Grand Rounds Recap 4.19.23
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CPC WITH Dr. Davis and Dr. Paulsen
Patient is a teenager with a history of a seizure disorder…
The patient is presenting for concerns of a midline neck mass that is 2-3cm that is tender to palpation and mobile with swallowing
Noted to have a positive strep test, Leukocytosis to 18, and a normal TSH
Evaluation and thought process for Neck Masses
Sick or not sick? Respiratory distress?
Age?
Adults > 35
80% of non-thyroid masses are neoplastic
80% are malignant
Children
90% benign
55% congenital
Any infectious symptoms?
Any infectious symptoms? Present for < 2 weeks?
Treat with antibiotics, watch, and wait
Any constitutional symptoms? Present for > 2 weeks?
Work up for malignancy
Anterior or posterior?
Anterior
Tender
Lymphadenitis
Sialadenitis
Ludwig’s angina
Nontender
Dermoid
Branchial cleft cyst
Thyroglossal duct cyst
Malignancy
Midline or lateral?
Midline
Ludwig’s angina
Dermoid cyst
Thyroglossal duct cyst
Thyroid mass
Thyroid goiter
Lateral
Sialadenitis
Branchial cleft cyst
Kawasaki’s
Lymphoma
Diagnosis: Thyroglossal Duct cyst with a superimposed strep throat infection without typical symptoms of pharyngitis
Test of choice: Ultrasound
Thyroglossal Duct cyst
Most common pediatric cervical congenital anomaly
Most common pediatric midline neck mass
Occur anywhere in the anterior midline neck
Often asymptomatic, develop symptoms with an infectious trigger
Taming the SRU: ETHYLENE GLycol POISONING WITH Dr. KletseL
The case
Middle age male was found in a shower unresponsive. EMS was bagging him on arrival
Primary notable for Compromised Airway Protection, bilateral Breath sounds, strong pulses,GCS 3
CT images of Head, Chest, Abdomen, Pelvis, and Spine
No acute findings
pH of 6.75 with a lactate > 31
Anion gap of 35
Further history noted that the patient was found down at the car dealership he was working at and likely drank some ethylene glycol
Ethylene glycol toxicity
The molecule of ethylene glycol itself is not toxic, but it is metabolized to glycolic acid and then oxalic acid
Glycolic acid is the toxic metabolite
Metabolic acidosis
End organ damage
Oxalic acid can bind to Ca2+
Calcium oxalate crystals in tissues/urine
Hypocalcemia
Stages of ingestion
1st Stage “neurologic stage”
Due to ethylene glycol
CNS depression
Seizure
Coma
Abd pain, nausea, vomiting
2nd Stage “cardiopulmonary stage”
Due to glycolic acid
Tachypnea
Multi-organ failure
Myocardial dysfunction
ARDS
3rd Stage “renal stage”
Due to oxalic acid
Renal failure
Hypocalcemia
Diagnosis
Osmolar Gap
Osm Gap = Osm meas – Osm calc
Gap >10-15mOsm/kg
Due to ethylene gylcol
Poor sensitivity
The gap is due to the parent molecule
Peaks in 30-60 mins
Wide range of normal gap values
Gap >10-15mOsm/kg H2O is concerning
Ethylene glycol >20mg/dL only adds 3mOsm/L to the gap
Poor specificity
Other causes of the osmolar gap
Ketoacidosis, sepsis, shock
Ethanol
Urine Crystals
Calcium oxalate crystals on UA
Seen in half of patients
Tips and tricks
Portable blood gas machines will mistake glycolate for lactate, giving a false elevation
Lab assays actually use lactate dehydrogenase, therefore measuring actual lactate
Treatment
Metabolic Blockade
Indications
Strong suspicion of ingestion
Serum ethylene glycol level >20mg/dL
Fomepizole
Ethanol
Correct Acidosis
Sodium bicarb
Maintain pH >7.3
Decreases penetration into tissue
Increases excretion in urine
Hemodialysis
Role
Clears ethylene glycol
Clears toxic metabolites
Indications
Acidosis
Electrolytes
Ingestion
Overload
Uremia
Vitamin therapy
Helps with the clearance of toxic metabolites
Thiamine
Pyridoxine
R1 CLinical DIAGNOSTICS: Toxic Plants WITH Dr. Arnold
General info
The majority of cases are pediatric
Also, cases of recreational use, alternative medicines, self-harm
Dermatitis and GI upset are the most commonly reported effects of plant toxicity
Moderate systemic effects of plant toxicity account for approximately 1% of reported toxicity, severe and life-threatening poisonings are much less common (0.04%)
Skin Irritants
Mechanical
Needles, nettles
Calcium oxalate crystal bundles
Causes dermal injury where the skin is already punctured
Plants: Dieffenbachia, Philodendron
Irritant
Phorbol esters
Contact dermatitis
Plants: Euphorbiaceae
Proteolytic enzymes
Pro-inflammatory compounds
Allergic Contact Dermatitis
Urushiol
Resin-bound to proteins on the surface of the skin is recognized as an antigen. Subsequent exposure results in a T-cell mediated response (Type IV hypersensitivity reaction)
Plants: Toxicodendron species (poison ivy, poison oak, poison sumac)
Also present in foods, including pistachio, cashew, and mango. In some individuals, the urushiol can result in anaphylaxis (Type I hypersensitivity reaction)
Treatment
Soothing measures
Oral antihistamines
Topical corticosteroids
Nicotinic toxins
Mechanism: Over-stimulates nicotinic receptors
Acts as an agonist at nicotinic acetylcholine receptors in the sympathetic and parasympathetic nervous systems, as well as neuromuscular junction of skeletal muscle
Nicotinic acetylcholine receptors are named as such because nicotine and nicotine-like compounds bind to them
At low doses, receptors are stimulated
At higher doses or more sustained exposures, inhibitory effects predominate
Example: Hemlock
Presentation
Mild: anxiety, tremor
Moderate to severe: sympathetic findings, parasympathetic findings, paralysis
Treatment
Decontamination
Supportive care
Cardiotoxins
Mechanism: Inhibits myocardial Na+/K+ ATPase (sound familiar?)
Examples
Foxglove
Oleander
Lily of the valley
Presentation
GI symptoms
Visual disturbances
Hyperkalemia
Arrhythmia
Treatment
DigiFab (if arrhythmia and/or K+ > 5 is present)
Supportive care
a Digoxin level may be useful if you are considering this as a plant toxicity, as long as the patient isn’t on Digoxin therapy to begin with. Poisoned patients will have a Digoxin level, but it is not at all quantitative like it is when dealing with an actual Digoxin overdose.
Belladona alkaloids
Mechanism: Inhibits the action of acetylcholine at receptors
Toxicity
Anticholinergic toxidrome:
Tachycardia
Hyperthermia
Mydriasis
Anhidrosis
Altered mental status
Urinary retention
Physostigmine is generally reserved for moderate-to-severe case
Works by increasing the concentration of acetylcholine present in the synapses, which can help overcome some of the antagonism to relieve symptoms
benzodiazepines for agitation on an as-needed basis,
anti-psychotics have anticholinergic side effects, so they should be avoided in these patients.
Nightshade: Atropa belladonna
Historical tidbit: Belladonna translates to “beautiful woman” in Italian. The juice from the berries of the plant were used to make eyedrops, which Renaissance women used to dilate their pupils for cosmetic purposes.
Jimson weed: devil’s snare, devil’s trumpet
Quick Hit: FASCICULAR Blocks WITH Dr. Baez
Fasicular Blocks
Left Anterior Fasicular Block
rS pattern inferior leads and qR complex in leads I and aVL
QRS generally negative in the inferior leads and positive in I and aVL
Left axis deviation
Left Posterior
qR Pattern in the inferior leads with rS in the lateral leads
Right axis deviation
If 2 fascicles are blocked
Avoid nodal blockers
If 3 Fasicles are “blocked”
PR prolongation with a fascicular block
These patients need to be seen by cardiology and are at high risk for complete heart block
Research Lit Blitz WITH Dr. Wosiski-Kuhn and Dr. Zalesky
Theraputics
Risk for Recurrent Venous Thromboembolism and Bleeding With Apixaban Compared With Rivaroxaban: An Analysis of Real-World Data
Bottom Line: Apixaban was shown to have fewer bleeding events and fewer re-occurrences of VTE in patients being treated for a new VTE.
A retrospective evaluation of phenobarbital versus benzodiazepines for the treatment of alcohol withdrawal in a regional Canadian emergency department
Bottom Line: This study in a small regional ED showed a QI project rolling out a Phenobarbital or Diazepam for Alchohol withdrawal syndrome. This study showed patients managed safely in the ED with Phenobarbital, and a large portion of these were discharged home.
Prospective real-time evaluation of the QTc interval variation after low-dose droperidol among emergency department patients
Bottom Line: Using Droperidol in doses of 2.5mg or less caused a mean change in QTC of 29.9ms. No episodes of TdP or arrhythmia occurred.
Neurology
PECARN algorithms for minor head trauma: Risk stratification estimates from a prospective PREDICT cohort study
This study confirmed that the probabilities of disease are consistent in their validation cohort when compared to the initial study population. Risk of TBI increases as the number of factors present increases.
Imaging Characteristics and CT Sensitivity for pyogenic spinal infections
Bottom Line: CT scans of the lumbar spine have a less than 20% sensitivity for Spinal epidural abscess and a 50% sensitivity for any Pyogenic spinal infection (osteo/discitis, septic facet joint, SEA, or Paravertebral abscess). Only 18% of SEA were isolated infections most had at least one other kind of Pyogenic spinal infection also present.
Head computed tomography findings in geriatric emergency department patients with delirium, altered mental status, and confusion: A systematic review
Bottom Line: Amongst geriatric ED patients presenting with AMS ~16% were noted to have a CT with Ischemia, Hemmorage, mass or finding to explain their AMS. Focal Neurologic deficits on exam had an OR of 101.8 for having a positive Head CT. Being on anticoagulation did not increase the odds of a positive head CT.
Use of Computed Tomography of the Head in Patients With Acute Atraumatic Altered Mental Status: A Systematic Review and Meta-analysis
Bottom Line: Amongst patients presenting with atraumatic AMS a high proportion of all care settings utilize head CTs in the patients’ evaluation. In the ED 17% of these studies were noted to be “positive” but the meaning of positive in this review was not known.
Trauma/Pre-Hosp
Optimal Out-of-Hospital Blood Pressure in Major Traumatic Brain Injury: A Challenge to the Current Understanding of Hypotension
Bottom Line: Think about maintaining normotension rather than simply avoiding hypotension in isolated TBI. This observational study showed that a pre-hospital SBP of 130-180mmHg conferred a lower probability of death, decreased hospital LOS, decreased ICU LOS, decreased need for IPR at discharge, and decreased total hospital cost.
MSK
Up in Flames: The Safety of Electrocautery Trephination of Subungual Hematomas with Acrylic Nails
Bottom Lint: Dont use electrocautery on acrylic nails as they can combust.
Higher sensitivity with the lever sign test for diagnosis of anterior cruciate ligament rupture in the emergency department
The lever test outperformed all other tests of ACL integrity in the ED, having the best sensitivity (92.5) and NPV(50%).
Cardiology
Higher intensity of 72-h noninvasive cardiac test referral does not improve short-term outcomes among emergency department patients with chest pain
Patients who presented to the ED for Chest pain and were discharged had similar outcomes despite being cared for by physicians with different referral patterns for outpatient stress testing. A higher intensity of Outpatient stress tests from the ED did not improve MACE at 60 days.
Anteroposterior Pacer Pad Position Is More Likely to Capture Than Anterolateral for Transcutaneous Cardiac Pacing
Bottom Line: The Anterior-posterior pad position is more effective for transcutaneous pacing at a lower pacing threshold (~95mA) when compared to an Anterior-lateral placement (~125mA)
Oral Boards
Brugada syndrome
This is a sodium channelopathy within the cardiac myocytes. This can predispose patients to fatal arrhythmias.
Patients must have EKG findings and meet one of a few other criteria (ie family history of sudden death, VF or VT episode, syncope, nocturnal agonal respirations)
Most common in patients of Southeast Asian descent and the mean age of death from arrhythmia if untreated is in the 4th decade of life.
Exertional Hyperthermia
Patients with heat stroke will present with Temp > 104, AMS, or seizures.
Need a high index of suspicion in the right patient population
Confirm Temperatur with Core temp (likely rectal)
Check GLucose and Monitor for significant electrolyte derangements
Anticipate Rhabdo
Evaporative cooling and cooled fluids can be used to rapidly change drop core temperature
Ice bath Immersion is the most effective way but logistically difficult
