Today we had a wonderful conference (in person!) kicked off with a really cool case presented by the brilliant Dr. Yum.
M+M with Dr. Yum:
28 year old M BIBEMS s/p suicide attempt. As per EMS drank antifreeze. Found in cemetery unresponsive. Currently on 10L NRB
Upon arrival:
ABCS- intact
BP 167/94, HR 81, RR 14, SPo2 94% T: afebrile Blood glucose: WNL
PE: Unresponsive, copious secretions in mouth, no external signs trauma. Neuro: not speaking, not opening eyes, not moving extremities. GCS 3.
Initial VBG: pH normal, glucose normal. Lactate 10.1
Intubate? Factors involved in making clinical decision:
GCS 3, copious secretions
Jaw thrust being applied, has decent capnography
Course of disease/management
Patient was intubated.
Wide DDX for AMS: AEIOUTIPS:
Highest on differential: Alcohol, infection, tox, icp, poisoning, seizure
Plan: Rainbow lab, utox, salicylate, acetaminophen levels, etoh/methanol/ethylene glycol level (send out), serum osmolarity, cxr, ekg
Start fomepizole pyridoxine, thiamine early for high clinical suspicion
Consults:
Poison control
Nephrology
MICU
Family arrived shortly after and provided additional history:
Patient had previous suicide attempts and psychiatric history. He had recently stopped taking his psych meds. New stressors in family, including recent passing of mother. Patient stated he went to cemetery to be with mother. Called family right after taking antifreeze.
Initial labs significant for:
CBC WNL, BMP: anion gap: 15
ED Course:
Nephrology asked for HD, started in ED
Accepted by MICU- started bicarb and folic acid on him
Osmolality: 311, Osmolar gap: 21
Osmolality: Normal 285-295. Number osmoles in kg of solvent
Osmolar gap: measured osmolarity – calculated osmolarity
Gap should be less than 10. IF gap >10, there is osmol that is not being accounted for, like possibly a toxic alcohol
*Urine placed under black light: patient’s urine glows positive after ingestion of ethylene glycol
Send out labs:
Methanol: none, Ethylene glycol: 588
Hospital course:
Extubated 2 days later in MICU
Evaluated and transferred to psych, started on abilify
7/12 completed safety plan and discharged home
Toxic Alcohol Poisoning:
Seen with intentional suicidal attempt, accidental, recreational ingestion
All these alcohols get metabolized by alcohol dehydrogenase
Ethylene Glycol
Radiator fluid, antifreeze, brake fluid
Rapidly absorbed, eliminated by kidneys, 17 hours half life
Inebriated --> cardiopulmonary stage --> kidney failure --> neurological sequelae
Methanol
Windshield wiper fluid
Deicing products
Moonshine
Windex
Rapidly absorbed, eliminated by expiration
Little renal elimination
Inebriated -> visual symptoms, neurological sx, late neuro Parkinson’s like symptoms
Clinical clues:
Tachypnea in absence of respiratory illness, visual changes (if awake and able to communicate)
Not sobering up as expected
Seizures
Lab clues:
Low ethanol in intoxicated patient
Hypocalcemia with prolonged QT
Anion gap metabolic acidosis
High osmolality + osmolar gap
Get metabolic acidosis from build up of toxic metabolites
Our patient: had lactate of 10, but normal pH
The lactate gap: Glycolic acid --> glycolate from breakdown of ethylene glycol similar to lactate chemically, and mimics it on VBG lab
Can send serum lactate, which is more specific for serum lactate; can compare to VBG, which cannot differentiate between lactate and glycolic acid
**On initial ingestion: high osmolar gap, low anion gap. As metabolized, lower osmolar gap, but increasing anion gap
Important labs:
Anion gap metabolic acidosis elevated osmolar gap/osmolarity
Low ethanol level
Send out labs of levels of toxic alcohols
Testing urine for ethylene glycol:
Calcium oxalate crystals in urine. Not specific for testing urine for toxic alcohol ingestion. Also not put in commercial toxic alcohols
Fluorescence of urine under woods lamp
Management Goals:
Block toxic metabolites formation
Correct pH
Eliminate toxic metabolites formed
Get poison control and other consultants on board early
GI contamination: NG suction if within 30 min to 1 hour after ingestion, no role for activated charcoal
Fomepizole
Blocks alcohol dehydrogenase. Keeps toxic alcohol in parent compound
If suspicion high enough- give it
15mg/kg initial dose à 10mg/kg q12h x 4 doses for 2 days
Ethanol
2nd line after fomepizole
Alcohol dehydrogenase favors ethanol over toxic alcohol
Ethanol metabolized with zero order kinetics, nee to get levels, associated with longer ICU stays compared to fomepizole
Vitamins and Cofactors
Bicarb
Correct until pH >7.2
Normalization of pH keeps toxic metabolites in ionized form
More support for methanol poisoning
Less able to penetrate tissues
Hemodialysis
Takes out parent compound and toxic metabolites
Corrects metabolic acidosis and electrolyte abnormalities
Indications: if enough toxic alcohol/metabolites to have end organ damage, or pH <7.15,or anion gap >24
Ethylene glycol may not require HD, while methanol always does
Dr. Vasquez: Three Common Medical Ear Problems in Children
Ear anatomy: outer, middle, inner ear
Eustachian tube: connects nasopharynx to ear. Acts as a way to drain middle ear. In children, the tube is shorter, smaller, and easily clogged. Leads to infection
Otitis Media
Diagnosis and Management of acute Otitis Media
Definition: Needs
Moderate to severe bulging of TM (or new otorrhea not due to AOE)
Acute signs of illness
Signs of middle ear effusion
Bugs:
Strep pneumo, H flu, Moraxella catarrhalis
How to examine ear:
Have child sit in moms lap, distract child
Parent holding head and arms against chest
Take elbows, hold them to patients ears to examine mouth then nose
Rest dominate hand against patient for stabilization
Characteristics of the TM
Color: translucent or opaque
contour : bulging or retracted
translucency
mobility
AOM Vs OME
OME: no signs of illness, but may see effusion
TM Rupture
Bullous AOM
ABX
Any child with otorrhea, signs of ear pain, signs of fever
Any child with severe symptoms
Uncertainty to follow up after visit
ABX or additional observation
>2 years old with BL AOM without otorrhea
Unilateral AOM without otorrhea
Strep pneumonia resistance
Penicillin binding proteins
Overcome by high dose amox
Failure after three days:
Amox clav
H flu and Moraxella produce beta lactamase
Ceftriaxone 50mg kg IM q day x 3days
Otitis conjunctivitis syndrome:
Treat with amox clav
Mastoiditis
NNT of AOM to prevent 1 mastoiditis: 4800
Infection of mastoid air cells
Swollen area with ear turned forward
High fever, discharge from canal, swelling mastoid process, ear protrudes
Evaluation and treatment:
Consult with ent, consider CT scan
IV ceftriaxone and myringotomy
If fails, needs mastoidectomy
Can develop meningitis
Otitis Externa: Swimmers Ear
Swimmers ear
Ear pai, discharge, pruritis, hearing loss, lymphadenopathy
Treatment: topical abx ear drops, and pain
Small Groups:
Dr. Sokolovsky: Rashes
3 year old tachycardic out of proportion of fever. Rash disseminated, back of mouth
DDX: coxsackie, herpes, eczema herpeticum
Tx: fluids bolus, antipyretics, rainbow labs
Labs significant for: elevated wbc, low bicarb, mild thrombophilia
Diagnosis: Atypical Coxsackie aka disseminated coxsackie
If child appears well, PO well, has good follow up, can possibly go home
(But what if rash was more vesicular, given picture of similar looking rash)
Diagnosis: eczema herpeticum aka disseminated herpes
Needs to be admitted, needs IV acyclovir
But these rashes look so similar.
An RVP can help- if receive back a positive result such as enterovirus
If no RVP available, unsure if it is disseminated herpes or not, would need to admit
Rapid Fire Images and Questions:
Parvovirus: slapped cheek. Mom may develop fetal hydrops
Rash: pityriasis: tx Benadryl for itching
Dacryoadenitis: tx: warm compresses
Chicken pox: multiple stages of rash
Melanoma: screen for ABCDE
Osler nodes: endocarditis, admit
Erythema migrans with cardiac complaints/heart block: IV ceftriaxone à CCU
Roseola: the fever that rashes
Erysipelas: strep
Seborrheic keratosis: stuck on appearance
Basal cell carcinoma
Kawasaki: IVIG, aspirin, coronary aneurysms
Circumferential burn crosses joint lines. Parkland formula for fluids
Herpes ophthalmic, Hutchinson sign
Dendritic lesions on herpes. VZV has pseudo dendrites
Anaphylaxis: epinephrine IM
Pox virus
Dr.Kurbedin: Basic cutaneous rashes
Pox virus
not dangerous, + contagious, spread skin to skin.
Tx self limiting, can have derm follow up. Catharidin
Popular growths, dome shaped, flesh colored
Shingles
Dermatomal. If in more than 1 dermatome: disseminated. If it crosses midline: disseminated This person needs to be admitted, IV meds
Reactivation of vzd
Can have pain and itching at site before vesicles appear
Tx: acyclovir, vaclyclovir PO within 72 hours, or if new lesions still occurring
Gabapentin for post herpetic neuralgia
If disseminated or including eye: IV acyclovir, or if cannot tolerate PO
Disseminated zoster requires airborne precautions
Zoster Ophthalmicus (shingles)
Risk of blindness
PE: look in ear, slit lamp, fluorescein dye, look for dendritic pattern
If present, admit, give IV acyclovir, ophthalmology consult
Cold sore. Herpes 1 and 2
+contagious
Tx: initial episode, recurrence, suppressive therapy are different doses
Acyclovir vs valacyclovir vs famciclovir
Herpetic Whitlow
Don’t I+D, contagious
Can give acyclovir, follow up
Necrotizing Fasciitis
Can be missed if not careful
Severe pain, crepitus, pain out of proportion
Fast evolving on history
Needs IV ABX, broad spectrum, +clinda for antitoxin properties, OR, debridement
Multimicrobial in nature
High mortality 30-50% with treatment
Xray, CT, MRI, US not sensitive enough compared to clinical suspicion
If concern for vibrio- water based, fish take, recent vacation, add doxycycline
Dr. Cueva: Dermatology Bizz Buzz
Basal Cell Carcinoma: irregular, heterogenous, raises edges, sun soaked edges. Pearly. Telangiectasia. Locally invasive. Not metastatic. Follow up dermatology.
Squamous Cell Carcinoma: scabby, transformation actinic keratosis, metastatic, derm follow up for biopsy. Associated with hypercalcemia
Melanoma: Asymmetry, irregular borders, colorful, diameter, evolving and elevation. Refer to biopsy. Most common mets to brain
Shingles: unilateral, one dermatome, painful and itchy, then rash. Pain control. When sores open, they are still infectious. Contact precautions. Check eye, nose, ears.
Bullous pemphigoid: chronic, autoimmune disorder. Older patients, antibodies to basement membrane. Negative Nikolsky.
Pemphigoid vulgaris: autoimmune, drug induced, +nikolsky, mucosal involving, high mortality, tx steroids, a/p burn center
Sacral decubit ulcers: stage 2 with intact skin. Black eschar on decubiti: this is unstable, needs debridement to be able to stage. Stage 4: bone visible
Trauma Conference:
Trauma panel: Drs Marshal, King, Patel, Chen, Zapolsky
Hemothorax/Pneumothorax
Traditionally taught to use large bore chest tube for hemothorax
Some literature suggests no difference between pigtail and large chest tube for hemothorax
Additionally can consider pigtail for
pneumothorax- for obvious ones, for patients who are stable, no respiratory distress, can be prep and draped, anesthetic, sterile pigtail procedure
Occult pneumothoracies on CT but not on xray- is patient stable/resp distress? How busy is team? If can't perform serial exams/monitor patient, if the patient is going to floor, then likely important to put chest tube due to risk of worsening pneumothorax
If no improvement, then can escalate with a second chest tube/larger chest tube
If several days passed, hemothorax found on imaging, but now has fibrosis and clotted, consider OR; chest tube may not be of use
Delayed chest tubes have their own risks
Consider putting large bore in unstable patients, patients in the trauma bay where oyu have limited histroy/timeline of assessment, prior history of pneumothorax/hemothorax with possibility of old scarring
Time outs in chest tube placements are important. Easy to mix up side of placement, etc.
Delayed brain bleeds
Still need period of observation once found, serial imaging. Still need interval imaging to prove stability.
Unlikely for neurosurgical intervention in delayed presentation, depending on multiple factors, including length of delayed presentation, baseline functional status
Have a fantastic rest of your Wednesday!
-SD