Grand Rounds Summary 3/9/2016

Back Pain with Dr. Summers

Of the more than 2.5 million ED cases of back pain every year, roughly 5% of these actually have an emergent cause. Conventional red flags include:

  • Age >50 or <20 yo
  • History of cancer
  • Immunocompromised
  • HIV
  • Steroid use
  • IV Drug Use
  • Known aortic aneurysm
  • Motor neurologic deficit
  • Urinary retention, bowel incontinence, or saddle anesthesia

Any time we suspect an emergent cause of back pain, an MRI of the ENTIRE spine is indicated. Even when it seems that pain and neurologic lesions can be localized to a certain region of the spine, multiple pathologies (including cancer and epidural abscess) can present with multifocal or skip lesions which may be missed with limited imaging.

Quick rules for imaging of 3 of the most common emergent pathologies:

Spinal Cancer --> MRI timeframe depends on

Evidence of neuro compromise:

  • MRI immediately or up to 24 hours (depending on timeline and progression)
  • IV steroids (e.g. Dexamethasone 10mg)
  • Consult spine surgeon and oncology

No evidence of neuro compromise:

  • May delay MRI up to 2-3 days
  • No IV steroids
  • Consult spine surgeon and oncology once imaging returns

Osteomyelitis --> MRI as soon as possible

Neuro symptoms OR MRI evidence of compression OR patient is septic

  • Broad spectrum antibiotics (Vanc + Cefepime/Ceftriaxone)
  • Consult spine surgeon

No neurologic symptoms, no compression, not septic:

  • Withhold antibiotics
  • Send for CT guided biopsy
  • Consult spine surgeon

Spinal Epidural Abscess --> MRI as soon as possible

Evidence of abscess:

  • Broad spectrum antibiotics (Vanc + Cefepime/Ceftriaxone)
  • Consult spine surgeon

R4 Capstone with Dr. Nelson

Talking to Serious Ill Patients

  • Determining what is valuable to a patient is often the most important communication task
  • Offer recommendations for care based on the patient's values
  • Help patients build a big picture rather than focusing on specific medical interventions
  • Acknowledge emotion without trying to "fix" it
  • Having families focus on a patient's wishes lifts their feelings of guilt or responsibility about making difficult decisions
  • Acknowledgement is a process. If the patient has not acknowledged the possibility of death, then it's unlikely that they will consider not performing "life saving" treatment like CPR
  • Allow patients to make their own decisions, even if these differ from your recommendations

Airway Update with Dr. Carleton

Hypoxemia: The most common adverse event during intubation.

Mitigating this risk requires pre-oxygenation- the focus of which is to prolong the safe apnea time, which is classically taught to be performed by 3-5 minutes of tidal breathing of hi FiO2.

Apneic oxygenation maintains PaO2 by passive diffusion, despite no active ventilation and this is accomplished by nasal cannula, 5-15 L/m.

Inspiratory flow rate is normally 24-30 L/m, and up to 60-100 L/m, which exceeds the flow rate generated by NC, thus significant room air is inspired

A Venturi mask, or even a (nonrebreather) NRB mask (Hudson mask) are still low flow devices, but  using a high flow regulator with a standard NRB mask is possible

Other options for pre-oxygenation include:

  • Non-invasive Positive Pressure (NIPPV) pre-oxygenation: ePAP provided PEEP and stents open small airways and alveoli, while iPAP provides pressure support improving ventilation
  • High flow Nasal Cannula (HFNC)- delivers up to 70 L/m. We currently carry OptiFlo, this can improve nitrogen and CO2 washout while generating low levels of PEEP

Lung Ultrasound with Dr. Continenza

Ultrasound is more sensitive than supine CXR for pulmonary effusion and pneumothorax.

Position the patient supine and look at the midclavicular line for PNX (air goes up), start in the RUQ/LUQ fast views and look cephalad to the diaphragm for effusion.

There are 3 things to look for when evaluating for a pneumothorax

  1. Lung sliding - negative for PNX
  2. Comet tails or B lines - negative for PNX
  3. Lung point -positive for PNX

A-lines are a horizontal artifact - they signify aerated lung

B-lines are vertical artifacts that originate at the pleural line and run to the bottom of the screen. They signify interstitial fluid. The number of B -lines correlates with the degree of interstitial fluid. Plural irregularities, subpleural consolidations, skip lesions, and reduced/absent lung sliding can be signs that the interstitial edema is from a process other than acute heart failure such as ARDS, multifocal PNA, or pulmonary fibrosis.

> 3 B lines in multiple rib spaces (at least 1 on each side, better study if looking in all 8 locations) can be a useful tool in diagnosis of AHF.

Ultrasound is a great tool but always look at the full clinical picture when making medical decisions. 

Vertigo with Dr. Adeoye

The physical exam matters.

2-4% of the 2.6 million annual ED visits for dizziness are actually attributable to stroke.

Vast majority of dizziness if from benign causes: vestibular neuritis, benign paroxysmal positional vertigo (BPPV), Meniere's disease, vestibular migraine

Nystagmus: the fast component is the correction. Nystagmus in vestibular neuritis should be on lateral gaze and unidirectional

Head Impulse Test (HIT) can be used to assist the physical exam

In BPPV, vertigo typically lasts < 1 minute. It is caused by debris in the semicircular canal and typically it is initially triggered by movement. The Dix-Hallpike test is 75% sensitive & specific.

Meniere's: HIT is normal and nystagmus doesn't follow specific pattern. No definitive diagnosis, and difficult to diagnose out of ED given overlap with in presentation with central causes of vertigo.

A negative head CT can not rule out a central cause, all vertigo is worse with movement, BPPV is triggered by movement. 

Head Impulse Nystagmus test of Skew (HINTS) Exam:

  • Skew is a result of right/left imbalance in vestibular tone and is concerning for posterior fossa pathology
  • No skew with +HIT makes vestibular neuritis more likely
  • +skem with negative HIT is indeterminate and a central cause must continue to be considered

Pediatric Emergency Medicine Simulation: Pediatric SVT

Supraventricular tachycardia presents a difficult diagnostic challenge in children, and can often mimic serious infection.

Depending upon the conduction pathway, the presence of p-waves, or a temporary response to fluid therapy, may not reliably differentiate between a physiologic or pathologic tachycardia.

A past medical history of Wolff-Parkinson-White presenting with wide-complex tachycardia is a contraindication to adenosine therapy.

Likely avoid the use of verapamil, or at least consider pediatric given potential adverse myocardial events in infants and young children.

Consider expert pediatric cardiology consultation in a stable patient for whom the maximum recommended dose of adenosine 0.2mg/kg is ineffective. Use of a long-acting medication, such as amiodarone, prior to Cardiology involvement can make their subsequent evaluation and management more difficult.

Electric cardioversion is recommended in unstable patients, or in those recalcitrant to medical therapy. Anecdotally, midazolam (Versed) is the premedication of choice in children for its anxiolytic and amnestic characteristics prior to cardioversion.