Conference Notes 11-27-2012

Putman/Coghlan    Oral Boards

Case 1: Pt with TIA 8 days after AMI.  Pt had a persistent ventricular aneurysm with likely mural thrombus.   Dr. Coghlan said heparin would be indicated for mural thrombus.   Mural thrombus develops in the first week after AMI and embolizes in the second week. 

Case2: Child with sickle cell disease and splenic sequestration crisis.  Have to assess for splenic rupture. Give IV fluids and transfuse 10ml/kg PRBC’s.   Mortality in splenic sequestration crisis is 12%.

Case3: Child swallowed a button battery.  Battery was identified in stomach. Management was to observe as outpt with serial xrays.  

Elise comments: Fluids and O2 in sickle cell is no longer universally indicated.  If spleen is enlarged you know you will need a blood transfusion.   NL systolic BP in Kids is 2 X age plus 70.   If button battery is ingested with magnets it increases risk of perforation. 

Harwood comment: If button battery is not making progress on serial xrays, the kid will need a scope.  Transfusing blood in kids with shock you can give 20ml/kg of PRBC’s.

Coghlan comment: Sharp objects such as needles need to be removed.

Group discussion about heparin for TIA with possible mural thrombus.  Everyone agreed that this was a difficult/ controversial situation.  You would like to have an echo and have neuro and cardiology consults to help make this decision.

RLT/Residents  Applicant Review

Discussion of the progress of recruiting season.

Schroeder  Visual Diagnosis in Pediatric Patients

Paronychia with lymphangitis.  Lymphangits is associated with Group A strep infection.  In young kids, admit for iv antibiotics.  Older, well appearing kids can go home on po antibiotics.

Mucocoele on inner lip.  Blockage of minor salivary gland due to biting lip.  Can refer for excision.

Mastoiditis: Trend to do less ct’s and manage clinically with antibiotics.

Salmon colored debris in diaper is urate crystals.  Young kids excrete more urate crystals. It is benign. Not associated with infection or other problems.  

Thick white exudate on a 2yo tongue=thrush.  Could be due to inhaled steroids.  Could be due to having child sleep with bottle in the mouth.

Erythema migrans from lyme disease.  Circular erythematous rash. Pt had tick in hair.  Lyme disease is increasingly found in Illinois counties.

Herpetic whitlow can be complicated by Group a strep causing lymphangitis.  Herpetic whitlow also uncommonly can have signs of lymphangitis due to the virus itself.  Harwood comment: I would treat with both anti-strep antibiotic and antiviral medication.

Eruption hematoma is basically a blood blister associated with an erupting tooth.  Nothing to do about it.

Kids can have a sucking blister on their lips from sucking on their lips.  It can look like cyanosis in darker skinned children.

Bed bug bites result in a rash that is nonspecific.  With itchy macular-papular rashes think scabies and bed bugs.   Families with bed bug infestations need to consult a professional company. 

Aphthous ulcers are caused by T-cell immunity.   Treat with mouthwash rinses or oral steroid gel.

Cobblestoning of the posterior pharynx can be due to post nasal drip.  Treat with nasal steroid or Sudafed.

Bullous impetigo can be treated with mupirocin topically.  Can treat more extensive infections orally with bactrim and keflex.  There have been MRSA strains of impetigo isolated.  Treat all impetigo as potential MRSA infection.  Mupirocin covers MRSA.  If using oral abx: bactrim/keflex or clinda to cover both MRSA and strep. 

Eczema herpeticum is a disseminated HSV infection.  Most often in kids with bad eczema. Treat with IV acyclovir.    Also give iv antibiotics  for possible severe impetigo until cultures clarify diagnosis.  You can use the new cultures we have in the ED for both bacterial and viral cultures.

Unilateral parotid swelling is more likely to be bacterial so treat with abx.  Bilateral swelling is more likely viral.   Harwood comment: with parotid swelling from infection the ipsilateral ear will pop out somewhat like mastoiditis.  This can be a clue to help you localize the swelling to the parotid.

Bill showed pictures of hand foot mouth.  The vesicles with HFM are thick walled, flat and grey compared to chickenpox vesicles.   Also Chicken pox won’t affect the palms and soles.  HFM can have lesions on more proximal extremities and face in addition to hands and feet.  There are seasonal variations to the severity of HFM.  In Cambodia there was a fatal form of HFM.  Bill felt that fatal cases have been localized to Asia and we should not alter our practice of discharging most patients in the US at this time.

Kerwin  Atrial Fibrillation

Who gets afib: age, htn, coronary heart disease, valvular disease, chf, HCM, congenital heart disease, obesity, dm, thyroid disease, CKD, cardiac surgery,  family hx, ETOH (holiday heart syndrome), PE, sleep apnea, numerous medications cause.

A-fib increases risk of all-cause mortality, CHF, and stroke.  

Paroxysmal AFIB lasts less than 7 days.  Persistent AFIB  last longer than 7 days. Permanent AFIB is afib in which attempts at cardioversion failed.   Lone afib is in patients <60 with no cardiopulmonary disease including HTN.

Get usual labs and TSH to work up. Get troponin as part of  work up only if ischemia is suspected.

NEJM study 2002 showed no survival advantage of rhythm control vs. rate control. Multiple other studies confirm this finding.  But in 2012 study in Circulation showed decreased rate of stroke in rhythm control patients.

ED management: Divide patients into 3 categories.  Pts who are unstable.  Pts with afib less than 48 hours.  Pts with afib more than 48 hours.  

Afib >48 hours: Rate control and anticoagulation are management goals.  No clear data on superiority of beta-blocker or calcium channel blockers for rate control.   No benefit from strict rate control (<80) vs. lenient rate control (<110).   For patients with heart failure consider digoxin or amiodarone instead of beta blocker/ca channel blockers.

CHADS2: CHF, HTN, Age>75, DM, Prior stroke or TIA. This tool assesses stroke risk with afib.  With a CHADS2 score of  0 or 1 you can opt to treat with ASA and not warfarin. 

Hemodynamically unstable patient: Cardiovert.  Anterior-posterior pad positioning is optimal.  Higher energy doses are more effective.  Cardioversion does not cause myocardial injury so higher dose is not really a concern.  If you have to shock more than once, wait at least a minute between shocks.  Consider giving push dose pressors to support BP prior to cardioversion.  1ml of phenylepherine in a 100ml bag of saline.  Mix and draw up 10ml of this solution. Can give 1-2 ml every 5 minutes.  

Afib<48 hours: Can attempt rhythm control. It avoids admission and meds.    Ottawa aggressive protocol includes procainamide 1gm over 60 minutes.  If that doesn’t work sedate and cardiovert with 150j. Converted patients discharged on no meds.  Multiple studies seem to show No increased risk of death or stroke from early cardioversion protocol.  About 8% of patients had 7 day recurrence.   Another consideration is that the rate of spontaneous conversion in new onset afib patients is up to 70%!  So centers will send patients home and ask them to return in 24 hours for a recheck.

Afib with WPW use cardioversion if unstable. Use procainamide if stable.

Afib in pregnancy: CCB’s , Beta-blockers, and digoxin are all ok. Cardioversion is ok if unstable. IV heparin is ok.

Harwood comment: Treating unstable afib patients use highest dose possible of cardioversion.  If not effective, wait a minute or two and try again.   If second shock is ineffective, give procainamide over 30 minutes and retry shocking.  Get cardiologyto help you if the first two shocks don’t work.  If you need to support BP give push dose pressors or pressors on drip.

Barounis comment: How do you manage the septic patient with afib?  Harwood responded to give digoxin.  Shock if necessary but most of these patients are in afib chronically.  Other attending suggested IV magnesium or amiodarone as alternative approaches.