Morbidity and Mortality - R4 Capstone: New Parent Fears / Peds Cases - R1 Clinical Diagnostics: Ocular US - CPC: Retroviral Syndrome

Morbidity and mortality WITH Dr. ham

Ovarian Torsion

Ovarian torsion represents 3% of gynecologic emergencies and is most common in reproductive years. Slight predilection in the R ovary and associated with cysts >5cm. Classic presentation includes sharp, sudden, unilateral pain that can waxing and waning, but in reality only 50% will present with sudden onset. 70% present with nausea and vomiting as well as sharp pain. Overall physical exam is very unreliable.

Imaging choices:

US is much better at detailing the characteristics of the cyst itself, however 60% of surgically proven torsion will have documented blood flow.
CT is a reasonable place to start when presentation is atypical or differential is broad. Retrospective studies of patients with torsion found that every single one had some abnormality noted of the ovary. So while negative CTs cannot rule out torsion, if the ovaries are normal it is very unlikely.

Pearls from gynecology:

Cysts <5cm are at low risk for torsion. With cysts >5cm, recommend talking to gyn if features fit for torsion.
Dermoid cysts have a higher chance of torsion given the high concentration of adipose tissue and therefore more buoyant.
Laterality can be deceptive as a cystic ovary can migrate from one side of the pelvis to the other.

Dural Venous Sinus Thrombosis

Very difficult diagnosis to make due to heterogeneity of clot size and acuity of formation, which produces differences in symptoms reported. 90% of patients tend to make full recovery with diagnosis. Risk factors include female, age 30-40s, inherited or acquired thrombophilia.

Common Presentations

Headache, focal neurologic deficits, seizures, changes in mental status, hemorrhagic infarctions, cranial nerve deficits if cavernous sinus is involved

Imaging

A few CT scan findings can suggest presence of DVST:
- Hyperdensity of thrombosed sinus or deep vein
- Infarction or hemorrhage in a non-arterial location
CTV has comparable sensitivity to MRV if done with a multi-detector scanner (approaches 100% sensitivity). Note that MRI/MRV are still gold standard, but CTV is often easier to obtain with similar testing characteristics

DVST and SAH

Most sources agree that SAH is a rare presentation of DVST at only 3-10% of an already rare diagnosis and physiology not well understood. Certain features should clue you towards further workup which include 1) SAH doesn’t involve the basal cisterns 2) when you have a patient with typical risk factors and demographics.

Acute Fulminant Liver Failure

Rare diagnosis that affects about 2000 people a year, however mortality is about 45% without transplant. Most common causes are acetaminophen ingestion (46%), viral causes and hypoperfusion (shock liver).

Management

Support: intubation if patient is in respiratory distress which can occur secondary to ascites, be judicious with fluids, pressors (norepinephrine), hydrocortisone for refractory hypotension, hypertonic saline for stupor thought to be related to cerebral edema, treat coagulopathy especially if ICH present. Coagulopathy and refractory hypoglycemia should be considered and corrected as needed.
Treat the underlying cause: Examples include a) NAC for tylenol toxicity b) carnitine for valproic acid toxicity c) acyclovir for for HSV and d) penicillin G for amanita
Managing complications: mostly managed by colleagues in the ICU, however consider transferring to a transplant capable institution

chronic acetaminophen ingestion

Toxic dose is 7.5-10mg in normal adults, but 4-6mg in patients with chronic liver disease. Key differences between acute vs chronic ingestions:

Any ingestion that isn’t a single, acute ingestion
Rumack nomogram can’t help when deciding NAC treatment
Give NAC if tylenol level is detected or if AST is elevated

Basilar Stroke

Physical exam findings for posterior stroke include:

Unilateral weakness (38%)
Gait Ataxia (31%)
Unilateral limb ataxia (30%)
Dysarthria (28%)
Nystagmus (24%)

However, it can be difficult to perform neuro exam on an obtunded patient, especially if needing to address airway. It is important to at least perform a “crash” neuro exam which may include:

looking for nystagmus (24%)
oculomotor deficit including dysconjugate gaze or vertical skew (22%)
positive babinski (24%)

Also important to consider ordering CTA for evaluation of posterior stroke if on your exam there appears to be something wrong with the brainstem.

Medical Errors and Safe Discharges

A prospective cohort study at a tertiary emergency department looked at incidence of errors and it was found that almost half of errors occurred in return admits within 72 hours, meaning patients that were discharged.

Factors contributing to failed discharges include (those bolded being the most common):

uninsured, homelessness, low income, lack of PCP, poor health literacy, race or ethnicity, EtOH or drugs, psychiatric illnesses, physical/cognitive impairment, multiple chief complaints, advanced or young age, male

Consider a discharge just like a procedure in terms of checklist in your mind:

Assess barriers
Review labs and vitals
Relevant parties present
Review visit, plan, return precautions
Assess patient understanding
Summarize in your note

Valacyclovir Toxicity

Patients with renal disease can't eliminate acyclovir. Half life increases from 2-3 hours up to 14 hours in ESRD. This leads to dose stacking and accumulation. Presentation includes:

delirium
myoclonus
seizures
death delusion also known as Cotard syndrome

R4 Capstone: Lessons from a Dad in the ED WITH dr. harty

Case 1: Fussy Infant

Differential for a fussy infant includes IT CRIES:

I - Infections (UTI, meningitis, sepsis)
T - Trauma (subdural hemorrhage, NAT, fractures)
C - Cardiac disease (SVT)
R - Reaction to meds, reflux, rectal/anal fissure
I - Intussusception
E - Eyes (corneal abrasion, foreign body, glaucoma)
S - Strangulation or surgical process (testicular/ovarian torsion, hernia)

One study showed that of all presenting crying infants about 5% had serious underlying pathology. A thorough H&P is usually all you need, however recommend sending UA and urine culture if in first months of life.

However it is important to counsel these parents extensively as crying can lead to NAT. Can start with the 5 S’s (swaddling, sucking, swinging, stomach positioning while awake, shushing).

Case 2: Bronchiolitis

Management:

Nasal suction: BBG or bulb suction in hospital; recommend Nose Frieda for home
Rehydration: evaluate hydration status as bronchiolitis can lead to decreased intake and increase in insensible losses
Supplemental O2: recommend adding oxygen if sats less than 90-92%, most often with a NC. HFNC is currently very controversial and data is mixed.
Albuterol?: Some will trial, although not currently recommended for the treatment of bronchiolitis

Case 3: Aspirated Foreign Body

Possible locations of foreign body include 1) laryngotracheal (most concerning due to possible complete occlusion of the airway) 2) large bronchi 3) lower airways. Two potential algorithms depending on patient presentation:

Algorithm 1: evidence of total or near total airway obstruction
- cannot speak or cough, cyanosis, severe respiratory distress
- Try back slap or use McGills to pull out FB if back slap not working
- If patient greater than 12, perform cricothyrotomy. If less than 12, perform needle cric.
- Still need to watch for post obstructive pulmonary edema
Algorithm 2: asymptomatic or symptomatic but stable
- Obtain plain film: CXR usually only sees FB about 10% of time, but there can be secondary findings such as hyperinflated lung; sensitivity also increases with inspiratory and expiratory films
- ENT consult for rigid bronchoscopy to remove FB

R1 Clinical diagnostics: ocular US WITH Dr. ramsey and Dr. Gauger

For a primer - see Dr. Ramsey’s post on Ocular US

Eye complaints equate to 3% of overall ED visits. Most common ICD-10 diagnoses are conjunctivitis, corneal injury, foreign body, eye pain. Most common admitted diagnoses are orbital fractures, visual disturbance, open globe, retinal disorders.

Indications for ocular US include:

Vision Loss: retinal detachment, vitreous detachment, vitreous hemorrhage, central retinal artery occlusion, acute angle closure glaucoma
Trauma: foreign body, lens dislocation
Headache: optic nerve sheath diameter

*Important to note that ocular US is currently contraindicated if concerned for open globe.

Technique includes using the high linear probe, the ocular setting on the US, tegaderm over the eye is an option, copious gel, use caution with gain and findings can become more apparent when asking patient to move their eye.

It is also important to distinguish etiologies of painful vs painless causes of loss of vision:

Painless: retinal detachment, vitreous hemorrhage, posterior vitreous detachment, CRAO/CRVO, CVA/TIA, mass
Painful: acute angle closure glaucoma, traumatic lens dislocation, foreign body, optic neuritis, giant cell arteritis, retrobulbar hemorrhage, corneal abrasion, chemical injury, endophthalmitis

Case 1: Acute Angle Closure Glaucoma

Although typically diagnosed by tonometry, if unavailable can use US as seen in a case report where they measured the anterior chamber (normally 2-3 mm) and if less can suggest diagnosis. Important to note that there is not a robust amount of data to support US diagnosis at this time.

Case 2: Retinal Detachment

Risk factors: age > 50, family history, previous retinal detachment, extreme nearsightedness, pervious eye surgery or eye injury
About 97% sensitive to diagnose on US
The retina appears as a thick and hyperechoic wiggly line.

Case 3: Vitreous Hemorrhage

Most commonly due to diabetic retinopathy
Globular echogenic material, often more subtle than retinal detachment with “washing machine” appearance

Case 4: CRAO

Central retinal artery runs parallel to optic nerve
Plaque embolism can show up as a hyper echoic dot on US
Can also apply color flow and will raise concern if no arterial flow is seen

Case 5: Idiopathic Intracranial Hypertension

Should measure optic nerve sheath diameter 3mm down from posterior end of globe.
If diameter >5mm, this is considered abnormal and should suspect ICP elevation.

Case 6: Lens Dislocation

Hyperchoic appearance of lens in the posterior chamber
Often seen in the setting of trauma and may see with other abnormalities such as vitreous hemorrhage

CPC WITH DR. Connelly and Dr. Adan

Acute Retroviral Syndrome

Time Course

Usually takes about 1-2 weeks before viral RNA can be detected
Symptomatic illness typically occurs before peak viremia.
- Usually 2-4 weeks after exposure and 1-2 weeks before RNA can be detected
Symptoms typically last 2-4 weeks

Presentation

About 75% will present with fever
Fatigue occurs in approximately 66%
40-50% will have myalgias, rash, headache, pharyngitis, adenopathy
25-30% will have GI symptoms (most often diarrhea), night sweats, arthralgia
Should consider the diagnosis of HIV if: 1) symptoms > 2 weeks, 2) presence of mucocutaneous ulcers

Testing and diagnosis

Labs may show: leukopenia, mild anemia, thrombocytopenia, transaminitis
RNA quantitative will be positive around day 10-11. Antigen positive around day 14 and antibody positive around day 21.
Will start testing with HIV Ag/Ab immunoassay. If positive, will then test antibody differentiation immunoassay.

Mangement

Goals of antiretroviral therapy (ART) include:
- Maximally suppress plasma HIV RNA
- Restore and preserve immune function
- Reduce HIV related mortality
- Improve quality and duration of survival
- Prevent transmission to others

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