Morbidity and Mortality Pearls with Dr. Curry
Incidence in the US is 0.5-1% (lifetime risk 10-15%). There is a 2:1 male predominance and the recurrence rate is fairly high (37% at 1 year, 50% at 10 years and 75% at 20 years).
Patients at risk for poorer outcomes with ureterolithiasis are those with risk factors for diminished renal function, history of difficulty with stones/urologic intervention and symptoms of infection.
- UA is only up to 90% sensitive for nephrolithiasis (with 0 RBC cutoff on microscopy)
- Sensitivity increases with higher RBC threshold, but specificity decreases precipitously
Abdominal Plain Film (KUB)
- Moderately specific (82%) but poorly sensitive (69%) for nephrolithiasis.
- Moderately sensitive (88%) and moderately specific (85%) for hydronephrosis when compared to CT.
- Has the advantages of decreased cost, no radiation and improved patient progression.
- Disadvantages are that it doesn't give information about stone size or location, can be somewhat user dependent.
Ureteral stones up to 5 mm have a 68% spontaneous passage rate, whereas >5 mm this rate decreases to 47%.
American Urologic Association recommends that in selected patients who have stones <10 mm, no evidence of renal failure or infection, good symptom control and the availability of close outpatient follow up, a trial of medical expulsive therapy may be indicated.
Bacteremia in OHCA
According to a 2014 study in the journal Resuscitation, 38% of patients with OHCA presenting to a single center were noted to be bacteremic. (http://www.ncbi.nlm.nih.gov/pubmed/24128800)
There was no difference in 28-day mortality, though patients who were bacteremic were more likely to die in the ED than their nonbacteremic counterparts.
The most commonly isolated species were Streptococcus and Staphylococcus species.
In a different study in Resuscitation in 2013, they retrospectively evaluated the mortality of patients admitted to an ICU after OHCA depending on whether or not they received antibiotics. They postuled that post-ROSC syndrome and therapeutic hypothermia could easily mask symptoms of infection and that antibiotics could confer a survival benefit. All patients underwent therapeutic hypothermia. They report a statistically signficant improvement in survival at 30 days for patients who received antibiotics compared to those who did not. (http://www.ncbi.nlm.nih.gov/pubmed/23153650)
Bottom Line: Select patients with risk factors (immunosuppression/immunocompromise or chronic indwelling catheters) may warrant empiric antibiotics in the post-ROSC period if no other cause of arrest can be found. This area needs more research including prospective trials of empiric antibiotics.
Malignancy with SIRS
Don't think febrile neutropenia, the patients neither need to be febrile nor neutropenic to warrant empiric antibiotics. A better term (and the name of our internal protocol) is malignancy with SIRS.
UCMC Protocol: http://www.emergencykt.com/extern/Febrile%20Neutropenia.pdf
Goal time to antibiotic administration is <2 hours.
Start with empiric Gram negative coverage. Add Vancomycin if there is a clinical indication.
Clinical indications for the addition of Vancomycin
- Clinically apparent serious catheter related infection
- Blood culture positive for gram positive bacteremia
- Known colonization with PCN/Cephalosporin resistant pneumococci or MRSA
- Hypotension or septic shock
- Soft tissue infection
Post traumatic seizures (PTS) can be divided into early (<7 days) and late (>7 days).
Early PTS can be further delineated by immediate seizures which are defined either as seizure at the time of injury or within 24 hours. Early PTS is considered to be provoked, whereas late PTS is considered to be unprovoked.
Prophylactic AEDs are indicated for the prevention of early PTS in sTBI patients, though they have no proven effect on outcomes.
PTS is very rare in mild TBI. One study indicated the overall rate of seizures in mild TBI was the same as the baseline population without brain injury.
Procedural Complications/Sterile Cockpit
Maintain "sterile cockpit" procedures in even the most emergent cases by trying to minimize distractions as best you can.
New EAST guideline released this month: http://www.ncbi.nlm.nih.gov/pubmed/26091330
CPC with Drs. LaGasse and Bryant
Elderly female presents with tingling and progressive weakness over 5 days, legs >> arms
Differential diagnosis boiled down to Guillain-Barré Syndrome (GBS) vs Tick Paralysis vs Transverse Myelitis
Test of choice is lumbar puncture, diagnosis is GBS, indicated by cytoalbuminologic dissociation
GBS is thought to be immune mediated, often triggered by preceding infection (classically campylobacter)
Subtypes include demyelinating (N America & Europe) vs axonal
Management dictated by respiratory status, intubate for NIF < 20 cm water pressure
Treatment: plasma exchange (plex) or IVIG, performed within first 4 weeks of symptoms. Plex may work more rapidly
R4 Case follow up with Dr. Loftus
42 yo male with headache for 6 days that is bifrontal, fever and neck pain developed today
Classic triad of meningitis are fever, headache, and neck stiffness
Absence of all 3 signs of the classic triad of meningitis indicates 0-1% of meningitis, anything more than this may require a lumbar puncture
Kernig, Brud, Nuchal rigigity are individually 5-30% sensitive
Physical exam findings can increase suspicion of meningitis but can not exclude the diagnosis
Ultrasound guidance may increase success rate of LP in obese patient
Bacterial Meningitis Score of zero may allow us to predict pediatric patients that are appropriate for discharge with presumed viral meningitis
The Neurologic exam with Dr. Zammit
We must distinguish level of consciousness (arousal) vs content of consciousness (awareness)
Arousal is related to RAS or a global cerebral process, thus patients can be aware but not arousable, the classic example is "locked in syndrome"
Neurological Exam Pearls
- Mental status: Orientation, Attention, Front Lobe Signs
- Describe patient's mental status instead of assigning a broad label. Abulia: frontal lobe injury leads to preserved LOC but diminished motivation
- Gaze deviation:typically taught that gaze towards hemiplegia results from seizure and gaze towards unaffected side = ischemic stroke. The exception is a pontine stroke in which the gaze may be to the weak side
- Forced downgaze: dorsal midbrain compression
- Uncal herniation results in classic unilateral dilated pupil
- Central hernitation can result in direct brainstem ischemic 2/2 torsion
- Tonsillar herniation can result in isocoria
Dysarthria: difficulty annunciating
Aphasia: deficits in understanding or expressing language
Pronator Drift: it can be subtle and manifested by finger spread, then curl, then pronation
Neglect/Inattention: evaluate confused patients from both sides to eval for inattentiveness
UMN/LMN: UMN hyperreflexic, LMN hyporeflexic. Clonus in UMN.
Coordination/Cerebellar Exam: FTN go all the way to patient's arm length. Eval for both appendicular and truncal ataxia. ALWAYS walk your patients
Romberg: Tests cerebellum and proprioception
Asterixis: sign of encephalopathy- not specific to hyperammonemia
Tremor: Consider NCSE with subtle rhythmic movements
Vertigo: Clinical features can indicate peripheral vs. central vertigo. Peripheral usually has more nausea and vomiting. Central vertigo usually has more difficulty with ambulation. Peripheral vertigo should fatigue.
HINTS Exam: "Verified" in a single center study with all exams performed by a single neuro-ophthalmologist. This is not verified for your average practitioner and cannot dependably rule out acute ischemic stroke.