-clinical.  
  4. Allowed to use my podcasts for asynchronous learning?  Check out the test below!

Check out the podcast below, or go listen here


If you have gotten approval from your program director to use the EM Res Podcast for individualized interactive instruction (asynchronous learning), the check out the test below or go take it Posted in , , , |

Episode 23: What’s the “Best” Residency?

In Episode 23, with the upcoming US EM residency interview season about to descend upon us all, I talk about a recent survey that claims to list the best EM residencies, why you should ignore it, what applicants should look for in a residency, and our duty as educators to find the right fit.  

f you are a medical student going into the EM Match this year, check out the following great videos to see what you should be doing, and how you can be the best applicant you can be:

The EM Rotation, ERAS, and am I competitive

Interviewing Strategies

Here is the original link I saw to the list of top EM residencies as compiled by Doximity and USNWR’s survey

ere is a link to the consensus document regarding the problems with this report. 

Announcements:

  1. Want to write for the EM Res Blog?  Have an idea for an article, or even a series (US of the week, Image of the week…)?  Want to help with podcast episodes?  I want to expand the EM Res Blog and Podcast, but I need your help to do it.  Residents, educators, anyone anywhere - send your ideas to me at bobstuntzmd@gmail.com or @BobStuntz, and let’s see if we can make this thing even better!
  2. Please go join our Google Community.  The goal is to have this be a place that EM residents and educators (you can help answer resident questions) can get together to discuss resident issues and questions, both clinical and non-clinical.  

Listen here or check out the podcast below: