Conference Notes 9-16-2015

Williamson/Parker     Oral Boards

Case 1.  50 yo male with respiratory distress.  HR=100 BP=140/80RR=34T=98.7   Patient became SOB at subway station.   Exam reveals copious oral secretions. Patient also vomited and had abdominal cramping. EMS notes that other persons in the subway have similar symptoms.

*Cholinergic Toxidrome

Diagnosis is cholinergic toxidrome due to Sarin (organophosphate gas).   Treatment is high dose atropine until respiratory secretions have improved significantly, intubation,  and 2PAM.  Consult poison control.   Patient needs to be decontaminated. Staff needs to use PPI to prevent secondary exposure to toxin.  Patient’s clothing can off–let toxin for 30 minutes.  Sarin is colorless and odorless.

Elise comment: I saw a patient die of organophosphate poisoning in Africa.  It was horrible. The patient basically drowned in his own secretions because we did not have enough atropine.    Andrea comment: Initial dosing of atropine is 2-6 mg and go up from there until secretions are dried up.   There are stockpiles of atropine around the city and country.   The poison center has access to these stockpiles.  You have to get 2PAM into the patient as soon as possible to prevent irreversible aging of the acetylcholinesterase.

Case 2. 16 yo male with a headache for the last 10 days.  Vitals are normal.   Patient notes a weird feeling and paresthesias from waist down.  Legs have spasms occasionally.  Bedside ultrasound shows urinary retention.  MRI of the spine shows transverse myelitis. 

*transverse myelitis

Diagnosis is transverse myelitis due to multiple sclerosis.  Treatment is IV steroids.  Patient required foley catheter drainage of urine.   Transverse myelitis is an inflammation of the spinal cord.

In most cases a sensory level is documented, most commonly in the mid-thoracic region in adults or the cervical region in children. Pain in the back, extremities, or abdomen is also common while paresthesias (e.g., tingling, numbness, burning sensations) are typical in adults. Sexual dysfunction is also the result of sensory and autonomic involvement. Increased urinary urgency, bowel or bladder incontinence, difficulty or inability to void, and incomplete evacuation of bowel or constipation are other characteristic autonomic symptoms. Spasticity and fatigue are other symptoms common to transverse myelitis. Additionally, depression is often documented in TM patients and must be treated to prevent devastating consequences.  (Transverse Myelitis Association)

Case 3.  47 yo male presents with right foot pain for one week.  Vitals normal except for heart rate of 102.   Patient states that the pain began after a heavy board fell on his foot.   X-rays show lis franc injury.

*Lis Franc injury

Treatment requires ORIF and non-weightbearing for 6 weeks.   Harwood comment: this is a pretty severe lis franc injury.  Lis franc injuries usually involve the first and second metatarsals.  This xray shows all the metatarsals dislocated. 

Levato     Community Acquired Cellulitis

For uncomplicated cellulitis with no abscess use either cefazolin or clindamycin.   Elise raised concerns about the level of clindamycin resistance at our institution.   Harwood added that he would prefer to give Bactrim if you suspect MRSA.  

Levato’s Bottom line:  use more ancef and less vanco.  Patients without comorbiditities who have straightforward cellulitis with no fluctuance have a strep cellulitis. 

*Algorithm for soft tissue infections (Thanks Elise)

Remke      M & M

In order to respect the confidentiality of M&M, I am not going to give case details of M &M’s.  I will just present the take home points.

Be sure you have ordered a type and screen on pregnant patients who are bleeding.  If they deteriorate  and need transfusion, waiting for the type and screen can cause delay or necessitate the use of O negative blood.

Quantify vaginal bleeding based on whether it is more or less than a normal period.

On pelvic exam, if there is clot or tissue in the os, remove it.  Removing tissue and clot from the os can help the uterus to contract and lessen bleeding.

*Liklihood of Ectopic Pregnancy

In the setting of pregnancy, consult OB service for heavy bleeding, open cervical os, and positive beta hcg with no iup seen on ultrasound. 

Things to tell patients:

25% of pregnancies have bleeding

If a viable fetus is seen on ultrasound the risk of miscarriage is less than 10%.

Miscarriage is more likely with heavy bleeding, bleeding lasting a week or more, and if pain is associated with bleeding.

Emergency Physician Cognitive Issues:

Pay attention to subtle vital sign changes

Double check that the labs you need are ordered like type and screen.

Listen to your nurses when they raise a concern.

Get help from consultants when you are faced with a difficult situation.

Kelly Williamson comment: RH negative Patients who have a subchorionic hemorrhage on ultrasound but are not bleeding into the vagina do not need rhogam

Ortiz-Romero     Imaging the Pediatric Acute Abdomen

On ultrasound, a normal appendix is smaller than 6mm, compressible and has no surrounding free fluid.  Appendicitis is larger than 6mm, non compressible and hyper-vascular.  There will be point tenderness over the appendix with appendicitis.  Unfortunately 70% of the time the appendix is not visualized with ultrasound.

If you have an Alvarado score less than 5 and have an ultrasound with no inflammatory changes without visualization of the appendix, that clinical scenario has a negative predictive value of 99% for appendicitis!

Value of Focused Appendicitis Ultrasound and Alvarado Score in Predicting Appendicitis in Children: Can We Reduce the Use of CT?

Blitman NM1, Anwar M, Brady KB, Taragin BH, Freeman K.

Author information

• 11 Department of Radiology, Jacobi Medical Center, Albert Einstein College of Medicine, 1400 Pelham Pkwy S, Bronx, NY 10461.

Abstract

OBJECTIVE:

The purpose of this study was to evaluate the effectiveness of focused appendicitis ultrasound combined with Alvarado score to accurately identify appendicitis in children in whom it is suspected, thereby reducing unnecessary CT examinations and associated radiation exposure.

MATERIALS AND METHODS:

We retrospectively evaluated the focused appendicitis ultrasound, CT, clinical, and laboratory findings of 522 consecutively registered children (231 boys, 291 girls; mean age, 13.04 [SD, 5.02] years; range, 0.74 months-21 years) who underwent focused appendicitis ultrasound for abdominal pain in a pediatric emergency department from January 2008 through October 2009. All children underwent surgery or clinical follow-up to exclude missed appendicitis. Sonographic findings were characterized as positive, negative, or inconclusive (appendix not visualized). Alternative diagnoses were noted. Alvarado score (0-10 points based on multiple clinical criteria) was determined. Focused appendicitis ultrasound and Alvarado score results were compared with surgical and pathologic reports.

RESULTS:

Both focused appendicitis ultrasound results and Alvarado score were associated with likelihood of surgery for appendicitis (p = 0.0001). Focused appendicitis ultrasound had conclusive results: 105 positive and 27 negative in 132 of 522 (25.2%) children. In the 390 of 522 (74.7%) children with inconclusive focused appendicitis ultrasound findings, 43 of 390 (11.0%) eventually had a diagnosis of appendicitis with CT (n = 26) or Alvarado score (n = 17). Among children with inconclusive focused appendicitis ultrasound findings and an Alvarado score less than 5 (241/522, 46.1%), only one patient had appendicitis. The negative predictive value (NPV) of inconclusive ultrasound findings and low Alvarado score combined was 99.6%. Among children with inconclusive focused appendicitis ultrasound findings and an Alvarado score of 5-8, the NPV decreased to 89.7%.

CONCLUSION:

Children with inconclusive focused appendicitis ultrasound findings and a low Alvarado score are extremely unlikely to have appendicitis (NPV, 99.6%). Avoiding unnecessary CT of these patients is a safe approach to diagnosis.

When using CT for appendicitis, you need some peritoneal fat to identify the appendix.  So, very thin kids will be difficult to visualize the appendix on CT because they lack peritoneal fat.   However if there are no secondary signs of inflammation in the area of the appendix, that also makes appendicitis unlikely even if the appendix is not visualized.   To limit radiation exposure, you only need to do a pelvis CT.  Give IV and rectal contrast if the patient can tolerate them.   The cutoff for a normal appendix on CT is 7mm.

MRI can also be used to diagnose appendicitis. We are currently testing a MRI protocol for appendicitis.   The patient first gets scored on the pediatric appendicitis score.  If the score is 2 or more they are eligible for MRI testing.

Ultrasound is the first line test for identifying intussusception. 

Girzadas      ACGME Resident Survey Results

C Kulstad/Lovell    Preventing Diagnostic Error     Cognitive Bias

Misdiagnosis is the most common medical mistake and is a leading cause of malpractice claims. 

“Everyone is a human first and a novice or expert second”

There are 2types of causes for diagnostic error.  There are systems error and cognitive error.

*System and Cognitive Error

Error is more common when: uncertainty is high, the patient is unfamiliar to the physician, and the disease has an atypical presentation.   Cognitive error is a risk in high-pressure environments with many distractions. (the ER).

Nurses when acting as the wingman to the physician also need to be aware of their biases.  The nurse has the potential bias the physician either towards or away the right diagnosis.  If a nurse is biased against some aspect of the patient it can affect how the whole team approaches the patient. 

System 1 and System 2 Thinking.  To be a good EM Clinicianyou have to be able to switch back and forth between both systems.  Experienced clinicians have better developed system 1’s.  They have the experience to know when to switch into system 2 thinking.

*System 1 and System 2

Heuristics use pattern recognitions or mental shortcuts to solve problems.   Bias impacts heuristics a great deal.   This is a problem because ER docs use heuristics all the time in an environment that is prone to bias the heuristics.

Croskerry Six Biases:

1.     Over attachment to a particular diagnosis.  Anchoring on a specific feature too early and failing to adjust.

2.     Inheriting someone else’s thinking.  Following the cognitive path initiated by another provider.  This bias makes sign out a dangerous time.

3.     Failure to consider alternatives.  Tendency to stop looking once something is identified.

4.     Errors in estimation of prevalence.  Diagnoses that readily come to mind may be used more frequently.

5.     Bias related to patient characteristics or context.  Basically the physician has a personal perception about the patient and approaches the patient based on that concept of the patient.

6.     Errors associated with the clinician’s personality.  Over/under confidence is one example.   We need to have the appropriate level of both confidence and humility.

Tactics to overcome bias:

Cognitive debiasing:  Consider alternatives. Use metacognition or think about how you are thinking about a patient. 

Structured handovers:

Checklists :  Checklists help us to think of options we did not initially consider

QV&V: Qualify the source, validate the information, and verify the information.  Basically check that the info you are basing your decision on is correct and valid.

STEP Thinking: Story, Testing, Evaluate, and Plan

EMR Enhancements

Conference Notes 7-22-2015

A special Thank you to Christine Kulstad for her help with the Conference Notes this Week!

Lovell/Htet        Oral Boards

Critical Actions Case 1:  Septic Shock from Capnocytophaga canimorsus/dog bite

--Identify Sepsis

--Rapid IVF, early broad spectrum antibiotics including dog bite coverage

--Elicit history of dog bite

--Reassessment

--ICU admission

(also consider Xray, irrigation of wound, consider tetanus update, rabies)

Teaching points:  Capnocytophaga canimorsus

--fastidious GNR identified in 1976, likes to eat iron

--normal oral flora of kitties and doggies

--Risk groups:  asplenic, alcoholics, beta thal, smokers (high iron), immunosuppression

--Alcoholics have high blood iron + immune comp.

--WORST OUTCOMES in asplenics:  high iron + decreased phagocytosis; high M/M!!

--Symptoms usually within several days

--Fever, V/D, malaise, abdominal pain, myalgia, confusion, dyspnea, headaches, rashes

--Special culture media

--Tx:   Dogmentin!  so use IV Unasyn, also susceptible to third gen. Cephalosporins

Critical Actions Case 2:  Submassive to Massive PE

--Recognize risk for PE (travel)

--Diagnose PE

--Risk stratify (Echo, BNP, Trop)

--Recognize decompensation and need for thrombolytics

--Assess contraindications to tPA

--ICU admission, Intensivist consultation

Teaching points:   Submassive/Massive PE

--Submassive:Normal BP but RV dysfxn (Echo or BNP) or myocardial necrosis (Trop)

--Massive: Low BP for 15 minutes or code or resp. failure or need for pressors

--Thrombolytics for massive, case by case for submassive

--r-tPA dose 100 mg IV over 2 hours

--Code dose, 50 mg bolus (maybe + 50 mg)

--start IV Heparin when PTT < 2X nml

--Lytics in PE:  2% ICH risk, 6% major bleed/transfusion

Critical Actions Case 3:  Jellyfish envenomation

--Identify as Jellyfish envenomation

--Irrigate 

--Consider vinegar, hot water

--Monitor for systemic sx, allergic sx

--Treat with benadryl, consider steroids, analgesics

Teaching points: Jellyfish Envenomation

--Mechanism-tentacles with venom containing nematocysts

--Symptoms--Itch, swell, burn, tingling/numbness.  Severe with N/V, HA, weak, dizzy, SOB

--Treatment-irrigate with NS or sea water (fresh water makes worse), remove possible remaining nematocysts by shaving skin or scraping skin

--Use benadryl, consider steroids, give analgesics

--vinegar-prevent further nematocyst firing, hot water to breakdown venom-some controversy over effectiveness

Levato     Pharmacy Update

Community-acquired but complicated UTI- E coli, Klebsiella, Proteus most likely. We have been using ceftriaxone for this but it is a broad spectrum antibiotic that is causing c diff in our hospital. Cefazolin found to be 89% sensitivity in E coli, 90% in Klebsiella, 100% Proteus. So new guidelines are to use cefazolin for these patients. CAUTION- not appropriate for nursing home patients. OK for pyleonephritis.

Ketaneh  (Class of 2014)  Starting out as a New Attending

Looking for a job: Take some pressure off- its just your first job, you can change it later. He interviewed all over and recommends it. Prospective employers will usually pay for your interview expenses so don’t shy away from multiple interviews. It helps to see a lot of practice environments too, see where you fit in.  Use the faculty resources here (they know somebody everywhere).

You will have a lot more money- try to live like a resident and save for a while. Student loans will come due, 401k should be funded. Need to find your work-life balance- how many shifts due you want to work to pay for your lifestyle.

Starting a new job- get familiar with the EMR before your first real shift. Will save you tons of time and pain before your first shift.

Have your charting macros prepared before you start.

Know where you are going to look stuff up.

Be super nice and respectful to everyone.

Get your charting done so you stay off the medical records radar. 

Get to know the culture of your workplace: protocols, antibiotic choices, sedative choices.

Nick told a scary story of how he ordered a fentanyl drip and the pharmacists and nurses were not familiar with using fentanyl as sedation and dosing errors were made.

At most ED’s you at times will be working alone with a couple of nurses.

Be very clear when communicating with nurses, they will do exactly whatever you say.

An important part of our job is charting and billing.  It’s just a fact of life.  Your income and job security depend on it.

*Ups and downs.   You have to be able bounce back from the downs as an ER doc and temper/be humble with the Ups

There are other jobs out there.  You can change jobs.   It is important to protect your reputation so people think well of you and you keep the door open to other opportunities.

Be smart with your money.   It is OK to rent for awhile until you have a clear idea of your monthly income.  Then live below your means so you are funding your retirement properly.

As a resident and attending, going the extra mile will not go unnoticed.

Get your paper work done. 

Favorite FOAM websites:  lifeinthefastlane.com, aliem.com, emcrit.com

The goal for an ED doc in the community is to not be ultra cutting edge and not be practicing medicine from 20 years ago.  You want to be somewhere in the middle and up to date. 

Regan       Seizures

*Causes of Seizures

Generalized Seizures: Affects both Cerebral Hemispheres. There is loss of consciousness.

*Seizure Types

Partial Seizures include: Simple in which conscious is maintained and Complex in which consciousness is altered.

Initial questions to ask the patient:  Do you have a seizure disorder?     Is there anything that would have lowered you seizure threshold?  (sleep deprivation, fever, etoh use, missed medication, stress)

EKG can be a quick initial test to pick up electrolyte abnormalities causing seizure.

*Medications for seizure management

Elise comment: In the Peds ED there is frequently the availability to get an EEG rapidly for a child with a new onset seizure.  This rapid turn around of an EEG can be very helpful to neurology to make good management decisions for the patient.

Case 1.  Etoh withdrawl seizures can be treated with Ativan first line and Phenobarbitol second line for persistant  seizures despite Ativan.    Christine comment: You can push the upper dosage range of Ativan in the ETOH withdrawal patient. Their GABA receptors are down regulated.   Elise comment: If your Ativan is not working in any type of patient, start thinking about underlying causes such as hypoglycemia, hyponatremia, INH poisoning, intracranial hemorrhage.

20mg/kg loading dose works for Phenytoin, fosphenytoin, Phenobarbital, Valproic Acid, and Keppra.  Basically 20mg/kg works for all commonly used epileptics other than Ativan.

Check the patient’s tongue for lacerations and hematoma.  Serious tongue injuries  could pose an airway obstruction issue.

Neuro exam in infants

Look for:

Balled fists with thumbs tucked in, this is an upper motor neuron sign (Babinski sign in infants)

Altered/increased tone

Abnormal Reflexes

Eye deviation

Elise comment: Midazolam IM is a very rapid acting anti-seizure medication that is useful in kids.   Eye deviation is an important finding in kids to identify a seizure.

30-50% of patients with pseudo seizures also have epileptic seizures.  This makes diagnosis and management possible psuedoseizures very difficult. 

Carlson                      Antidotes

*Antidotes

Isopropyl alcohol ingestion is not an indication for fomepizole.  It is metabolized to acetone.

Lead has 3 potential antidotes: BAL,  EDTA, and Succimer.   Peanut allergy is an absolute contraindication to BAL therapy.

Gyromitra mushrooms look like a brain and can cause seizures.  The antidote is pyridoxine (also the INH antidote/INH also causes refractory seizures).

*Gyromitra mushroom

Sodium Bicarbonate is an antidote for TCA poisoning.  The sodium overcomes Na Channel blockade.  The Bicarbonate decreases free TCA.   Andrea prefers bolus dosing with 1-2 ampules while closely observing the patient and the monitor.

Calcium channel overdose can cause bradycardia, hypotension, and hyperglycemia.  The antidote is the “perfusion salad”: calcium chloride, glucagon, intralipid, atropine, and insulin euglycemic therapy.

Deadly nightshade contains bella donna toxin.  Bella donna can be thought of as a Benadryl overdose.  Both cause an anticholinergic toxdrome.  The antidote for anticholinergic toxidromes is physostigmine.   Physostigmine should not be used in undifferentiated coma or in mixed overdoses.  However, it is safe in pure anticholinergic toxidromes.  

*Deadly nightshade berries

*Deadly nightshade leaves  (note the little “ears” small leaves around the big leaf)

Paint stripper that contains methylene chloride if ingested will be metabolized to CO.  Methylene chloride gets metabolized by liver to CO and can cause CO toxicity.    Antidote is hyperbaric oxygen. 

Statistically the most common cause of CO toxicity in the summer is indoor grilling or using a grill on a screened-in porch. 

*Hyperbaric indications for CO Toxicity

Causes of cardiac glycoside poisoning: digoxin, oleander, foxglove, Lilly of the valley, and the practice of toad licking.   Antidote is FAB fragments

West      Fever in Kids

Rectal temperature measurement is most accurate.   The temperature that determines a fever is 38C.

*Fever algorithm for kids </= to 3 months

For febrile kids (with immunizations up to date) over 3 months of age with no source on physical exam the next best diagnostic study is to check the urine.

Brain damage is not a complication of fever due to infection.

Faculty comment: Parents frequently under-dose Tylenol and Ibuprofen.  Check the dosing parents are giving to kids if the antipyretic is not bringing down the fever.

Harwood comment:  You may not need to do an LP on febrile kids age 30-60 days old if they have the following:

Well appearing child

Normal urine

Normal ANC

Normal Procalcitonin

This decision rule has not been validated. 

Elise comment: Right now there is a grey zone (based on age of infant) of whether there is a need to do an LP.  There is reasonable practice variation in non-toxic appearing, febrile kids age 30 days to 60 days.   Most faculty have a cut-off at 6 weeks, but up to 8 weeks is reasonable.  Ill appearing kids at any age require LP.

Fever Algorithm for ages Newborn to 36months

Bonder     Patient Satisfaction

Patient satisfaction rates are a factor in medicare reimbursement.

Research has shown that patient satisfaction measurements are biased and don’t correlate with clinical quality metrics.   Also, mortality rates tend to be higher in hospitals with high patient satisfaction levels.

Safety net hospitals and teaching hospitals regularly perform more poorly on patient satisfaction measurements.   There are geographic variabilities as well with California and East Coast hospitals usually scoring lower than other regions.

*Kaiser 4 Habits Model from Kaiser Health

Elise comment: Patient satisfaction measurements are not based on your clinical care or diagnostic accuracy.  They are based on how you communicate with the patient.

Christine comment: At the completion of the ED visit, take the time to explain to the patient what the tests showed and how they ruled out dangerous diagnoses.

*Patient Satisfaction Measures