Katiyar/Davis                               Oral Boards

Case 1. 70 yo female patient presents with altered mental status.  Patient is tachycardic and hypotensive. Patient’s temperature is 106F.  Diagnosis is heat stroke with rhabdomyolysis.

 The cardinal features of heat stroke are hyperthermia (>40°C [>104°F]) and altered mental status. Although patients presenting with classic (nonexertional) heat stroke may exhibit anhidrosis, the absence of sweat is not considered a diagnostic criterion because sweat is present in over half of patients with heat stroke.15

The CNS is particularly vulnerable in heat stroke. The cerebellum is highly sensitive to heat, and ataxia can be an early neurologic finding. Virtually any neurologic abnormality may be present in heat stroke, including irritability, confusion, bizarre behavior, combativeness, hallucinations, plantar responses, decorticate and decerebrate posturing, hemiplegia, status epilepticus, and coma. Seizures are quite common, especially during cooling. Neurologic injury is a function of the maximum temperature reached and the duration of exposure.15

The distinction between exertional and classic (nonexertional) heat stroke is not clinically important, because immediate cooling and support of organ system function is the therapeutic goal for both. A delay in cooling increases the mortality rate. (Tintinalli 8th edition)

Case 2. 8 yo male patient was playing in the woodshed and came into the house screaming in pain. Patient had persistent pain despite IV morphine.  There appears to be a spider bite on exam.

Diagnosis was black widow spider bite.

The bite mark itself tends to be limited to a small puncture wound or wheal and flare reaction that often is associated with a halo (Table 115–3). However, the bite from L. mactans produces latrodectism, a constellation of signs and symptoms resulting from systemic toxicity. Some cases do not progress; others show severe neuromuscular effects within 30 to 60 minutes. The effects from the bite spread contiguously. For example, if a person is bitten on the hand, the pain progresses up the arm to the elbow, shoulder, and then toward the trunk during systemic poisoning.

The myopathic syndrome of latrodectism involves muscle cramps that usually begin 15 to 60 minutes after the bite. The muscle cramps initially occur at the site of the bite, but later involves rigidity of other skeletal muscles, particularly muscles of the chest, abdomen, and face. The pain increases over time and occurs in waves that cause the patient to writhe. Large muscle groups are affected first. Classically, severe abdominal wall spasm occurs and is confused with a surgical abdomen, especially in children who cannot relate the history to the initial bite.38 Muscle pain often subsides within a few hours but can recur for several days. Transient muscle weakness and spasms is reported to persist for weeks to months.

In the past, 10 mL 10% calcium gluconate solution was given IV to decrease cramping. However, a retrospective chart review of 163 patients envenomated by the black widow concluded that calcium gluconate was ineffective for pain relief compared with a combination of IV opioids and benzodiazepines.56,138 Another study found greater neurotransmitter release when extracellular calcium concentrations were increased, suggesting that administration of calcium is irrational in patients suffering from latrodectism.191 The mechanism of action of calcium remains unknown, and its efficacy is anecdotal; therefore, we do not recommend calcium administration for pain management.

Although often recommended, methocarbamol (a centrally acting muscle relaxant) and dantrolene also are ineffective for treatment of latrodectism.138,196 A benzodiazepine, such as diazepam, is more effective for controlling muscle spasms and achieves sedation, anxiolysis, and amnesia. Management should primarily emphasize supportive care, with opioids and benzodiazepines for controlling pain and muscle spasms, because the use of antivenom risks anaphylaxis and serum sickness.

Latrodectus antivenom (Merck) is rapidly effective and curative. In the United States the antivenom formulation is effective for all species, but is available as a crude hyperimmune horse serum that is reported to cause anaphylaxis and serum sickness. The morbidity of latrodectism is high, with pain, cramping, and autonomic disturbances, but mortality is low. (Tintinalli 8th edition)

Case 3. 67 yo male with weakness and difficulty walking. Diagnosis is Guillain-Barre syndrome

Signs and symptoms of the classic form include an ascending symmetric weakness or paralysis and areflexia or hyporeflexia. Paralysis may ascend to the diaphragm, compromising respiratory function and requiring mechanical ventilation. Autonomic dysfunction may be present as well.

Cerebrospinal fluid analysis shows high protein levels (>45 milligrams/dL) and WBC counts typically <10 cells/mm3, with predominantly mononuclear cells. When there are >100 cells/mm3, other considerations include HIV, Lyme disease, syphilis, sarcoidosis, tuberculous or bacterial meningitis, leukemic infiltration, or CNS vasculitis. Electrodiagnostic testing demonstrates demyelination. Nerve biopsy reveals a mononuclear inflammatory infiltrate. If MRI is performed to rule out alternative diagnoses, it will show enhancement of affected nerves.

The first step in management is assessment of respiratory function. Airway protection in advance of respiratory compromise decreases the incidence of aspiration and other complications. A well-established monitoring parameter is vital capacity, with normal values ranging from 60 to 70 mL/kg.

Avoid depolarizing neuromuscular blockers like succinylcholine for intubation in Guillain-Barré syndrome due to the risk of a hyperkalemic response.

Both IV immunoglobulin and plasma exchange shorten the time to recovery.1,2 Neither has been shown to be superior to the other, nor are they more efficacious when used together. There are adverse effects seen with both modalities of treatment. IV immunoglobulin has been associated with thromboembolism and aseptic meningitis; plasma exchange is associated with hemodynamic instability and a small increase in the rate of relapse, though full recovery is still more likely. In general, IV immunoglobulin is more widely available and less cumbersome to administer. Corticosteroids are of no benefit and may be harmful.3 (Tintinalli 8th edition)

Tekwani Difficult Airway Lecture

Inhaled nitrous oxide can be used to manage severe pulmonary hypertension.

Dr. Florek comment: Jaw thrust maneuver can be used to assist fiberoptic intubation. It opens up some additional space in the upper airway to maneuver the fiberoptic scope.

Dr. Harwood comment: In the patient with significant upper airway bleeding, use 2 yankaur suction devices to improve clearance of blood from the airway.

Girzadas Board Prep Zebras

This lecture was sent out in PDF form to all the residents.

Delbar Safety Lecture Inter Unit Transfers

“A wealth of information creates a poverty of attention” It is tough to balance enough info with too much info. Too much info in a handoff can cause the receiving physician to become distracted.

Emergency physicians and Admitting physicians have different perspectives on a specific patient. We are thinking acute care and they are thinking longer term hospital course.

We frequently don’t appreciate the stressors that admitting physicians are feeling.

Use of a standardized process, understood by both teams, that covers patient care info important to both teams, can be helpful in decreasing communication breakdowns.

Dr. Delbar reviewed the recent literature regarding inter Unit transfers.

Editor’s note: SBAR is a very widely accepted handoff tool that can be used. Giving your handoff in a standardized way covering: S situation B background A assessment and R recommendation may be helpful in improving handoff communication.