Good afternoon all, and happy Wednesday! Today's conference was opened with an insightful and humbling case presented by Dr. Wilder.
Pediatric M+M With Dr. Wilder:
18 year old male presenting with “head bump.”
Complains of head bump at top of head, maybe related to trauma, but unsure. Tender to touch, +headaches. No LOC.
Vitals: T: 98.9. BP 129/92, HR 99, RR 20, SpO2: 99% RA
Got into fight with 14 year old brother 3 weeks ago, and hit head on shelf. No LOC, no vomiting.
Asking to go home. Unclear if there was language barrier or developmentally delayed.
Decided to have patient worked up as trauma
PECARN: to rule out non clinically significant TBIs, defined as death, NSG intervention, Intubation >24 hours, hospital admission >2 nights.
Using PECARN, for patients older than 2 years old:
GCS <15? Signs of basilar skull fracture? AMS? No.
Vomiting? LOC? Severe mechanism? Severe headache? Also no.
CT is thus not indicated.
What does GCS of 15 look like in a child?
Differences compared to adult/older child: Best Verbal Response
<2 years old: best is smiles, follows objects, interacts, then cries but consolable, inconsistently inconsolable, grunting and agitated
Also with Best motor response: Infants moves spontaneously or purposefully, followed by withdrawal from stimulus
But something didn’t feel right.
Speak to mom with interpreter. Find out lump has been growing for 3 weeks
Speaking again to patient, headaches sometimes associated with dizziness, persistent, worse at night
Patient at baseline
Physical exam: Bump noted on vertex of head. Behavior seemed delayed Neurological exam otherwise benign
Most of the time headaches in the ED are low risk, such as tension HA, migraine, dehydration
Can’t miss headaches: Meningitis, ICH, mass… Red flags: sudden onset, thunderclap, worse with Valsalva, worse in morning or night, age >50, age <5, HIV, significant FH; physical exam significant for focal neuro signs, Diastolic BP >120, Papilledema, AMS
Chances of significant pathology:
HA referred to HA clinic have significant neuroimaging findings: 1.2%
HA x 4 weeks, normal neuro exam: 0.9%
SAH with thunderclap HA: 43%
Worrisome Likelihood Ratio:
Waking from sleep from HA: LR ratio 98%
Ha with dizziness or lack of coordination: LR 49%, ….though CI 95% is 3-710.
Undefined HA: LR 3.8
CT performed.
Radiology replies with read: Mixed intracranial/extracranial mass, epidural extension above and compressing superior saggital sinus at vertex. Component of superimposed blood products difficult to exclude. No acute bleed. Suggestive of lymphoma/cancer
NSG consulted, labs ordered, explained preliminary findings to family
Recommended obtain MRI and follow up within 1 week…
Initial Labs: WBC of 129,000.
Hb 10.1. Plts 233
Oncologic Emergencies:
Hyperviscocity sx: elevated WBC >100,000, hyperproteinemia, polycythemia. Waldenstrom macroglobinemia, MM, and leukemia
Classic triad: mucosal bleeding, visual disturbnance, neuro sx, end organ failure
Tx: Lots of IVF, plasmapheresis, phlebotomy 2-3 units
Tumor lysis sx: high turnover of malignant cells
Severe metabolic derangement: metabolic acidosis, aki, hypocalcemia, hyperkalemia, hyperphosphatemia, hyperuricemia
Present after recent chemo treatment, radiation, or high dose steroids.
Have edema, hematruia, fatigue, weakness, or ams
Tx: Ca Glu if needed if hypocalcemia, allopurinol/rasburicase for hyperuricemia, IVF and acetazolamide for hyperphosphatemia, aggressive hydration
Hypercalcemia of malignancy
Febrile neutropenia
Mass effect
Hospital Course
Flow cytometry confirms B cell ALL, spiked fever 101.4, started on cefepime
Started on Intrathecal cytyrabine, LP, PICC line placed, induction chemo started
Transferred to floor
Complained of arm pain: US showed DVT, PICC removed, started on lovenox
Tachycardic: shown to have BL PE
Post admission:
Multiple LPs and Chemo treatments
Social Concerns surrounding new diagnoses
Potentially life changing, far reaching consequences
Bias in beginning of case
Lessons:
Broad and flexible differential diagnosis
Head trauma vs headaches
Who gets worked up?
Pretest probability and LR
Incorporating specialists
Remaining Systematic
Overcoming bias and the socioeconomic implications of a diagnosis
Undifferentiated vs differentiated sick kid
Pediatric Soft Tissue and Skin Infections with Dr. Gonzalez:
History: Very important in these diagnoses
Immune status, pmh, MRSA risk factors
Surgery/trauma
Medications and allergies
Travel history/geographic locale
Animal exposure
Lifestyle/ hobbies
PE:
Site of infection
Purulent/nonpurulent
Color/size/texture/shape/scale
Systemic Symptoms
Impetigo: Classic honey crusted, facial region, can look varied in different people
Bullous: can have bullous lesions, fluid underneath, can inoculate different areas
Ecthyma: impetigo, but on deeper level in tissue. Classic cigarette burn appearance. One of child abuse mimics
Consider culture. Mupirocin or retapamulin for mild impetigo
Dicloxacillin or cephalexin for mssa
PCN for strep
Doxy, clinca, Bactrim for mrsa
Oral abx recommended during outbreaks psgn, helps prevent spread in the community
Purulent STI:
Purulence, fluctuance.
Abscesses, furuncles, carbuncles, infected cysts
Cause by staph, less likely strep
Consider culture
I+D
Add oral abx to cover staph with systemic symptoms
Consider MRSA coverage especially if worsening on initial oral abx, immunocompromised or shock
Consider decolonization regimen if recurrent
Cellulitis/Erysipelas
Most often caused by staph or strep
Consider other agents in immunocompromise, post surgical, trauma
Erysipelas aka st anthonys fire, is SUPERFICIAL and is usually GAS as cause
Cultures only recommended in immunocompromised, immersion injury, animal bites
Mild- cover strep- pcn, Keflex
Moderate ie with systemic symptoms: add MSSA coverage
Severe or with risk for MRSA: add something like Vanc
Very severe: broad spectrum such as vanc and meropenem or zosyn
Adjunctive tx:
Elevate
Treat underlying skin issues like eczema
Consider prednisone
Consider prophylactic antibiotics with recurrent cellulitis
Necrotizing Fasciitis
Aggressive skin and soft infection
Often starts below level of skin. Classic signs of warmth, redness, etc, not often seen
Pain out of proportion
Systemically ill patients
NEED surgical consultation for debridement, borad spectrum abx
Add clinda if GAS
Aggressive supportive care
Pyomyositis, also a deep infection:
Cultures
Imaging with MRI
Vancomycin, +/- gram negative coverage in immunosuppressed or open wound
Cefazolin, nafcillin, or oxacillin for mssa
Surgical consultation
Animal Bites:
Consider prophylaxis in immunocompromised, hand face, wounds, severe wounds
Infected wounds need coverage of aerobic and aerobic eg augmentin
Tetanus
Rabies prophylaxis as needed
Avoid suturing
Know your local antibiogram!
Pox Virus/Molluscum
Ringworm
Can get one or multiple lesions
Well appearing child
For capitus: need oral treatment
Tinea Versicolor
Hyper or hypopigmentation
Warts
Parents confuse with FB
Black dots, can be painful
Verrucal or flat in appearance
Duct tape, salicylic acid, derm
HSV
Gingivostomatitis
Fever, irritable, dehydration because of pain of PO
Herpes eye infection
Need oral treatment, ophthalmology
Whitlow
Can spread to other parts of body
Eczema Herpeticum
Herpes Simplex infection in babies
Scabies
Itchy, do others in the house have it, when is it most itchy (usually when they go to bed)
Low threshold to treat- permethrin cream, household cleaning/instructions
Classically involves web spaces fingers
Likely will need to treat everyone in home
Head Lice
Otc meds, household cleaning/instructions
Likely will need to treat everyone in home
Approach and management of the agitated patient with Dr. Strayer:
What patient defines EM?
Undifferentiated agitation, classically brought in by EMS or police
An immediate threat to themselves and others
Requires use of dangerous maneuvers including chemical and physical restraints
Could be drunk or dying
Simultaneous control, resuscitation, and risk stratification
Mild agitation:
Anxious but normal speech, persistently redirectable, responsive to engagement
Verbal de-escalation
Nonpharm interventions: food and water, symptoms control
Moderate
Most common
often disruptive, often requiring calming meds
distinguished by being intermittently assessable. Can usually get a bit of history. Can usually figure out dangerous or non dangerous cause
Usually related to alcohol
Prioritize safety over speed and efficacy
Often observed in unmonitored bed. Can be dangerous if received meds for calming, and then placed in unmonitored bed.
Classic: Haldol 5, Lorazepam 2
If fine, but slow and unreliable
Often needs redosing
Best option for treatment is to assess patient, obtain history, and treat underlying problem
Psychosis
Ethanol intox
Withdrawal
Cns stimulant intox
Delirium
Droperidol
Most effective
Safest
QT concerns but mostly nonsense
Dosing is 5-10mg IM (or IV)
Absorbed well in the IM route compared to Haldol, fast, more potent
Midazolam
Reliably and quickly absorbed intramuscularly
Good for alcohol withdrawal, seizures
Think of the M as standing for IM
Lorazepam is slow
For monotherapy for disruptive without danger
5-10mg
Monitor for hypoventilation. Has real potential to cause harm
Put patient on a monitor if receiving 3mg or more IM midazolam in span of 1 hour
Any patient receiving 10mg or more of IM midazolam should be monitored in resus
Faster than Haldol, but narrow therapeutic window
Severe Agitation
Immediate threat to self or others; combative, violent, uncontrollable, especially if concern for concomitant dangerous medical condition like trauma
Code white
Uncommon
Excited delirium: Delirium and danger to themselves and those around them
Disruptive vs delirious:
Screaming and thrashing, disregard for futility, pain, fatigue
Cannot engage
Incoherent
Fluctuating sensorium
Abnormal vitals- don’t fight for vitals
Err on treating the patient first
Need adequate force to safely approach patient.
Put face mask O2 on the patient for O2 delivery AND because it controls spit.
Relieve dangerous restraint holds. Err on using chemical restraints and NOT physical restraints. Focus on sedation.
Chemical restrains given IM, not IV. Prioritize safety. IM can be given through clothing
Speed and efficacy trump concern for over sedation
Treatment for uncontrollably violent, severe agitation patient, can use dissociative dose ketamine
Requires PSA monitoring
Used especially if worried about dangerous underlying condition that needs to be treated
Litmus test for ketamine: if this patient ended up intubated, does that seem like appropriate care?
Treat underlying condition
Keep broad differential when working up causes of agitation
Mood and Thought, Neurotic and Factitious Disorders with Dr. Kurbedin
28 year old male, unknown pmh, brought in by neighbor for AMS. “not acting right” over last week
Vitals WNL, NAD, going through stack of papers, laughing to self
Primary survey fine
Obtained more history: usually highly functional. Recent patients apartment with nothing in fridge, messy apartment. Patient states he feels fine. “I’ve been hand selected by the CIA to find a terrorist.” Hears the voice of God, has some headache, lost weight. Cannot perform ADLs. Should obtain social history when able. Denies drug use. No pmh or meds.
Does he have capacity? Not being able to take care of oneself
SI? HI? AVI?
Try to rule out other diagnoses when examining psychosis.
Try talking to family to obtain collateral information. Also check other hospital records. Family history.
Any increased risks of suicide, such as gun at home?
This guy is not a safe discharge. Will need psychiatric services.
Physical exam positive for psychomotor agitation, difficulty sitting still, pressured speech, denies SI, reports plan to capture and use appropriate force to subdue the terrorist, is asked, normal memory and attention. Otherwise PE benign.
Acute Psychosis:
Characterized by derangement of personality and loss of contact with reality causing a grossly disorganized mental capacity
Need to rule out can’t miss diagnoses. Need to keep a broad differential.
Get labs: bgm, cbc, bmp, vbg, alcohol levels, tsh, psych drug levels, lfts, salicylate levels, acetaminophen, urinalysis, utox, ct head
Avoid these meds in elderly:
BATMAN
Benzos, anticholinergics, tricyclic antidepressants, muscle relaxants, antiepileptics, and nitrofurantoin
Depression in the ED
Screening tool PHQ-2 may be useful
During the past month, have you been bothered by feeling down, depressed, or hopeless?
During the past month, have you been bothered by little interest or pleasure in doing things?
SIGECAPS
Needs to have 5 more more symptoms x 2 weeks. One sx has to be depressed mood or anhedonia. Sx cannot be related to drug use
Most important part of eval is assessment of suicide risk.
ASK ABOUT FIREARMS
Get psych consult for SI, plan, past SI attempt, substance use disorder, irritability/agitation/aggression, significant PMH
Antidepressants can take weeks to months to take effect, so not started in ED typically
Needs psych consult and needs follow up
55 year old male, h/o htn and dm, CC chest discomfort and SOB, starting 1 hour ago. +palpitations and weakness. Tachycardic. Patient states he has symptoms before and was diagnosed with anxiety.
Vitals tachy 122.
What to do for this guy? Work him up. NEED to rule out other dangerous causes of symptoms like ACS and PE.
Anxiety in the ED
Anxiety remains most common mental health diagnosis
Nonspecific symptoms common
Treatment:
Psychotherapy is effective as medication for GAD and PD with CBT having best evidence
Benzos in ED for symptomatic treatment, but does not improve long term outcomes
Give PO
Medical causes: 1st presentation of sx occurs >40, possible fluctuations of consciousness, and autonomic instability
Anxiety: 1st presentation of sx occurs between 18-40, FH of anxiety, patient is concerned about losing control and occurrence of recent/anticipated life event
Substance Use Disorders with Dr. Turchiano
Case 1: drunk patient received in sign out, is still metabolizing, but isn’t ready to go yet.
When trying to wake him up, he’s confused.
HR: 101. Normal O2 sat. Afebrile.
FSG 97. Draw labs. Hang fluids. Hang banana bag.
Full reassessment: Has bruise on forehead. Prior head CTs show volume loss.
Should still scan the patient’s head. à normal, unchanged from previous
Alcohol level is now 0.
Wernickes: thiamine deficiency causes diffuse brain injury
Thiamine is vitamin B1. Alcohol prevent GI absorption and is nutrient poor.
Three things that define wernickes: oculomotor findings, ataxia, confusion
Treatment: Thiamine 500mg IV TID, needs admission, needs magnesium
Case 2:
43 year old male coming to north wall- EMS states he knocked over all chips in bodega and doesn’t want to leave. Tachy to 130, hypertensive. Diaphoretic, trying to get out bed.
Needs sedation: give IM benzos. Give another 5mg IM, but keep on monitor.
Patient seems calmer. Repeat vitals with tachy again.
FSG: 112, EKG sinus tach, blood work. Lactate for 6, otherwise normal.
Delirious, tremulous.
Concern for alcohol withdrawal
Valium. Likely will need high doses. Possibly phenobarb. Redose as intervals to achieve desired effect.
May need propofol and intubation
There is likely to be an underlying medical condition alongside/that may have precipitated withdrawal. Keep a broad differential and perform a thorough workup.
CQR With Dr. Dhanraj
Confirm patient’s info in chart whenever possible, especially when patient wants to AMA/needs follow up
Do not take AMAs personal, the best treatment may be “suboptimal” if that is the most the patient is willing to do; such as in the AMA’ing patient requiring admission and IV abx, but at least agreeing to an Rx for oral ABX.
Document these interactions in depth and as much as possible
Have low threshold to work up cardiac syncope in patients with significant cardiac history.
Bedside sonography is a cheap and easy bedside test. Should have low threshold to use.
Be careful giving benign diagnoses to patients in the ED, such as gastritis or costochondritis. Every patient should be given thorough return precautions and what to expect and look out for.
Live on NY with Dr. Levin
Consult LiveOnNY within one hour of
Every death
Mechanically vented patients meeting any of these conditions:
Absence of two or more brain stem reflexes
GCS </=5
Family discussion of withdrawal ofd life sustaining therapies is anticipated
Call 1800 GIFT 4 NY
1800 442 8469
DO NOT initiate conversation with family about possible organ donation. This can be a conflict of interest. Direct them to LiveOnNY and introduce them as the team best equipped to discuss such matters.
Need neurological testing and apnea test. These are the bare minimum tests.
If unable to do either, may be able to perform ancillary tests
Have LiveOnNY involved as early as possible
Thank you all!
Enjoy the rest of your Wednesday!
-SD