Conference Notes 7-2-2013   There are images in this document.  If you don't see them scroll to the bottom and click on "read in browser"

Herrmann/Harwood    Oral Boards

Case 1: 60yo man with botulism.  Critical actions:  Evaluate respiratory status, give trivalent antitoxin.  Military has heptavalent antitoxin that is not yet commercially available.   Babies should not receive antitoxin, instead they get human botulism immune globulin (BabyBIG).     Most cases of botulism are infantile (72%).  Another 25% of botulism cases (mostly adults)  are due to improperly canned food.  The rest of the cases are due to wound infections. There are about 150 cases of botulism in the US per year.  Botulinum toxin blocks the release of acetyl choline at the neuromuscular junction resulting in weakness.   Physical exam shows ptosis, dysconjugate gaze, dilated pupils, weakness.

    

Google image

 Cranial nerve involvement most commonly marks the onset of symptomatic illness and can include blurred vision (secondary to fixed pupillary dilation and palsies of cranial nerves III, IV, and VI), diplopia, nystagmus, ptosis, dysphagia, dysarthria, and facial weakness. Descending muscle weakness usually progresses to the trunk and upper extremities, followed by the lower extremities. Urinary retention and constipation are common resulting from smooth muscle paralysis. Occasionally paresthesias and asymmetric limb weakness are seen [37]. Similar to infant botulism, respiratory difficulties (eg, dyspnea) requiring intubation and mechanical ventilation are common, caused by diaphragmatic paralysis, upper airway compromise, or both. Despite the evidence of neurologic involvement, cerebrospinal fluid analysis is normal.  (Up to date_)

     

Picture of bilateral ptosis due to botulism

Elise comment: If you give antitoxin to infants they potentially may develop severe anaphylaxis to antitoxin and they can develop life-long sensitization to equine proteins.  

Case2:  11yo male stabbed in chest by his mom.  Pt had a sucking chest wound.  Pt had a pericardial tamponade.  Pt lost vitals and required ED thoracotomy.  Pericardial sac was opened, clots were removed, and heart was delivered.  RV wound was stapled closed.   Critical actions: Place a chest tube initially, intubate, do a thoracotomy, get them to the OR.    Harwood made the point that if you have a tension pneumo with a open chest wound, you can often relieve the tension by removing any dressing on the wound so air can be released.  Harwood comment: Stab to the chest with no pneumo and no suspected cardiac or vascular injury  can be managed with a repeat 6 hour CXR. If still no pneumo, patient can go home.   For an ER doc the best chance you have to save a patient with a thoracotomy is a stab wound to the chest causing pericardial tamponade.  If you can relieve the tamponade and staple the heart, patients can survive this injury.   Girzadas comment:  AT one point in this case, the echo showed pericardial fluid, BP was 80/40, and pt was mentating.  Should you perfrom pericardiocentesis, crack the chest in the ER, or go to OR.   Harwood: If you are at a Trauma Center, Just get the patient to the OR.  IF you are at an ED where you will have to transfer patient, pericardiocentesis is a reasonable temporizing maneuver.   Only perform an ED thoracotomy if patient loses vitals or goes into extremis.

Case 3:  Pt presented with severe muscle and abdominal cramps while working in hot weather.   Pt had heat cramps.  This is due to a combination of salt loss, fluid loss and muscle fatigue.   Harwood comment: Old southern remedy is pickle juice. It has fluid/salt/some carbs.  Critical actions:  IV normal saline is the treatment.

Nierzwicki    Dental emergencies

Dentoalveolar trauma:  With any dental trauma, make sure there is not a dental FB or boney FB somewhere in the mouth or pharynx.   Normal adults have 32 teeth.  With wisdom teeth removed, the normal adult has 28 teeth.   Fun fact: If people don’t get their wisdom teeth removed, they are at higher risk for low birth weight babies (not sure why) and unstable coronary plaques (due to strep colonization of wisdom teeth and subsequently the coronary artery plaque).   

Ellis fracture’s: Class 1 is through enamel.  Class 2 is through enamel and dentin,  Class 3 is through enamel,dentin,pulp.   Dr. Nierzwicki said the main ED management is to make sure the patient did not aspirate the fracture fragment.   You don’t need to patch over the fractured tooth in the ED.   Even an ellis class3 fracture is not an emergency.  Consider antibiotics and pain meds.  That’s it.   Girzadas comment: This is great news!  EM texts  say Ellis class 3’s require emergent calcium hydroxide coverage. This is basically not super easy to do.  So hearing that it is not emergently necessary is great.  Elise comment: Do you want us to mix up calcium hydroxide and cover an Ellis 3 dental fracture?   Nierzwicki says no.  The main issue is they need follow up with a dentist or oral surgeon.  This of course is difficult for people with no dental coverage.

  Loose teeth:  If tooth is moveable in ant/post plane or ant/post and lateral plane it probably will heal and remain stable.  If it is moveable in 3 planes (a/p, lateral, up and down in the socket) the tooth will need stabilization.   The ER doc should not try to improve the luxation of an injured tooth.  Leave it for the dentist or oral surgeon.  Even the oral surgeons don’t attempt to improve intrusion injuries (impacted teeth).  They let them come down naturally.  Elise comment: For subluxations injuries do you want the ER doc to do anything besides referral?   Nierzwicki said no, unless the tooth is dangling and is at risk of being aspirated or lost.   As for imaging, if a single tooth is injured and the tooth is relatively stable and the bone around the injured tooth is stable, then you don’t need to get xrays in the ED.   For a completely avulsed tooth, you want to get it back in the socket within 2 hours.   To transport tooth Hanks solution is the best transport medium, followed by saliva, milk and saline.  The ER doc can rinse the tooth with saline. Don’t scrub or rub the tooth.   The tooth needs to be splinted in place for 10 days.  Girzadas comment:  Everyone has sandwich bags at home.  Can the parents put the tooth in a baggie and spit a few times in the bag?  Nierzwicki said sure, or put milk in the bag.   To differentiate between an alveolar fracture and a Le Fort 1 fracture, put your fingers posterior to the upper molars and apply anterior force.  If all the upper teeth move forward, you have a Le fort 1 Fracture.  

Carlson          Lithium and Valproate Toxicity

Lithium   Discovered in 1818 and initially used for gout and kidney stones.   It was used as a table salt and was an ingredient in 7UP!    Commonly used for bipolar disorder and has possible utility for cluster and migraine headaches, impulsive behavior, neutropenia and etohism. 

A way to think about lithium is that it acts like potassium in the body. It is a positive cation.  It’s therapeutic mechanism is unknown.   Adverse effects include decreased ability to concentrate urine to the point of nephrogenic DI.  It also causes hypothyroidsm and hyperparathyroidism.   Long term lithium treatment commonly causes goiter.   Lithium can cause nonspecific  t wave changes and U waves. Girzadas comment: U waves are not intuitive if you think of lithium as analogous to K+.  Andrea said U waves were noted in case reports.  There is some concern about teratogenicity (specifically ebstein’s anamoly of the tricuspid valve and RV).

Don’t  use NSAID’s in patients with lithium.  Lithium is excreted by a prostaglandin dependent renal mechanism. NSAID’s inhibit this mechanism.  This is a known interaction and the emergency physician should be aware of it.   Postassium sparing diuretics can increase lithium levels.   Lithium + SSRI can possibly cause serotonin syndrome.  Lithium +antipsychotic medications  can possibly cause NMS.

Toxicology Factoid:  Volume of distribution <1 means the toxin is mostly limited to the blood compartment and can be dialyzed well.  If volume of distribution is >1 that means the toxin is distributed throughout the body and is not well dialyzed.    The other thing that makes a toxin dialyzable is low protein binding in the bloodstream.  

Lithium has a volume of distribution <1 and is not significantly protein bound in blood stream.  Hence dialysis is an effective treatment for significant lithium toxicity.

Toxicity of Lithium can look like thyrotoxicosis or gastroenteritis.  Can look like serotonin syndrome. 

• §  Gastrointestinal   Patients with acute lithium toxicity often develop and present with symptoms of nausea, vomiting, and diarrhea. If vomiting and diarrhea are severe, dehydration and compromised renal function can develop, impairing the ability to excrete lithium and exacerbating lithium toxicity.
• §  Cardiac  Although lithium toxicity can cause changes in the electrocardiogram (ECG), dangerous arrhythmias or other important clinical effects are rare [14,15]. Prolonged QTc intervals and bradycardia have been reported [15-17]. Lithium poisoning is not associated with elevations in cardiac biomarkers or left ventricular dysfunction
• §  Neurologic  Neurologic findings develop late in acute lithium poisoning because time is required for the drug to be absorbed and to penetrate the central nervous system (CNS). Potential neurologic symptoms and signs include sluggishness, ataxia, confusion or agitation, and neuromuscular excitability, which can manifest as irregular coarse tremors, fasciculations, or myoclonic jerks. Severe lithium intoxication can lead to seizures, nonconvulsive status epilepticus, and encephalopathy.  (Up to Date)

Get serial lithium levels until you are sure the level is going down.  Levels >4 are usually dialyzed.   All patients should receive IV hydration.  Kayexelate can help lower lithium level (remember lithium is analogous to potassium in the body).  Andrea discussed a curious case report  about a patient with a lithium level that stayed elevated even though the patient had stopped taking any lithium for multiple days.  It was learned the patient was ingesting their own urine and recycling the lithium in their body.

 

Valproic acid:  Indirectly increases GABA (neuroinhibitory/think benzos), and decreases glutamate (glutamate is neuroexcitatory).   Small volume of distribution like lithium, but it is highly protein bound in the bloodstream.  Consequently, dialysis is usually not useful in standard overdose due to protein binding.  In massive overdose, when protein binding sites are all full and there is still valproate in serum, dialysis can be helpful to remove unbound valproate.

Adverse effects: tremors, hair loss, liver effects.  Not used in kids under two because it can cause a Reyes-like syndrome.

Overdoses can cause hyperammonemia due to depletion of carnitine.   Valproate metabolites interfere with the urea cycle resulting in hyper ammonemia.   Clinical findings include: drowsiness, coma, respiratory depression, and thrombocytopenia.   Massive overdose (>850) can result in hypotension, lactic acidosis, pancreatitis, and bone marrow suppression.   Cerebral edema can result from acute or chronic overdose.

Management: Protect airway, give L-carnitine. There may be some benefit to whole bowel irrigation.  Get serial levels of valproate to document the level is going down.   Elise comment: When should we get a second level?   Andrea:  Check every 2 hours.

Administration    HIPAA Privacy

HIPPA= Health Insurance Portability and Accountability Act

Permitted uses of patient health information:  Can be given to the patient.  Can be used for treatment/payment/operations uses.  Can be used for the Public interest such as abuse reporting.  Limited data sets can be used  for teaching/training, research or performance improvement.

Mistry comment: How do we handle requests by law enforcement officers for patient info?    If the patient may have died by a criminal act, you can release info to the police.   If the patient is in custody, you can release info to police.  If the police are investigating a case, you can give patient info.   Document the officer’s name and badge number and the info you gave the officer.  Give the minimal information needed by the officer. 

You can be terminated from Advocate for posting even generic comments on social media about a case you saw.

When speaking to a patient and their family or friends in the ED, you can give info about the patient to everyone in the room with the patient if the patient consents or in your professional judgment it is appropriate to give to persons whom the patient brought with them.  Probably it is safest to ask the patient if you can speak freely about their medical information with other persons present.   It is stated on the federal HIPAA website that you can use professional judgment about when to discuss patient healthcare info when other persons are present with the patient. Christine comment: What about a 17 yo person who had a drug screen.  Can you tell their parents?   Bottom line yes.  If the patient came with the parent to the ED, the emergency physician can use their best judgment on whether or not to discuss the drug screen with the parent present.  The 17yo is still technically a minor so that has to also be considered. Harwood comment: A bright line decision rule for residents would be at age 18 the patient is considered an adult and probably you should discuss with the patient whether or not you can discuss results with the parent present.

If you feel that a patient is an immediate danger to someone else it is permissible under HIPPA to notify the person at risk.

You can share patient info with providers at other hospitals who are caring for a patient without prior patient authorization.  Photos can be shared between providers in order to care for patients.  Get verbal permission from  the patient before texting a picture to a  consultant.  Document that verbal consent in the chart.  Mistry comment: HIPAA is not meant to get in the way of patient care.     

Don’t save patient data on your computer/laptop/tablet/phone.  If the device has 500 or more patient records and it is lost, that will be considered a major breech in HIPAA.  This requires immediate government notification and a press release.

It is not a HIPAA violation to discuss medical issues with patients who are boarding in the hallway as long as you make reasonable attempts to be discrete (lowered voice, pulled curtains).   Elise comment: Do your best to get patients into a room for sensitive discussions. 

 

 From the HIPAA website:

  

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