Grand Rounds Recap 04.14.21

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R1 CLINICAL KNOWLEDGE: ORBITAL INFECTIONS WITH DR. FINNEY

Conjunctivitis - inflammation of the conjunctiva

  • Symptoms: dry eye, redness, foreign body sensation, photophobia, blurry vision 

    • Viral: may be part of a viral prodrome with adenopathy, fever, pharyngitis, URI

      • Watery or mucoserous discharge

      • Second eye may become infected within 24-48 hours although unilateral symptoms are not uncommon

      • Typically lasts 1-3 weeks

      • Adenovirus is most common

    • Bacterial: redness and discharge in one eye

      • Thick discharge with eye “stuck shut” in the morning

      • S. aureus, S. pneumoniae, H. influenzae, M. catarrhalis - don’t forget gonorrhea!

  • Treatment: topical antibiotics for bacterial infection especially for contact lenses users!

  • Take away: red eye with no “red flag” symptoms; topical antibiotics if concern for bacterial etiology

Blepharitis - inflammatory condition of the eyelid margin

  • Symptoms: itching and burning of eyelids with associated tearing and crusting, can report photophobia or blurred vision. Symptoms are typically worse in the morning. 

    • Eyelids may be diffusely inflamed and thickened, erythematous margins, telangiectasias surrounding eyelid margins. 

    • Not always infectious, but if secondary to a bacterial infection, it is typically Staph 

  • Treatment: 

    • eyelid hygiene - warm compresses, clean eyelid margins with baby shampoo to remove residual oils. 

    • topical antibiotics for symptomatic relief and bacterial eradication (bacitracin or erythromycin ointment)

    • Follow up with ophtho within 1 week, or 1-3 days if concern for infection

  • Take away: Itching, burning, crusting eye with lid inflammation - warm compresses +/- topical antibiotics

Stye - inflamed oil gland on margin of eyelid at level of eyelashes or in mid portion of eyelid. Caused by obstruction of a meibomian gland and/or inflammation

  • Symptoms: reported localized painful swelling of one or both eyelids - may start as generalized edema/erythema that then becomes localized

    • Painfully tender, erythematous swelling that can be infected. Should not have lymphadenopathy in simple stye

    • Most commonly due to Staph

  • Treatment: typically self-limited and resolve when glands become unobstructed. Use warm compresses, and if no relief, refer to ophtho for I&D 

  • Painful, red, tender nodule - warm compresses

Dacryocystitis - inflammation of the lacrimal sac that typically occurs secondary to an obstruction of nasolacrimal duct and backup/stagnation of tears within the lacrimal sac

  • Symptoms: Pain, erythema, edema over medial canthus that develops over hours to days. More common in females due to narrower duct diameter 

    • Pain, tenderness, swelling, erythema over lacrimal sac medial to eye. May be able to express purulent discharge

    • S. aureus, S. pneumoniae, H. influenzae, Serratia marcescenes, Pseudomonas

  • Treatment: massage, warm compresses, systemic antibiotics covering MRSA

    • Follow up with ophtho in 24-48 hours

    • Definitive treatment is surgery for the nasolacrimal duct obstruction 

  • Takeaway: medial eyelid inflammation with purulent material - warm compresses and systemic antibiotics to cover MRSA

Bacterial keratitis - bacterial infection of the cornea

  • Symptoms: rapid onset of pain, redness of eye, tearing, light sensitivity, blurry/hazy/decreased vision +/- discharge, foreign body sensation. Risk factors - contact lens users!

    • Conjunctival injection and focal white infiltrates (with epithelial demarcation and underlying stromal inflammation), corneal thinning, mucopurulent discharge, hypopyon, eyelid edema, ciliary flush

    • S. aureus, Strep, mycobacterium, pseudomonas in contact lens wearers, fungal pathogens in steroid drop users

  • Treatment: Discontinue contact lens use! Topical +/- oral antibiotics if severe. Ophtho consult in the ED - need daily follow up with possible admission

  • Takeaway: focal white infiltrate likely in contact lens wearer, consult ophtho, topical +/- systemic antibiotics

Herpes simplex keratitis 

  • Symptoms: recurrent corneal ulcers similar to recurrent labialis/genitalis

    • Blurry vision, photophobia, pain, redness, or tearing

    • Classic dendritic lesions on slit-lamp exam or have nonspecific findings such as punctate epithelial erosions, stromal whitening, thinning of the corneal with possibly herpetic vessels on lids or conjunctiva

    • Usually HSV-1

  • Treatment: emergent ophtho consult, topical antiviral agents such as acyclovir x14d, topical prophylactic antibiotics, avoid topical steroids

  • Takeaway: look for signs and symptoms of HSV on exam, remember the dendrites, topical or oral antivirals

Herpes Zoster Ophthalmicus

  • Symptoms: fever, malaise, headache, eye pain, painful rash in a single dermatome. May describe eye pressure, tearing, eye redness or decreasing vision.

    • Ophthalmic division of trigeminal nerve with rash over forehead and upper eyelid +/- nose, can have local Horner’s syndrome. Hutchinson’s sign consists of skin lesions at the tip, side, or root of nose. Can have decreased corneal sensation, ocular inflammation in any of the layers of the eye, can have increased intraocular pressure.

  • Treatment: emergent ophtho as this can result in permanent vision loss. Systemic therapy with high dose antivirals +/- systemic antibiotics and topical steroids - can take 2-6 weeks to recover. If retinal involvement occurs or patient is immunocompromised - inpatient treatment. Pain control needed - consider amitriptyline, narcotics, capsaicin cream

  • Takeaway: shingles on the forehead and eye, systemic therapy with antivirals, don’t forget pain control!

Blebitis - presumed infection in or around a filtering bleb without vitreous involvement. Trabeculectomy is the surgery performed to treat glaucoma - they create a bleb as a site for aqueous humor outflow tract out of the air. 

  • Symptoms: sudden onset pain, photophobia, discharge, can occur days to years after surgery

    • Hyperemic, injected conjunctiva with a white or opacified bleb as well as mildly reduced vision and an anterior chamber reaction with or without hypopyon

    • S. aureus, S. epidermis

  • Treatment: emergent ophtho. If no vitreal involvement, aggressive topical treatment with vancomycin, cefazolin, tobramycin

Endophthalmitis - purulent inflammation of the intraocular fluids (vitreous and aqueous)

  • Symptoms: acute and rapidly progressive pain, red eye, ocular discharge, blurry vision. Most common etiology is recent intraocular surgery (usually within 3-5 days), previous perforated globe, and endogenous infection

    • Decreased visual acuity, lid swelling, chemosis, hyperemia of the conjunctiva, intraocular inflammation evidenced by hypopyon, anterior chamber cells, vitreous inflammation, retinitis. 

    • Consider ultrasound of the eye to augment evaluation

    • Coagulase-neg staph, bacillus cereus, S. aureus, Strep

  • Treatment: medical emergency; systemic antibiotics not effective as they are too slow to enter the eye in adequate concentrations; need intravitreal antibiotics, may need vitrectomy (removal of infected vitreous similar to draining an abscess) in the OR. Needs admission

Preseptal vs Orbital Cellulitis - infections of the tissues surrounding the eye; differ based on location

  • Preseptal: limited to the tissue anterior to the orbital septum

    • Treatment: oral antibiotics, MRSA is rare, close follow-up with ophtho

  • Orbital: spread of infection beyond the septum

    • Treatment: IV antibiotics including MRSA coverage. Admission.

Who should you consider for a CT scan?

  • Proptosis, limited or painful EOM, double/decreased vision, relative afferent pupillary defect, edema beyond eyelid margin, ANC >10K, signs and symptoms of CNS involvement, exam limitations, no improvement in 24-48 hours of antibiotics

Reasons for urgent ophthalmologic evaluation

  • Reduction of visual acuity, difficulty with EOM, ciliary flush, photophobia, severe foreign body sensation, corneal opacity, high IOP, concerns about ability to follow-up, bounce-back from failing outpatient

R3 TAMING THE SRU WITH DR. FREDERICK

Female in her 40s who primarily communicates with ASL presenting with two hours worth of dyspnea, nausea, and upper back pain who is writhing around in the stretcher and diaphoretic.

She’s noted to have normal vital signs. EKG with strain in the inferior leads compared with prior, no STEMI. HSTroponin 19, labs otherwise unremarkable. During work up, she has a myoclonic seizure and goes unresponsive, noted to be in V.fib arrest. Taken to the SRU, given magnesium and shocks with ROSC. Post-arrest EKG concerning for lateral STEMI. Cath lab is activated.

Dynamic EKG changes in STEMI

Hyperacute T waves noted at 10-15mins of acute coronary occlusion → early ST elevation → ST elevation at 20-25mins → “Giant” R wave → ST elevation with oblique morphology at 50mins → Q wave with persistent ST elevation at 3wks

Women do not show the “typical” EKG changes as frequently when compared to men - frequently fall below the criteria that we use to diagnose STEMI (less ST elevation). Have a high index of suspicion in the appropriate patient presentation!

Post-ROSC EKG acquisition and TTE may help risk-stratify for cardiology

What makes a good consult?

[Kessler, 2012] Qualitative analysis and review that assessed what made a good ED consultation

  • Organization of the consult 

  • Interpersonal skills

  • Medical knowledge

[Riskin, 2015] An RCT assessing the impact of rudeness on medical team performance 

  • Rudeness lowers diagnostic and procedural performance

  • Rudeness obstructed help-seeking and information-sharing behaviors

“They are on my team...they just don’t know it yet...It’s my job to get them there”

  • They aren’t against you, they are just for themselves

  • Recognize that you have your own goal

  • Be quiet (and listen) to find out what their goal is

  • Create alignment between your goals

R4 CAPSTONE WITH DR. IPARRAGUIRRE

The big picture: 

  • Family: allow yourself to be vulnerable, open, real

  • Find yourself: experiment, find your practice pattern, and grow in confidence

  • Breathe: hide, give yourself time, find something that makes you smile

  • Confidence: amazing training, family, support, legacy

NICU:

  • Neonatal Resuscitation Program - save it somewhere for easy access!

    • >90% of neonates require minimal to no assistance

    • 10% will require some assistance, 1% will require intensive assistance

    • Get hands - call your consultants early if available

    • Is the baby term, crying/breathing, good tone?

      • Yes: go to mother for skin-to-skin

      • No: go to warmer. Warm, warm, warm, dry, stimulate, position airway, suction

        • Most important thing for neonatal resuscitation is ventilation - positive pressure ventilation will solve most of problems for difficulty with respirations or HR <100

        • MR. SOPA - successive steps to intervene, give each step ~15s to assess response

          • Mask

          • Reposition airway

          • Suction 

          • Open mouth

          • Increase PIP up to 40 if needed

          • Alternate airway

        • Start D10W as maintenance fluids

Ultrasound:

  • [Barjaktarevic] The evolution of ultrasound in critical care: was initially used in the 1990s for procedural guidance. Now it’s used for diagnostic evaluation for nuanced pathologies, iterative cross-sectional evaluation, and hemodynamic monitoring.

  • RUSH exam - cardiac, IVC, FAST, aorta, pulmonary - can be HUGE in your diagnosis and initial management. Do it do it do it!

OMFS

  • Learn your dental blocks! Inferior alveolar and buccal, local infiltration/supraperiosteal, infraorbital, greater palatine

  • Make sure positioning is ideal for both you and the patient

Addiction Medicine

  • Medication-assisted treatment works

    • Clinical trials on methadone, buprenorphine, and naloxone show that twice as many patients have curbed their opioid use as compared to placebo

Ophthalmology

  • DO all of the slit-lamp exams!

    • Emergent ophthalmology consults: open globe, endophthalmitis, acute angle closure, retrobulbar hematoma, alkali burns, retinal detachment

R1 CLINICAL TREATMENTS: AGITATION WITH DR. KEIN

See Dr. Kein’s full Agitation Post here

  • 5-10% of ED visits are for altered mental status, ~2.6% with acute agitation

  • Nearly 50% of ED personnel will experience violence over their career

  • Managing agitation protects patients and staff, and additionally facilitates medical work up to rule out dangerous etiologies

Non-pharmacologic management as recommended by the American Association for Emergency Psychiatry’s Project BETA

  • Respect personal space

  • Do not be provocative

  • Establish verbal contact

  • Be concise

  • Identify wants and feelings

  • Listen closely to what the patient is saying

  • Agree or agree to disagree

  • Lay down the law and set clear limits

  • Offer choices and optimism

  • Debrief the patient and staff

First Generation Antipsychotics

Haloperidol

  • Dosing 2.5-10mg PO/IM/IV (20mg max over 24hs)

  • Time to sedation 25-28min

  • Risks: QTC prolongation, EPS

  • Efficacy

    • Cochrane Review of 41 RCTs [Ostinelli, 2020] 

      • Patients with aggression/agitation thought to be secondary to psychosis

      • Compared haloperidol alone vs any other treatment

      • Outcomes: tranquilization by 30min, repeat medications, poor behaviors, adverse effects

      • Haloperidol OK if no alternative, otherwise high risk of dystonia

        • Better with promethazine, no strong evidence for combo with benzos in this population as it carries risk of additional harm

Droperidol

  • Dosing 2.5-5mg IV/IM

  • Time to sedation 15-30mins

  • Risks: QTC prolongation, EPS

  • Efficacy

    • Randomized double-blind study including 115 ED patients with acute agitation requiring parenteral sedation [Martel, 2020]  

      • Compared droperidol 5mg, ziprasidone 10mg, ziprasidone 20mg, lorazepam 2mg 

      • Primary outcome: proportion adequately sedated at 15min

      • Droperidol more effective and with fewer episodes of respiratory depression

    • Retrospective review of >11K patients receiving single dose of parenteral antipsychotic for agitation secondary to ETOH intoxication [Cole, 2019] 

      • Compared droperidol, haloperidol, and olanzapine monotherapy

      • Outcomes: ED LOS

      • Droperidol monotherapy associated with shortest ED LOS (by 30min)

      • No difference between haloperidol and olanzapine

      • No episodes of sudden cardiac death in 3790 patients receiving droperidol

    • Cochrane review of 6 RCTs [Khokhar, 2016] 

      • No evidence droperidol caused more arrhythmias compared to placebo

      • Compared to haloperidol: more patients sedated at 30min, less rescue medications needed, similar adverse events

      • Compared to midazolam: slower onset

      • Compared to olanzapine: similar proportion sedated at 30min, less rescue medications needed, no increase in arrhythmias

    • Black box warning:

      • recommend all patients get 12 lead prior to administration

      • recommend against giving in QT >440 in males and >450 in females

      • if benefits outweigh risks, recommend EKG monitoring prior to treatment and continued for 2-3 hours later

      • Risk factors: CHF, bradycardia, diuretic use, cardiac hypertrophy, hypokalemia, hypomagnesemia, concomitant QT prolonging medications, age>65, alcohol abuse, benzodiazepine use, volatile anesthetics, IV opiates

      • ***A literature search undertaken by Kao et al in 2003 presented evidence that was not convincing for a causal relationship between therapeutic droperidol administration and life-threatening cardiac events***

Summary of first-generation antipsychotics

  • Watch for EPS, QTC prolongation

  • Avoid using haloperidol alone in psychotic patients - droperidol may work well here

  • Droperidol benefits include relative rapid onset and short half life

  • Droperidol black box warning remains questionable

Second Generation Antipsychotics

Olanzapine

  • Dosing 5-10mg PO/IM/IV (max 20mg over 24 hours)

  • Time to sedation: 15-45mins

  • Risks: Less risk for EPS, hypotension, respiratory compromise

  • Efficacy

    • Retrospective observational study >15K patients who received IM medications for agitation [Klein, 2019] 

      • Primary outcome: proportion who required additional sedatives (requiring rescue medication) within 1 hours of administration

      • Olanzapine and droperidol lead to lower rates of required rescue sedation at 1 hour and overall compared to haloperidol

      • No significant difference in adverse events

      • Limitations: 92% of patients had alcohol intoxication; many received concomitant diphenhydramine likely lowering rates of EPS

    • Retrospective chart review of 96 patients receiving medication for agitation in ED [Wilson, 2012] 

      • Compared haloperidol, olanzapine, or either drug + benzos and explored hypotension and low oxygen saturations

      • Olanzapine was not associated with more hypotension

      • Olanzapine + benzo associated with lower oxygen saturations in ETOH patients

      • Recommend using haloperidol +/- benzo or olanzapine monotherapy in intoxicated patients

Ziprasidone

  • Dosing 10-20mg PO/IM (max 40mg over 24 hours)

  • Time to sedation: 15-20min with peak concentration at 30-45mins

  • Risks: highest risk of QTC prolongation among second generation antipsychotics

  • Efficacy

    • Systematic review of 8 studies [Schneider, 2020] 

      • Second generation antipsychotics are likely as effective as first generation antipsychotics 

      • Second generation antipsychotics with similar or lower risk of side effects, except in ETOH

      • Ziprasidone: least reduction in agitation at 15mins but greatest reduction at 60mins

Summary of second generation antipsychotics:

  • Have similar efficacy to first generation with less side effects

  • Require reconstitution for IM delivery

  • Olanzapine is a good choice for single agent therapy

  • Avoid olanzapine + benzos, especially in ETOH intoxication

  • Ziprasidone has a slow onset but long-lasting effects

Benzodiazepines

Midazolam 

  • Dosing 2-5mg IM/IV/PR/PO/IN

  • Time to sedation: 13-18mins

  • Risks: respiratory depression, hypotension, exacerbate delirium and high morbidity when used in the elderly

  • Efficacy

    • Prospective, double-blind, randomized trial of 111 agitated patients in the ED [Nobay, 2004] 

      • Compared midazolam 5mg IM, lorazepam 2mg IM, and haloperidol 5mg IM

      • Outcomes: time to sedation, time to arousal

      • Midazolam had significantly shorter time to sedation and significantly faster time to arousal without a significant difference in vital sign changes from baseline

    • Prospective observational study of 737 patients with acute agitation in the ED [Klein, 2018] 

      • Compared haloperidol 5mg IM, haloperidol 10mg IM, ziprasidone 20mg IM, olanzapine 10mg IM, and midazolam 5mg IM

      • Outcome: adequate sedation at 15mins

      • Midazolam had higher rates of sedation at 15min compared to others

      • Olanzapine performed better than ziprasidone and haloperidol at both doses

      • Adverse events were uncommon in all groups

Lorazepam

  • Dosing: 0.5-2mg IV/IM/PO/IN

  • Time to sedation: 32mins

  • Risks: respiratory depression, hypotension, exacerbation of delirium

Benzodiazepine summary:

  • Midazolam benefits from more rapid onset than other commonly used medications

  • Lorazepam has slower onset but is longer lasting

  • Avoid benzos in the elderly, patients with delirium, and alcohol intoxication

The 5&5 - combination of antipsychotic and benzodiazepine?

  • Randomized, double-blind, control trial of 349 patients with acute agitation [Taylor, 2017]

    • Compared midazolam 5mg + droperidol 5mg, droperidol 10mg, and olanzapine 10mg

    • Primary outcome: proportion of patients adequately sedated at 10min

    • Significantly  more patients sedated in the combination group

    • Fewer repeat doses required to reach adequate sedation in the combination group

  • Multi-center, double-blind, prospective randomized trial of 98 agitated ED patients [Battaglia, 1997]

    • Compared lorazepam 2mg, haloperidol 5mg, or combination of both

    • Outcome: reduction in agitation/adequate sedation

    • More rapid sedation in combination group without increased adverse events/side effects

    • More EPS in haloperidol only group compared to combination group

  • Randomized, double-blind, placebo-controlled trial of 336 adult patients requiring sedation for acute agitation [Chan, 2013]

    • Compared placebo, droperidol 5mg, and olanzapine 5mg IV

      • Initial bolus medication followed by IV midazolam boluses of 2.5-5mg until adequate sedation achieved

    • Primary outcome: time to sedation

    • Secondary outcome: need for rescue medications, adverse events

    • Droperidol and olanzapine groups showed decreased time to sedation compared to placebo + midazolam group

    • Droperidol and olanzapine groups required less rescue medications

  • Systematic review and meta-analysis of 7 studies comparing two+ chemical agents for sedation of agitated patients in the ED, >1100 patients [Korczak, 2016]

    • Outcomes: proportion sedated, need for repeat sedation, adverse events

    • Significantly higher proportion sedated at 15-20min with combination therapy than benzos alone

    • Less rescue medications used in combination and antipsychotics only

    • Risk of adverse events higher with benzos alone

Combination therapy summary

  • Promotes more rapid sedation

  • Patients require less rescue medication with combination

  • May offset adverse effects of either medication alone

Ketamine

  • Dosing 1-2mg/kg IV or 4-6mg/kg IM

  • Time to sedation: 2-3 mins overall (4-5mins for IM)

  • Risks: laryngospasm, airway compromise, hypersalivation, vomiting, HTN, tachycardia, emergence reaction

  • Efficacy 

    • Prospective study including 146 patients [Cole] 

      • Compared ketamine 5mg/kg IM, haloperidol 10mg IM for severe agitation in the prehospital setting

      • Primary outcome: time to adequate sedation

      • Time to sedation significantly faster with ketamine (5min v 17min)

      • 39% of ketamine group was intubated versus 4% of the haloperidol group

        • Failure to protect airway NOS

    • Retrospective chart review of adult patients who received ketamine IM for acute agitation or delirium in the ED including 37 patients [Mo, 2020]

      • There was less endotracheal intubation required in this cohort in comparison to the prehospital literature

      • Dosing averaged 3.2mg/kg IM rather than the recommended 4-6mg/kg IM

    • Prospective, single-center, randomized study of 93 patients requiring medication for agitation in ED [Lin, 2020]

      • Compared ketamine (4mkg/kg IM or 1mg/kg IV and haloperidol 5-10mg IM/IV + lorazepam 1-2mg IM/IV 

      • Primary outcome: sedation within 5 min

      • Significantly more patients receiving ketamine were sedated within 5min

    • Prospective, single-center, observational study including 98 severely agitated ED patients [Riddell, 2017]

      • Compared ketamine, haloperidol, benzos, and haloperidol + benzo

      • Examined adequate sedation at 5, 10, 15min

      • Significantly fewer patients receiving ketamine were still agitated at all timepoints

    • Structured review of 27 patients who received ketamine for acute agitation [Hopper, 2015]

      • Few major adverse effects on vitals, small increase in heart rate and blood pressure without hypoxic events

      • High proportion (62.5%) required rescue medications

    • Systematic review of trials using ketamine for agitation in ED and prehospital settings including 13 studies, 10 prehospital and 3 ED [Sullivan, 2020]

      • Outcomes: sedation status, need for airway management

      • 85% received adequate sedation, significantly higher than controls

      • 20% of patients required some form of airway management

Ketamine summary

  • Most rapid onset, even compared to benzos and combination therapy

  • Requires vigilance after administration for respiratory compromise, but risks may be overstated

  • Likely will require rescue medications as it is not as long-lasting

Routes of Administration

  • Structured review of 11 studies for acute agitation [Gault]

    • Treatment with oral medications as effective as IM for agitation in the ED (when possible)

Physical restraints

  • Utilized in >50% of acutely agitated patients

  • Not a benign intervention as there is risk to staff and the patient

  • Centers for Medicare and Medicaid Services guidelines regarding restrain time limits:

    • Adults - 4 hours

    • teens/adolescents - 2 hours

    • Children <8 - 1 hour

  • Continue verbal de-escalation strategies, reminders about behavioral modification

Special populations

Pediatric patients

  • 5% of pediatric ED visits for psychiatric or behavioral concerns

    • 6-10% of these patients require restraint/sedation

    • PO>IV>IM

    • Medication choice considerations:

      • Diphenhydramine, alpha-2-agonists, quetiapine, chlorpromazine

      • Home medications

      • Risk for paradoxical activation: diphenhydramine, benzos, ziprasidone

    • Aggressive behavior

      • Risperidone best evidence

      • Olanzapine second line

Pregnant patients

  • Risperidone is first line as it has no known teratogenic effects

    • Limitations is oral route

  • Haloperidol is relatively safe with small risk of fetal limb defects in the long term

  • Benzodiazepines have a risk of malformations/cleft lip in the long term

    • Avoid in first trimester if possible

  • Olanzapine, ziprasidone - very little information, avoid

  • Physical restraints may cause IVC compression - support the patient’s right side or place in left lateral decubitus

Elderly patients

  • ~40% of elderly patients present to the ED with some form of altered mentation

  • 25% have delirium

    • One third with agitated delirium that increases morbidity and mortality

  • Increased risk of medication interaction (QTC prolongation)

  • Benzodiazepines associated with poor outcomes, antipsychotics first line

  • Start low and go slow!!

Other notable patients

  • Intoxicated patients 

    • Drug or alcohol intoxication >80%

    • Benzos for stimulants

    • Antipsychotics for alcohol - haloperidol is most well-studied

  • Primary psychiatric disease

    • Antipsychotics preferred (second gen > haloperidol; risperidone with most evidence)

    • Benzos preferred for rescue over additional antipsychotic

  • Delirious patients

    • Second gen agents preferred

    • If withdrawal from medications, benzos preferred

  • The truly undifferentiated patient

    • Benzos may be drug of choice if no delirium or psychosis evident

R2 CPC WITH DRS. MULLEN & HAM

Female in her 60s with a history of DM, pancreatitis, and alcohol abuse who presented with suicidal ideation. Endorsed drinking several beers earlier today and now has diffuse abdominal pain, and nausea without vomiting. Noted to be a poor historian and possibly altered on presentation.

T 33.2 / HR 85 / BP 96/64 / RR 16 / SpO2 100% RA

Appears uncomfortable and acutely intoxicated. Has dry mucous membranes and cold extremities. Abdomen was diffusely tender to palpation with voluntary guarding. Alert and moving all four extremities to command.

Labs notable for Cr 5, K 5.8, anion gap 41, lactic acid 10.2, beta-hydroxybuterate >9, pH 6.87/CO2 19/HCO3 4, alk phos 302/AST 544/ ALT 138, EKG with NSR, CXR nothing acute, CT head non-con negative, CT chest/abdomen/pelvis without any focal findings to explain presentation.

During ED course she is noted to have hypotension refractory to IVF at which point a central line was placed and vasopressors initiated. She was placed in a Bair hugger for hypothermia.

And then...a test was ordered…

Diagnostics summary: macrocytic anemia, renal failure, hyponatremia, hypocalcemia, mild transaminitis, profound anion gap metabolic acidosis, lactic acidosis.

Ethylene glycol

Ethylene glycol gets broken down into two toxic metabolites: glycolic acid and oxalic acid

Glycolic acid causes anion gap metabolic acidosis

Oxalic acid leads to calcium oxalate formation and renal tubular necrosis with hypocalcemia

Timeline of symptom onset:

  • 0-12 hours: predominantly neurologic symptoms - encephalopathy, altered mental status, ataxia

  • 12-36 hours: cardiopulmonary complications - hypotension, ARDS

  • 24-72 hours: renal failure

Diagnostics:

  • Anion gap metabolic acidosis

  • Elevated lactate

  • Toxic alcohol panel

Treatment:

  • Fomepizole works on alcohol dehydrogenase that prolongs time to production of toxic metabolites

  • Dialysis works to remove the parent compound and the toxic metabolites

    • Indications include pH <7.3, elevated methanol/ethylene glycol levels, etc.

ATTENDING CASE FOLLOW UP WITH DR. LAFOLLETTE

Middle-aged woman with PMH DM, HTN, HLD who presents as a stroke alert - loss of vision. She is altered, does not blink to threat, speaks in 1-2 word sentences, has no pronator drift and sensation is intact. Glucose 57 and receives D50.

EKG with noisy baseline, no obvious ischemia. CT head non-con, CTA head/neck without acute focal finding.

After she comes back from CT imaging, she has resolution of her symptoms. A little while later, she again has recurrence of symptoms that she had on presentation. 

Labs demonstrate leukocytosis 17, hyperkalemia 5.6, CO2 3, anion gap 39, BUN 70, Cr 9.01, glucose 48, troponin 26, INR 1.3, pH 6.6/pCO2 21, lactic acid 14, beta-hydroxybuterate elevated.

Metformin-associated lactic acidosis

  • Occurs in 4.3/100,000 patient years

  • Contraindications for metformin use in GFR <45 and those at risk for AKI

Metformin

  • Large volume of distribution

  • Reduces gluconeogenesis

  • Mitochondrial respiratory uncoupling

[Calello] Systematic review and recommendations from the extracorporeal treatments in poisoning workgroup - dialysis should be pursued early for metformin poisoning!

  • Lactate elevation can be severe without the same morbidity as other etiologies of severe elevation in lactate

  • Severe acidosis can cause profound vasoplegia and coagulopathy, both were seen in this case and underscores early recognition and treatment

  • Coagulopathy of acidosis - R, K, alpha, MA all significantly worsened when blood acidified (interestingly, these values are worse in matched trauma blood at the same pH)

  • A dirty bicarb drip can be given using 3 amps (150mEq) NaHCO3 in 1L D5W, along with push amps of bicarb as long as your are not developing a concomitant respiratory acidosis.

RURAL PEM WITH DR. RUNKLE

Case 1: You are called to the OR for a code blue during a c-section. The patient is an infant on the warmer, with cyanosis, no chest movement with PPV via T-piece resuscitator, and a heart rate of 56. The baby is limp, with slow, gasping respirations, and no spontaneous movement or cry. The delivery occurred 5 minutes ago. You do not have vascular access.

Neonatal resuscitation:

  • 10% of all newborns will require some resuscitation at birth, and 1% will require extensive resuscitation. Only 3/1,000 will require epinephrine for persistent bradycardia.

  • Your initial FiO2 for neonatal resuscitation should be set at 21% using the oxygen blender. Use of 100% oxygen is associated with increased mortality as well as increased rates of bronchopulmonary dysplasia and retinopathy of prematurity. Only increase the FiO2 to 100% if the patient has persistent bradycardia and you are placing an advanced airway or starting compressions.

  • Positive pressure ventilation can be delivered using a self-inflating bag, a flow-inflating bag, or a T-piece resuscitator. Many hospitals use a T-piece resuscitator (such as a Neopuff) as their standard PPV device. To adjust the PIP of the T-piece resuscitator, use the dial on the right side of the machine (this is universal across manufacturers). To adjust the PEEP, use the dial on the top of the T-piece resuscitator.

  • This is an excellent concise video review of how to set up and use a T-piece resuscitator.

  • A size 1 LMA is incredibly useful tool for neonatal resuscitation. It is safe to use in neonates as small as 1500 g (approximately 33 weeks gestation). It is recommended for use in neonates with large tongues (such as Trisomy 21) or small mandibles (Pierre Robin) or other facial abnormalities that would make endotracheal intubation difficult.

  • The preferred vascular access in a neonate is a UVC.

  • For a very thorough overview of the procedure, see the NEJM procedure video. An emergent UVC is demonstrated at the 11:27 min mark.

  • For a more EM focused overview, see the IU sim center review.

Case 2: You are at a solo coverage 6 bed ED when you get a call that 5 patients from a high-speed MVC will be arriving at your ED in 15 minutes. Your first patient is a 6-year-old male patient who presents with bradycardia, hypoxia, and diminished breath sounds on the left. After decompressing your left pneumothorax, your heart rate is 126 and your BP is 102/80. Your secondary survey reveals extensive facial and head trauma, a dilated and minimally responsive left pupil, shallow respirations, abdominal bruising and distension, and extensor posturing.

Pediatric Polytrauma:

  • When preparing for a pediatric trauma at a critical access hospital, use your Broselow tape for equipment sizes for ETT, chest tube, and medication doses (RSI, hypertonic saline). Check that you actually have the correct size pediatric equipment available in the ED – you may need to get equipment from other areas of the hospital (OR, L&D).

  • Your backup airway in a can’t intubate can’t ventilate situation in a 6-year-old is a needle cricothyrotomy.

  • If you have limited blood supply at your hospital and your patient has signs of hemorrhagic shock, consider TXA at a dose of 15 mg/kg to a max of 1g. CCHMC guidelines currently recommend no TXA if the patient has TBI, but TBI patients are being included in the current PECARN TIC-TOC study of TXA for pediatric trauma.

General Resources: