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Conference Notes 12-11-2012

Walchuk/Watts   Oral Boards

Case 1 Esophogeal variceal bleeding:  Fluid/blood resuscitation.  Manage airway as patient becomes confused.  Protonix drip.  Octreotide 50microgram bolus followed by 25-50mics/hr.  Consult GI.  Could consider IR for TIPs procedure.   Correct any coagulation defect with FFP or Factor 7A. Give rocephin or cipro to avoid infectious complications and limit re-bleeding.   Endoscopy with sclerotherapy or banding teamed up with Octretide has better outcome than either endoscopy or octreotide alone.

Case 2 Organophosphate Poisoning: IV hydration, decontaminate, give Atropine and 2-PAM.   Usually need large doses of atropine. SLUDGE BBB=salivation/lacrimation/urination/diarrhea/gastric emptying/bronchospasm/bronchorhea.  Usually due to insecticide poisoning.  Most common pitfall is inadequate atropinization.

Case 3 Roseola infantum:  Also known as sixth’s disease/exanthema subitum/three day fever.  Patient is not contagious at the time of rash appearance.   Non-pruritic Rash appears after 3-5 days of fever.  Pt is well appearing.      Erythema infectiousum (fifth’s disease) will have slapped cheeks and lacey extremity rash.  It is usually in school age children.

Elise comment: Utilize massive transfusion protocol for GI bleeders in shock.  Could also consider FEIBA for coagulopathy.  Get 2 IV’s or a cordis in these patients to give large volume crystalloid/blood product replacement.   Any tox case on oral boards call poison control.   Figure out the OD by talking to family/friends/pre-hospital personnel.

Harwood comment:  Start to mobilize atropine 10-50 amps for treatment of organophosphate poisoning as soon as you suspect the diagnosis.   You will burn through all the atropine in the ED.  

Ketanneh  Trauma

The NEXUS decision instrument stipulates that radiography is not necessary if patients satisfy ALL five of the following low-risk criteria:

• §  Absence of posterior midline cervical tenderness
• §  Normal level of alertness
• §  No evidence of intoxication
• §  No abnormal neurologic findings
• §  No painful distracting injuries

Insignificant injuries were defined as those that would not lead to any consequences if left undiagnosed. The NEXUS investigators evaluated 34,069 blunt trauma patients who underwent radiography of the cervical spine comprised of either a three-view cervical spine x-ray or a cervical spine computed tomography (CT) scan. Of these patients, 818 (2.4 percent) had sustained a cervical spinal column injury. Sensitivity, specificity, and negative predictive value (NPV) of the NLC were found to be 99.6 percent (95% CI 98.6-100), 12.9 percent (95% CI 12.8-13.0), and 99.9 percent (95% CI 99.8-100), respectively. (These notes cut/pasted from Up to Date)

Tenderness should have objective signs like physical evidence of discomfort.

Altered level of alertness: GCS<15, disorientation, Inability to remember 3 objects at 5 minutes.

Painful distracting injury: Undefined and varies by physician. 

 Canadian C-Spine rule

The CCR involves the following steps:

• §  Condition One: Perform radiography in patients with any of the following:
  • ·         Age 65 years or older
  • ·         Dangerous mechanism of injury: fall from 1 m (3 ft) or five stairs; axial load to the head, such as diving accident; motor vehicle crash at high speed (>100 km/hour [>62 mph]); motorized recreational vehicle accident; ejection from a vehicle; bicycle collision with an immovable object, such as tree or parked car
  • ·         Paresthesias in the extremities
• § 
  • ·         Simple rear end motor vehicle accident; excludes: pushed into oncoming traffic; hit by bus or large truck; rollover; hit by high speed (>100 km/hour [>62 mph]) vehicle
  • ·         Sitting position in emergency department
  • ·         Ambulatory at any time
  • ·         Delayed onset of neck pain
  • ·         Absence of midline cervical spine tenderness

Patients who do not exhibit any of the low-risk factors listed here are NOT suitable for range of motion testing and must be assessed with radiographs.

If a patient does exhibit any of the low-risk factors, perform range of motion testing, as described in Condition Three below.

• §  not

In the derivation study, the CCR demonstrated a sensitivity of 100 percent and a specificity of 42.5 percent for identifying clinically important cervical spine injuries [22]. In 2003, the CCR was prospectively studied in the emergency departments of nine Canadian tertiary care hospitals. Of 8283 patients, 162 were found to have clinically significant injuries, and the sensitivity, specificity, and negative predictive values of the CCR were respectively 99.4 percent (95% CI 96-100), 45.1 percent (95% CI 44-46), and 100 percent [23]. The investigators reported that the CCR would have missed one patient with a clinically important cervical spine injury, while the NLC would have missed 16. The CCR has also been validated in larger hospital-based studies and in an out-of-hospital study of paramedics [24,25].  (These Notes cut and pasted from Up to Date)

Negative CT Cspine with persistent pain:  3 management options: continue collar with f/u with neurosurg.  Get MRI if neg then remove collar.  Get the dreaded flex-ext cspine films.   The utility of Flex/ext films is controversial.

Negative CT Cspine and Obtunded:  Don’t do flex/ext films.  Do MRI.   One study found 9% rate of abnormal MRI in obtunded patients with negative CT Cspine.   If you need to leave patient in collar for a prolonged time, use an Aspen Collar.

EAST guidelines were discussed and are basically a combination of NEXUS/Canadian rules with the above recommendations for what to do with the patient with negative CT cspine and continued concern for injury.  (If you want more info you can find the EAST guidelines at east.org)

Girzadas/C. Kulstad/Harwood comment:  Agreement  of commenters that there is still some utility to do a Cspine plain film series in a low risk/young patient.  You avoid excess radiation exposure and still can see C1 to C7. In a patient with higher risk or any increased difficulty in getting good quality plain films go right to CT Cspine.   Dr. Smith (Trauma) felt strongly you need a CT to rule out Cspine fracture.

Barounis comment: If you are working in a community ED and are transferring a severely injured patient that is obtunded, get a cspine film/cxr/pelvis xray.

Harwood/Smith comment: Don’t do flex/ext films.  Go right to MRI in the patient with significant neck pain or obtunded and negative CT Cspine.

Gottesman  M and M

25yo male with GSW to right face.  CT head showed facial fractures.  No intracranial injury. No cspine injury on CT Cspine

Lefort Fractures:  Type 1 fracture line goes through alveolar ridge and allows the front teeth to move with traction.    Type 2 fractures allow the nose to move.  Type 3 fractures allow the zygomas to move.

Patient in case became agitated in CT and developed hypoxia.  Trauma team moves to attempting intubation.   Glidescope intubation was successful.

Avoid nasal intubation in patients with facial fractures.

Pt developed increased bleeding from facial wound.  Wound/nose/oral cavity were all packed.

Causes of agitation: Head injurying/toxins/infection/hypoxia/hypoglycemia/intracranial injury/stroke/seizures/emotional stress/sensory deprivation.  Psychiatric cause is basically a diagnosis of exclusion.

Pt was found to have a high Internal Carotid Injury on CTA.  Went to OR but pt did not have surgery because he had an injury that the surgeons could not get to.   His injury was zone 3.

Harwood comment:  sometimes these high zone 3 injuries require surgical removal of mandible during the time of surgery.  Patients that have this procedure frequently have difficulty with eating and talking the rest of their lives.

Elise and Harwood comment: If you see this patient in a community ED, Tube/get facial film/cross table lateral cspine film/cxr prior to transfer.  

Patient in Case blows a pupil.  Pt stroked from left internal carotid injury and developed herniation

Take home point: Beware the agitated patient.  Think of hypoxia and other serious causes prior to attributing to psych reasons.

Harwood comment: As soon as you decided this patient has to go to CT you should have intubated him.

Garrett-Hauser     Ethics   Mandatory Reporting

Case 1:  Female patient with AIDs was having sexual relations with a man who did not know her HIV status.  They use condoms during intercourse.   Do we have obligation to notify her partner?

There is a law on the Illinois’ books titled Criminal Transmission of HIV.  Person has to know they have HIV and have sex without a condom with a person who does not know they have HIV.   Prosecution requires a court order for release of medical records.   So we don’t need to notify the police.     Harwood comment: If you know that HIV person knowingly    has sex with partner with no condom, do you notify the non-HIV partner?   He would first try to convince the HIV patient to notify the non-HIV patient.  Dr. Garrett-Hauser made a strong point that it likely would be a HIPPA violation to call the police.  There was a animated discussion among residents and attendings about whether and  how to notify the partner at risk.   Elise and Harwood would notify the at-risk partner.   C. Kulstand and Girzadas would give the at-risk partner a more obtuse warning such as: As a physician, I would advise you not to have sexual relations with that person until you have a detailed conversation with that person.

Case2: Intoxicated parents bring child to ER. Don’t let parents drive the child home.  Notify DCFS.

Case 3: 14yo female found to be pregnant at PMD’s office.  Pt’s mom brings child to ER that same day for U/S and was threatening lawsuit because the 14yo was in ER one week ago and diagnosed with pregnancy  and mom was not told.   ER records from previous ER visit documents that 14 yo patient refused to allow staff to notify mom of her pregnancy.     Shayla discussed that the decision to notify parents of medical condition of a minor is a balance of patient’s cognitive maturity and risk of medical condition.   The state law for emancipated minors specifically gives emancipated minors the right to consent for treatment  but not specifically the right to privacy.   Discussion of risk came down to: the parent is much more likely to sue you for not notifying them than the young patient is to sue you for ratting them out.

Case 3: Illinois does not have a mandatory reporting law for domestic violence.  The only state with such a law is California.  In California, ED physicians are mandated immediate reporters.  These laws are controversial because there has been increased morbidity or mortality for patients in which MD’s reported before the patients were personally ready to have abuse reported.

RLT Applicant Review

Procedural Tip: when performing a digital block, wait 10-15 minutes to optimize anesthesia.  Tell the patient you are going to see another patient and will be back in a few minutes. Don’t leave them too long though.  It’s embarrassing to have to anesthetize them twice.   I like to use bupivicaine without epi because it lasts longer than lido.