A simple cellulitis of the foot?

a simple cellulitis of the foot?

Case Introduction

A 47 year old woman comes to a community ED complaining of pain and redness in her right foot developing quickly over two days. She denies any trauma and otherwise feels well. She is not sure, but may have had a “sore” near her toes that has already healed. Patient has diabetes but is normoglycemic. She has no prior history of cellulitis, joint infections or gout. There is no history of immunocompromise, including steroids, or any IV drug use. All vitals are within normal limits and review of systems is negative for fever, chills, respiratory or gastrointestinal symptoms.

On exam, there is generalized edema, erythema and tenderness, but no tenderness out of proportion, and no open sores or ulcerations. A sub-acute appearing callus is apparent on the plantar surface opposite fifth and fourth distal metatarsals. The ankle joint is tender but less so than the foot, and ranging it does not elicit more pain than at baseline. Distal sensation, pulses and toe motion are intact, though capillary refill is slightly delayed.

cellulitis - foot
cellulitis - foot 2

Initial Questions

  • What would be your plan?  And when and how would you present this case to an attending?
  • Are labs indicated, which ones, and what are they expected to show?  Will that change your plan?
  • Any imaging? Your choices range from nothing, to bedside US to look for an abscess, to XR, CT scan or even an MRI, if available.
  • Is she a candidate for oral antibiotics and discharge? If so, what sort of follow up does she need?
  • Is there any benefit of IV antibiotics if the patient is going to go home?
  • What is the worst case scenario here that may not be apparent? Is there any threat to life, limb or both?

Basic labs obtained are unremarkable and patient is receiving IV broad spectrum antibiotics, including MRSA coverage. Plain films are obtained, and there is some concern for small air pockets in the soft tissues.

cellulitis - xray 2
cellulitis - xray

A phone consultation with podiatry is obtained. A decision is made to take the patient to the OR on the same evening. No further imaging or diagnostic studies are advised.

Additional Questions

  • What if there is no podiatry, and your general or orthopedic surgeon does not handle foot cases? What if there is no surgical coverage at all?
  • Would there be a role for a limited ED I&D or needle aspiration in this case?
  • Would you transfer this case? How do you justify it, if all the labs and vitals are normal?

After the callus is taken off in the OR, large amount of frank pus is obtained that tracks all the way to the third metatarsal. A debridement is performed, and long term antibiotics with close follow up are needed. Overall impression was that while no necrotizing infection was found, any further delay would have risked a trans-metatarsal amputation (at the least).

Key Points

While we do not have room for a lengthy discussion on differentiating plain cellulitis from “other”, it is worthwhile to note several things:

  • Do not get locked in onto cellulitis as the diagnosis. Abscesses, necrotizing infections and septic joints need to be considered and ruled out at all times.
  • Susceptible populations such as diabetics and IV drug users are easy.  But the rapidity of symptom development is just as important in any population.
  • Beware even chronic appearing calluses as masking places for pus and as barriers to its natural drainage.
  • More advanced imaging is not always the answer. Careful exam, plain films and the OR is often the right answer too. Labs are overrated. Period.
  • More advanced imaging is not always the answer. Careful exam, plain films and the OR is often the right answer too. Labs are overrated. Period.
  • To I&D or not to I&D is often the question. Good news is that more often than not I&D is the right answer. There is a reason you have already thought of it. You are in the ED - the last line of defense for many patients. Pus needs to come out. The surgeons are not the only guys with knives. Don’t let yourself or anyone talk you out of it. For the tremulous patients (and providers), there is ketamine.
Cite this article as: Anthony Rodigin, USA, "A simple cellulitis of the foot?," in International Emergency Medicine Education Project, February 7, 2020, https://iem-student.org/2020/02/07/educational-case-a-simple-cellulitis-of-the-foot/, date accessed: March 29, 2020

Further Reading

Sickle Cell, Pain and the Emergency Department

Sickle Cell Disease

It’s 2 AM, and the Pediatric Emergency Department (ED) at a community  hospital in New York is overflowing with children and caregivers. A young Nigerian boy is being transported down the center of a hallway, past a long line of doors to patient rooms. The porter is calm and walks briskly, determined to bring this boy to get immediate care. The boy winces, his hands outstretched next to him, rigid, and frozen in space, and while he is seated in the wheelchair, his legs bent at the knees are thin frames, held in place with his feet planted on the wheelchair pedestals. He is afraid to move any of his extremities; tears are rolling down his face; he is fighting the urge to grimace and furrow his brow. He cries how much it hurts to move. He knows he needs help.  Behind him, his mother follows close holding a one-year-old baby in her arms, and behind her, five other young children aged 3 through to thirteen stream in. There is quiet concern on all of their faces. The older siblings have seen this before. We learn that he has Sickle Cell Disease (SCD). He has been in excruciating pain for the past 4 hours and is now presenting with dactylitis. This case has not been the first in this ED, and like other EDs across the United States and in the world, the number of cases presenting with SCD will increase.

Sickle Cell Disease in the Emergency Dept: a global public health issue iEM Dhir

Sickle Cell Disease (SCD)

SCD is a condition that causes red blood cells to morph from a biconcave dumbbell-shaped disc, into a rigid semi-circular shape. This disease is inherited genetically by receiving two sickle genes, one from each parent and risk for complications are attributed to a variety of factors, including deoxygenation, dehydration. It is most common in African Americans as well as Latinos and people of Middle Eastern, Indian, Asian and Mediterranean backgrounds.  In the United States, SCD is the most common genetic blood disorder and affects approximately 100,000 Americans(1) and although babies are screened at birth, management plans vary with the degree of disease progression and exacerbation severity, as well as with the availability of resources and education.

RBCs in Sickle Cell Disease
Image: Sickle cells and normal red blood cells from Sickle Cell Disease, Genome. Gov

Why Emergency Physicians need to be Familiar with SCD

SCD affects both pediatric and adult patients, and it has been reported that patients between the ages of 18 to 30 years old have increased emergency department utilization. A major reason for this is due to the transition by young adults from pediatric to adult care in the management of SCD, and this population is simultaneously also learning to navigate the health care system and community resources (pediatric to adult care, insurance, independent decision making, housing, education, workforce) as discussed further below(2). In addition, the use of community health workers is important as they can act as liaisons between the health care systems and patients to disseminate information and resources. However, despite the awareness of the disproportionate use of the ED among patients with SCD, the social factors that impact care remain unknown(3) and more research and investigation is needed to understand this patient population.

Often when a complication or crisis occurs in patients with SCD, patients seek immediate care in the Emergency Department. Included in the potential list of complications include infections, such as those with encapsulated bacteria; sepsis; stroke; splenic sequestration, and early treatment is essential in managing patients. Of these complaints, the emergent cases to be aware of in the ED include vaso-occlusive crisis and pain, sickle cell anemia (SCA)(4) central nervous system such as stroke, and acute chest syndrome (ACS), where ACS due to blocked capillaries in the lungs, may be caused by infections, asthma exacerbations and/or pulmonary embolisms, and is the leading cause of morbidity in patients with SCD. Further, the Emergency Severity Index (ESI) Version 4 triage system, commonly used in the majority of EDs in the United States, suggest that patients with SCD be triaged as ESI level 2, indicating a very high priority, and that rapid placement be facilitated(5).

Although the discussion of complications of SCD including the presentation and management is a complex topic, and will be covered in detail in future posts, information and algorithms for clinicians are available online for reference. One such resource is a treatment algorithm that acts as a how-to guide for SCD and is available online in the Annals of Emergency Medicine(6). This approach is based on the point-of-care hemoglobin level, and discusses issues such as myonecrosis, aplastic crisis, ACS.

Sickle Cell Disease in the Emergency Dept: 1 in 4 patients in the USA with SCD receive standard care iEM Dhir

Pain in SCD

When tissues and organs are not adequately perfused with oxygen, in part due to the sickled shape of RBCs, tissue damage and death can occur. Patient management of vaso-occulusive crisis and pain varies by practices and the medications available for use around the world, however it is important to note that pain in patients with SCD is often extreme and may require treatment with opioids. In a response to the American Society of Hematology (ASH) draft recommendations to Sickle Cell Disease-Related Pain in May 2019(7),  emDOCs.net published a response to the drafted recommendations and offered insight to pain management and includes an algorithm(8). The insight provided is essential in decreasing the suffering experienced by patients during an SCD crisis, and notes the use of Dilaudid, Ketamine, Dexmedetomidine, and Lidocaine. Further, the understanding of limiting the use of NSAIDS due to impaired renal function caused by the disease is also outlined in the response.

Management of pain in pediatric patients with SCA and vaso-occulsive pain also varies according to hospital and individual provider practices, and scientific investigation and patient research is needed to provide proper care to this population. An example includes a study by PECARN addressing the use of a normal saline bolus in pediatric emergency departments found an association with poorer pain control(9). Identifying and implementing results from research studies is important in understanding and managing SCD in both adult and pediatric patients.

Emergency Physicians around the world should be aware of strategies for identifying SCD, and management, specifically in areas around the world where refugees from countries with SCD prevalence is common. Countries where refugees and migrants are commonly are known to disembark, such as those in southern Europe(10) and certain areas in the United States and Canada would benefit from in-depth analysis of the issue and could allow for appropriate and accessible health care to vulnerable populations, as well as educate providers who are unexposed to managing emergencies in SCD patients while setting in place integrated and individual health plans away from emergency room dependence(11). In developing countries with SCD populations, such as Nigeria, there is a high prevalence of pediatric emergency cases, and the proper management of the disease as well as policy and hospital organization for high volume and off-hour admissions, may reduce hospital stays(12). Further, the self-efficacy of adult patients with SCD, from education, pro-active efforts, understanding of disease management, also can allow for decreased ED visits and hospitalizations for pain(13).

SCD affects approx 100,000 Americans Sickle Cell Disease in the Emergency Dept iEM Dhir

Investigations, Resources, Education

A number of investigative studies, clinical trials and research is being conducted around the world for a better understanding of SCD, including patient care in adult and pediatric patients, genetic factors, supportive services, associated co-morbidities, and search for cures. Investigations around the world include collaborations and information sharing between academic researchers, patients, clinical providers, and health care providers and officials around the world.

The National Heart, Lung, and Blood Institute hosted a series of Webinars in September 2018, during Sickle Cell awareness month from experts in blood science and sickle science research and are available to watch for free online(14). Some of the key highlights from two of the webinars: Serving the Sickle Cell Disease Community Here and Abroad; Sickle Cell Transitional Care from Childhood to Adulthood, are discussed here.

SCD occurs in 1 out of ever 365 Black or African American births, Sickle Cell Disease in the Emergency Dept, iEM Dhir

Webinar Overview Serving the Sickle Cell Disease Community Here and Abroad
Presented by Dr. Keith Hoots, Director of Division of Blood Diseases and Resources, NHLBI
  • Prevalence of the disease is so much larger in Africa than most places in the world. There are as many babies born with SCD born in Nigeria there are babies born with SCD, by estimate, as there almost are total people with SCD in the United States.
  • There is a need to share research and practices in the developed world with the developing world.
Three New Research Initiatives in Africa:
  • The Sickle Pan-African Research Consortium (SPARCO)
    Overview: The study sites for this research include East Africa (Tanzania), West Africa (Ghana, Nigeria) and central Africa (Cameroon, Democratic Republic of Congo) with the goal to later include 20 sites in 15 countries. SPARCO’s aim is to develop an SCD database, standards of care, and strengthen research investigation.
  • Realizing Effectiveness Across Continents With Hydroxyurea (REACH):
    Overview: Safety and dosing of hydroxyurea therapy for SCA in pediatric patients in sub-Saharan Africa; sponsored by the Children’s Hospital Medical Center, Cincinnati
  • Sickle Cell Disease Genomics of Africa (SickleGenAfrica)
    Overview: The purpose is to develop strategies to predict, prevent and treat organ damage in SCD and to investigate biomarkers associated with the development of organ damage, including molecules released during red blood cell damage in sub-Saharan African populations.
Webinar Overview: Sickle Cell Transitional Care from Childhood to Adulthood
Part 1 Presented by Dr. David Wong, MD, FAAP, Medical Officer, Office of Minority Health
  • SCD is no longer a childhood disease. Young adults are at a higher risk for hospitalization due to illness and pain.
  • Treatment and management examples in childhood include annual transcranial dopplers to assess for risk of stroke; vaccinations; hydroxyurea; L-glutamine; opioids for pain management; penicillin prophylaxis; RBC transfusions;  water intake to avoid exacerbations due to dehydration; splenectomy. The cure available is bone marrow transplant.
  • Prior to July 2017, Hydroxyurea was the only FDA approved therapy for 20 It is used in adults and children. It has been shown to reduces hospital admissions, pain crisis, and ACS however barriers to hydroxyurea use exist. These include difficulty with communicating the use to patients and caregivers, issues with frequent monitoring, lack of adherence, lack of provider knowledge and comfort with its use.
  • Community Health Workers (CHWs) are key players in effective patient care. CHW can provide information affected by social and health determinants from local economic and environmental (housing, employment), local communities (families, safety, support), activities (learn, work, play, move, shop), lifestyles (alcohol, drugs, smoking, sexual health, physical activity, and individual needs (age, genetics). CHW are experts in condition-specific information and navigating complex health systems, including accessing care in a medical home (the approach to providing comprehensive care). This is particularly important when care is not always contained or organized by one organization, where care should be accessible, continuous, comprehensive, family-oriented, coordinated, compassionate and culturally competent. Pediatric medical home principles include family-centered partnerships, community-based systems, transition care, value.  Interventions for education such as warning signs and treatment options and links to care are important.
  • The SCD Newborn screening program, and the Sickle Cell Disease Treatment Demonstration Program for patients who solely rely on the ED for SCD care, aid the care options for patients with SCD.

Follow this iEM story for part two which will include information on adult and pediatric management of SCD in the ED, as well as an overview of four NHLBI webinars: Holistic Health and Sickle Cell Disease A Focus on Mental and Behavioral Health; Genetic Therapies in Sickle Cell Disease; Bone Marrow Transplants, Other Therapies, and Sickle Cell; Improvement Initiatives and Ongoing Research.

SCD occurs 1 out of ever 16,300 Hispanic-American birthds, Sickle Cell Disease in the Emergency Dept, iEM Dhir

Further Reading

Emergency Department Sickle Cell Care Coalition: Resources
https://www.acep.org/by-medical-focus/hematology/sickle-cell/resources/

National Institute of Health’s Cure Sickle Cell Initiative:
https://www.nhlbi.nih.gov/science/cure-sickle-cell-initiative

2019 sickle cell disease guidelines by the American Society of Hematology: methodology, challenges, and innovations: https://www.ncbi.nlm.nih.gov/pubmed/31794603

Sickle Cell Disease Training And Mentoring Program (STAMP): https://www.minorityhealth.hhs.gov/sicklecell/#stamp

Episode 68 Emergency Management of Sickle Cell Disease: https://emergencymedicinecases.com/emergency-management-of-sickle-cell-disease/

Practice Variation in Emergency Department Management of Children With Sickle Cell Disease Who Present With Fever. https://www.ncbi.nlm.nih.gov/pubmed/30020250

 

References

1 Centers for Disease Control and Prevention: Sickle Cell Disease 

2 Sickle Cell Transitional Care from Childhood to Adulthood: Youtube

3 Journal of Pediatric Hematology/Oncology. 42(1):e42–e45, JANUARY 2020, DOI: 10.1097/MPH.0000000000001669 PMID: 31743315

4 Porter M. Rapid fire: sickle cell disease. Emerg Med Clin North Am. 2018;36:567–576

5 Evidence Based Management of Sickle Cell Disease: Report

6 Sickle Cell Crisis and You: A How-to Guide, Raam R., Mallemat H., Jhun P., Herbert M. (2016)  Annals of Emergency Medicine,  67  (6) , pp. 787-790

7 The American Society of Hematology Website: 

8 ED Management of Sickle Cell Vaso-occlusive Crises: Myths, Facts, and A Novel Approach to Acute Pain Management, EMdocs.net website

9 Normal saline bolus use in pediatric emergency departments is associated with poorer pain control in children with sickle cell anemia and vaso-occlusive pain, Am J Hematol. 2019 Jun;94(6):689-696

10 Lucia De Franceschi, Caterina Lux, Frédéric B. Piel, Barbara Gianesin, Federico Bonetti, Maddalena Casale, Giovanna Graziadei, Roberto Lisi, Valeria Pinto, Maria Caterina Putti, Paolo Rigano, Rossellina Rosso, Giovanna Russo, Vincenzo Spadola, Claudio Pulvirenti, Monica Rizzi, Filippo Mazzi, Giovanbattista Ruffo, Gian Luca Forni; Access to emergency departments for acute events and identification of sickle cell disease in refugees. Blood 2019; 133 (19): 2100–2103

11 Sickle Cell Disease Training And Mentoring Program Website 

12 Robert M Cronin, Tim Lucas Dorner, Amol Utrankar, Whitney Allen, Mark Rodeghier, Adetola A Kassim, Gretchen Purcell Jackson, Michael R DeBaun, Increased Patient Activation Is Associated with Fewer Emergency Room Visits and Hospitalizations for Pain in Adults with Sickle Cell Disease, Pain Medicine, Volume 20, Issue 8, August 2019, Pages 1464–1471

13 Enyuma, Callistus Oa et al. “Patterns of paediatric emergency admissions and predictors of prolonged hospital stay at the children emergency room, University of Calabar Teaching Hospital, Calabar, Nigeria.” African health sciences vol. 19,2 (2019): 1910-1923. doi:10.4314/ahs.v19i2.14

14 National Heart, Lung, and Blood Institute Webinars

* Images from The Sickle Cell Disease Tool Kit.

Cite this article as: Bryn Dhir, USA, "Sickle Cell, Pain and the Emergency Department," in International Emergency Medicine Education Project, January 27, 2020, https://iem-student.org/2020/01/27/sickle-cell-pain-and-the-emergency-department/, date accessed: March 29, 2020

Clinical examination of the hemodynamically unstable patient

Clinical examination of the hemodynamically unstable patient

Authors: Job Rodríguez Guillén. Chief of Emergency Department. Hospital H+ Querétaro. México and Paola Rivero Castañeda. Medical Intern, Anahuac Querétaro University, Mexico. 

Introduction

Clinical examination accounts as a fundamental part in the management of most critical scenarios. Although there are few publications and it remains controversial, its value considered as limited by 50% of medical practicioners (1). None of the well-known semiology books include any section about the physical examination in the critically ill patient (2). Nonetheless, an adequate clinical evaluation at the patient’s bedside may save lives in the context of a serious situation.

Clinical Examination Objectives

The main objectives are identifying and discerning from types of shock, emphasizing in the identification of life-threatening conditions, clinical signs of organic hypoperfusion, as well as to evaluate treatment response regarding therapies employed, and risk stratifying.

Identify hemodynamic instability

  • Life-threatening conditions (Tension pneumothorax, Cardiac tamponade, Pulmonary thromboembolism, Active hemorrhage, etc.)
  • Organ hypoperfusion
    (Altered mental state, decreased uresis, mottled skin, prolonged CFT, etc.)

Evaluate treatment response

  • Vital signs and normalization of the clinical state
    (Mental state improvement, diminished skin mottling, improved uresis, normalization of prolonged capillary filling time, etc.)

Risk stratifying

  • Scale and prognostic scores calculation. Prognostic scores use a combination of clinical and/or laboratoy variables (SOFA: Squential Organ Failure Assessment; APACHE: Acute Physiology and Chronic Health Evaluation; SAPS: Simplified Acute Physiology Score; MPM: Mortality Probability Models, etc.)

Clinical Exam Systematization

The clinician must be able to do a quick and efficient clinical examination to recognize different states of shock as early as possible, or even situations that may compromise organic perfusion. At a given time, it’s suggested to check out the clinical history, re-interrogate the patient and his/her family members, as well as patient’s family/regular physician (or even look for their previous medical notes), in order to help clinical integration, and so for decision making.

Systematization of the evaluating process, based on the previously proposed objectives, can be identified with the following mnemonic: PROA.

PROA - Summary

P - Probabilistic thinking

  • Think about any probability.
  • Look for intentionally.
  • Analyze clinical context and individualize.

R - Risk of dying

Identify life-threatening causes: Cardiac tamponade, Tensionpneumothorax, Pulmonary thromboembolism, Active hemorrhage, etc.

O - Organic hypoperfusion

Cutaneous perfusion signs: examine mottled skin and capillary filling time.

A - Approach of the clinical examination

Clinical exam by regions. Some components may not be relevant for all patients, even requiring other physical maneuvers. Even though laboratory and imaging are not part of the clinical exam, their interpretation must be integrated with the examination findings.

Probabilistic Thinking

Medicine is a science of uncertainty and an art of probability.

— William Osler

Clinical decision making in the emergency department begins with the estimation of the probability of a determined patient to have or do not have specific conditions (Bayesian reasoning or pretest probability).

Example; the probability of septic shock in a young patient after having a car crash is very low compared to the high probability of presenting with hemorrhagic or obstructive shock.

Proposed decisions related to initial probabilistic thinking vary in clinical relevance depending on the patient’s condition. It should always be re-evaluated through available additional data (posttest probability) (Figure 1).

Relationship between probability thresholds and decision‐making zones
Figure 1: Relationship between probability thresholds and decision‐making zones (3).

Risk of Dying

Shock is a momentary pause in the act of death.

— John Collins Warren

Currently, there are four types of shock, all with a common pathophysiological pathway: acute circulatory insufficiency associated with cell oxygen utilization dysfunction (altered-balance between oxygen input and consumption: DO2/VO2 dysfunction), a central situation that takes part in the development of multiorgan dysfunction (4-5).

Initial physical examination should be directed to the identification of immediate life-threating pathologies such as obstructive shock (Tension pneumothorax, cardiac tamponade, pulmonary thromboembolism), hemorrhagic shock etc.

These pathologies require immediate action. Otherwise, early multi-organ dysfunction and death may occur. The Point of Care Ultrasound (PoCUS), is a fundamental tool used for the evaluation of patients with hemodynamic instability of unknown origin.

Organ Hypoperfusion

When assessing the damage an earthquake or fire has caused inside a building, one looks through the windows. Using this analogy, it would be useful to be able to see inside the body to view the damage caused by the shock process.

— Jean-Louis Vincent

The initial approach to clinical examination begins with the skin. It is essential to remember that microcirculation cannot be globally defined through its dependency with macrocirculation, autoregulation mechanisms and organ interactions. Moreover, the availability of devices to evaluate it remains limited. Therefore, the evaluation is done from clinical, biochemical and hemodynamic data integration (6) (Figure 2)

Figure 2: three windows of shock

The correct way of measuring capillary filling time

Approach of The Clinical Examination

Clinical exam is not an art, is an essential ability.

— Leonel Martínez-Ramírez

During the initial evaluation, multiple situations can affect the accomplishment of a detailed physical examination. Therefore, it is recommended to follow a structured exploration method, looking at every main organ system and region. Documenting its results would allow avoiding the inclusion of essential data, and would permit to identify tendencies or any change in the patient’s clinical status.

Clinical examination approach in the critically-ill patient.

7Clinical examination approach emphasized in the critically-ill patient. This examination is realized based on every region in the body. Some components may not be relevant for all patients, or even some other maneuvers shall be executed in the physical examination. The verification list should be modified to be adapted to each patient’s circumstances. Laboratory and other studies analysis does not conform part of the clinical examination, although, their interpretation should be added to exploration findings (7).

  • General appearance

    Introduce yourself to the patient. Evaluate general appearance, physical state, complexity or the presence of particular face patterns, etc.

  • Head

    Inspect pupils' symmetry and reactiveness to light. Look for facial asymmetry and signs of bleeding in nostrils and oropharynx. Inspect lips, mouth and tongue, searching for lesions or signs of ulceration.

  • Neck

    Evaluate neck symmetry, venous distension and tracheal positioning. Palpate searching for adenopathies, subcutaneous emphysema, etc.

  • Thorax

    Expose the thorax, inspect the use of accessory respiratory muscles, diaphragmatic movement, and type of respiration. Also, look for ecchymosis or hematomas. Palpate searching for subcutaneous emphysema or bone crepitations. Auscultate respiratory sounds bilaterally, as well as heart sounds, noting the physiological splitting of the second heart sound, murmurs, friction and gallop rhythm or third heart sound.

  • Upper extremities

    Evaluate upper extremities symmetry. Inspect all arterial and venous line catheters. Evaluate for presence of mottled skin, peripheral pulses and perfusion through capillary filling time.

  • Abdomen

    Take into consideration the diaphragmatic movement during ventilation. Evaluate distension and tympanic sounds during the percussion of the abdomen. Palpate for any rigidity or involuntary guarding. Evaluate abnormal growth of spleen and liver, palpable masses, murmurs or other intestinal sounds.

  • Lower extremities

    Evaluate all sites of vascular accesses and palpate pulses. Evaluate mottled skin, peripheral perfusion and edema.

  • Central Nervous System and Mental State

    Evaluate if the patient is able to follow orders and if his/her four extremities can move equally. Evaluate plantar response as well as withdrawal to pain stimuli. Check pupils and facial symmetry if they were not previously evaluated.

  • Devices and Incisions

    Every possible surgical site should be evaluated, as well as the entrance of every device, including endotracheal tubes, vascular accesses, thoracic tubes, enteral probes and urinary catheters. It should be taken into consideration the characteristics and quantity of urine in the Foley bag.

  • Monitors and waveforms

    The mode, pressures, ventilation per minute and waveforms, hemodynamic monitor (venous pressure, arterial pressure), telemetry and vital signs, as well as any other type of bedside monitor, should be inspected in order to detect any qualitative or quantitative alteration/abnormality.

  • Posterior region

    Exam executed when the patient is in a prone position. Inspect looking for lesions or penetrating wounds. Pressure ulcer appearance should be evaluated.

  • Environment

    Family’s or visitors' moods should be taken into consideration. Light quality, ambient temperature, etc. should be evaluated.

Conclusions

Clinical integration of initial clinical history and the physical examination should be added to the biochemical complementation as well as advanced hemodynamic monitoring parameters, when these are available. Even so, if clinical examination answers raised questions during the initial evaluating process, the clinician must act according to physiological principles. There is no ideal hemodynamic monitoring, meaning that all parameters have to be individualized for each patient and his/her clinical context. Therefore, clinical examination systematization results are an excellent aid for the clinician regarding his/her clinical practice.  

References and Further Reading

  1. Vazquez R, Vazquez Guillamet C, Adeel Rishi M, Florindez J, Dhawan PS, Allen SE, Manthous CA, Lighthall G.  Physical examination in the intensive care unit: opinions of physicians at three teaching hospitals. Southwest J Pulm Crit Care. 2015;10(1):34-43. DOI: http://dx.doi.org/10.13175/swjpcc165-14
  2. Cook CJ, Smith GB. Do textbooks of clinical examination contain information regarding the assessment of critically ill patients?Resuscitation. 2004;60:129–136.
  3. Zehtabchi S, Kline J.A. The Art and Science of Probabilistic Decision‐making in Emergency Medicine. Academic Emergency Medicine, 17:521-523. DOI: http://doi.org/10.1111/j.1553-2712.2010.00739.x
  4. Weil MH, Shubin H. Proposed reclassification of shock states with special reference to distributive defects. Adv Exp Med Biol.1971 Oct;23(0):13-23.
  5. Ince C. The microcirculation is the motor of sepsis. Crit Care. 2005;9 Suppl 4:S13-9. DOI: 1186/cc3753
  6. Vincent JL, Ince C, Bakker J. Clinical review: Circulatory shock–an update: a tribute to Professor Max Harry Weil.Crit Care. 2012 Nov 20;16(6):239. DOI: 10.1186/cc11510.
  7. Metkus TS, Kim BS. Bedside Diagnosis in the Intensive Care Unit. Is Looking Overlooked?. Ann Am Thorac Soc.2015 Oct;12(10):1447-50. DOI: 10.1513/AnnalsATS.201505-271OI.
Cite this article as: Job Guillen, Mexico, "Clinical examination of the hemodynamically unstable patient," in International Emergency Medicine Education Project, December 6, 2019, https://iem-student.org/2019/12/06/clinical-examination-of-the-hemodynamically-unstable-patient/, date accessed: March 29, 2020

Deadly ECG Patterns – 5 Can’t Miss ECG Findings

5 Can’t Miss ECG findings

An average ER physician performs around 100 tasks in an hour and gets interrupted at least every 6 minutes. One of the common interruptions in the ED is a request to “sign off” on an ECG of a patient who has been triaged but not seen by a doctor yet. Therefore, knowing deadly ECG patterns is an essential skill for emergency physicians, residents, as well as medical students who rotate in the emergency department.

Below are five ECG patterns that should raise concerns for red flag conditions.

ECG #1

A 37-years-old female patient presented to the ED with complains of dizziness and generalized fatigue. She was started on ACE inhibitors few months ago and missed her clinic appointments. Her bedside VBG revealed a K+ of 8.1

ECG source - Dr. Smith's ECG blog

The ECG shows severe bradycardia, wide QRS complexes and symmetrically peaked T waves in V2-V5.

Key Take Home Points

Hyperkalemia can present with multiple abnormalities on an ECG, including

  • Tall, peaked T waves with a narrow base (best seen in precordial leads)
  • Progressive flattening and eventually disappearance of P waves
  • Wide QRS complexes
  • Bradyarrhythmias (sinus bradycardia, slow AF, second and third-degree AV blocks)
  • Sine wave appearance (pre-terminal rhythm)
  • Endgame: Ventricular fibrillation

Always consider the diagnosis of hyperkalemia in a patient with a history of dialysis, renal failure, or treatment with drugs like ACE inhibitors, ARBs, spironolactone especially if the ECG shows bradycardia or complete heart block.

ECG #2

A 56-years-old patient presented to the ED with lightheadedness and dizziness. Initial vitals showed hypotension and tachycardia.

ECG source - Dr. Smith's ECG blog
ECG source - Dr. Smith's ECG blog

The above ECG shows low voltage, lectrical alternans: the beat-by-beat R-wave amplitude changes best appreciated in the precordial leads. A bedside ECHO completed after the initial ECG showed a large pericardial effusion.

Key Take Home Points

Massive pericardial effusion can produce a triad of:

  • Low QRS voltage
  • Tachycardia
  • Electrical alternans (consecutive, normally-conducted QRS complexes alternate in height)

Consider the possibility of pericardial effusion and a potential impending cardiac tamponade in patients with electrical alternans on ECG.

ECG #3

A 65-years-old patient was brought to the ED by family members in a disoriented state. Further history revealed that the patient was taking digoxin as one of his regular medications. His serum digoxin level was 2.7 ng/ml.

ECG Source - learntheheart.com
ECG Source - learntheheart.com

The above rhythm strip shows atrial tachycardia with 2:1 AV block.

Key Take Home Points

Always have a high suspicion of digoxin toxicity in a patient taking digoxin presenting with the disoriented state.

Digoxin toxicity can cause a wide variety of arrhythmias. It is classically associated with supraventricular tachycardias but a slow ventricular response (e.g.: atrial tachycardia with high-grade AV block).

The other common rhythms include:

  • Regularized atrial fibrillation (AF with complete heart block + accelerated junctional escape rhythm which produces a paradoxically regular rhythm)
  • Bidirectional VT (polymorphic VT with QRS complexes alternating between LBBB and RBBB morphology)

Digoxin toxicity should be separated from the normal digoxin effect that can occur in patients taking the expected dose of digoxin. The digoxin effect (image below) includes sagging ST-segment depression, abnormal T waves (flat, inverted or biphasic) and a short QT.

ECG source - Dr. Smith's ECG blog

ECG #4

A 45-years-old patient presented to the ED with a history of severe central chest pain lasting about 10 – 15 minutes. Cardiac enzymes were negative. However, with the above ECG findings, the patient was sent to the Cath lab and subsequent coronary angiography revealed proximal LAD artery occlusion.

By Jer5150 - Own work, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=19598089

The above ECG shows deep T wave inversions in precordial leads. This is known as the Wellen’s sign.

Key Take Home Points

Wellens syndrome is a pattern of deeply inverted or biphasic T waves in V2-V3 which is highly specific for critical stenosis of left anterior descending (LAD) artery.

There are two patterns of T wave abnormality in Wellens syndrome

  • Type A: Biphasic T waves (initially positive and terminally negative)
  • Type B: Deep and symmetrically inverted (Most common type)

Note that patients can be completely pain-free with normal cardiac enzyme levels. Patients are, however, at extremely high risk of anterior wall MI due to the critical LAD stenosis and need appropriate Cardiology consultation and management urgently.

ECG #5

A 17-years-old previously healthy male patient who had one attack of syncope earlier in the day presented to the ED.

ECG Source - Peter Allely - liftl.com
ECG Source - Peter Allely - liftl.com

The ECG pattern is diagnostic of Brugada syndrome – coved shaped ST-elevation > 2mm followed by an inverted T wave seen in V1 and V2.

Key Take Home Points

Such finding is very serious in a patient with a recent episode of unconsciousness.

The suspicion of Brugada syndrome must be confirmed or excluded by an urgent consultation with a cardiologist.

Conclusion

ECGs in isolation are usually not enough to make a diagnosis – always correlate with clinical history and/or confirmatory investigations.

Try looking at as many ECGs as possible to improve your skills of pattern recognition and picking up subtle changes in ECGs.

Cite this article as: Neha Hudlikar, UAE, "Deadly ECG Patterns – 5 Can’t Miss ECG Findings," in International Emergency Medicine Education Project, November 22, 2019, https://iem-student.org/2019/11/22/deadly-ecg-patterns-5-cant-miss-ecg-findings/, date accessed: March 29, 2020

ELECTRIC SHOCK; Injuries beyond what the eyes see.​

electric shock

Authors: Dr. Nour Saleh and Dr. Kilalo Mjema

Case presentation

A 53-years-old male, sustained burn wounds on both hands 40 minutes prior presentation to the ED

Primary survey

  • Airway: patent and protected.
  • Breathing: bilateral equal air entry
  • Circulation: warm extremities, capillary refill time is 1 second
    • Vitals on presentation
      • BP: 177/114mmHg
      • HR: 115
      • RR: 16
      • SPO2: 96% in room air
      • T: 36.4
  • Disability: alert and oriented, pupils 5mm bilateral equal light reaction, glucose: 7.3mmol
  • Exposure: holding his hands up in pain with some black discoloration

SAMPLE History

  • Sign and symptoms: pain, see pictures
  • Allergy: no known allergies
  • Medications: not on any medication
  • Past medical history: no known comorbid or any significant medical history
    Last meal: he ate about 2.5 hours prior presentation
  • Event: pain on both hands after sustaining burn injury forty minutes prior presentation to the ED while trying to connect two circuits that sparked causing burn wounds on his hands and felt a jolt of electricity.

No history of heartbeat awareness or any loss of consciousness

electrical injury
electrical injury

Interventions and key steps in management

  • Make sure ABCD is checked and there is no critical intervention needed
  • IV access and fluid resuscitation may be considered depending on the case
  • Analgesics: depends on the severity of pain. Fentanyl 50mcg IV stat can be necessary for many patients.
  • Informed consent for procedural sedation for the dressing of the wounds.
  • Sedation: during the dressing of wounds
  • Point-of-care investigations: ECG, Urine dipstick
  • Blood samples for some labs should be taken; Creatinine, CK, Myoglobin, Electrolytes, Calcium, and Troponin
  • Imaging: X-ray if there is a worry for associated fracture
  • Monitor: input of fluids and output of urine to watch for acute kidney injury, compartment syndrome and rhabdomyolysis
  • Do not forget tetanus immunization

Associated injuries

  • Cardiac arrhythmias

    Ventricular fibrillation is the most common. It occurs in 60% of patients with electrical current traveling from one hand to the other.

  • Renal - Rhabdomyolysis

    Massive tissue necrosis may result in acute kidney injury. Labs to check includes; Creatinine, Blood Urea Nitrogen, Total CK, myoglobin.

  • Neurological

    Damage to both central and peripheral nervous systems can occur. The presentation may include weakness or paralysis, respiratory depression, autonomic dysfunction, memory disturbances, loss of consciousness.

  • Skin

    Degree of injury cannot determine the extent of internal damage especially with low voltage injuries. Minor surface burns may co-exist with massive muscle coagulation and necrosis.

  • Musculoskeletal

    Bones have the highest resistance of any body tissues resulting in the greatest amount of heat when exposed to an electrical current. Results in surrounding tissue damage and potentially may lead to periosteal burns, destruction of bone matrix and osteonecrosis.

  • Vascular / Coagulation system

    Due to electrical coagulation of small blood vessels or acute compartment syndrome.

  • Internal organs

    The internal organ injury is not common but when it happens may result serious problems such as bowel perforations leading to polymicrobial infection, sepsis, and death.

Disposition

Admission and discharge decisions of burn patients depend on the patient’s current situation, burn percentage according to body surface area, location of the burn, and complications of burn. Low voltage electrocutions, if they are asymptomatic with normal physical examinations, can be discharged. Discharge precautions regarding burn care and complications should be clearly explained to the patient and relatives.

Further Reading

Cite this article as: Kilalo Mjema, "ELECTRIC SHOCK; Injuries beyond what the eyes see.​," in International Emergency Medicine Education Project, October 2, 2019, https://iem-student.org/2019/10/02/electric-shock-injuries-beyond-what-the-eyes-see-%e2%80%8b/, date accessed: March 29, 2020

Purple Rain: A Rare Spot Diagnosis

Purple rain urine

Case Presentation

A 70-year-old pleasant elderly male was brought in by his son, surprisingly complaining of purple-colored urine. The son got worried once he saw the purple urine bag and rushed his dad to the Emergency Department.

Upon further questioning, he reports a sweet elderly gentleman, known with previous cerebrovascular accidents, dysphasia and neurogenic bladder, that he has a urinary catheter inserted for. He claims that his dad has been having low appetite and passing less stool in the past week. Otherwise, he didn’t notice any other alarming symptoms. Furthermore, he denied noticing any fever, vomiting, behavioral changes indicating any pain, or recent change in his medications or diet. He had no known allergies as well. Upon full review of symptoms, chronic constipation was appreciated, otherwise, it was unremarkable.

Physical Exam

The patient was lying in bed, a bit uncomfortable, with an attached urinary catheter bag. He was afebrile and vitally stable. Proceeding with a focused physical examination, his chest was clear, and abdomen was soft, lax and nontender, furthermore, his skin had no rashes, and limbs were non-edematous. Inspecting the Urine Catheter Collection Bag, it did reveal Purple Urine Sediment.

Purple Urine in the Urinary Catheter Bag
Purple Urine in the Urinary Catheter Bag

Differential Diagnosis and Workup

Thinking of differential diagnoses of discolored urine, a purple urine bag is almost a spot diagnosis in our practice, definitely after ruling out any possible confounders if any.

We reassured the family and explained to them that we would order some blood and urine tests to confirm the diagnosis and start the appropriate treatment plan.

Case Management and Disposition

Laboratory test revealed mild leukocytosis with neutrophilia and mild elevated CRP. Otherwise, his urea, creatinine, liver function tests and electrolytes were reported normal.

Furthermore, a urine dipstick was done in the ED that reported positive for leukocytes, nitrites, and consequently sent to the lab for culture and full analysis which confirmed the diagnosis of a urinary tract infection (UTI).

We informed the son of the workup results, and a diagnosis of a UTI, given his leukocytosis, positive urine dipstick and the presence of a urinary catheter putting him at risk UTI. We reassured him about the urine color and explained the need to start antibiotics to cover the UTI, and changes the urinary catheter, which left us to explain only why was the urine purple unlike usual cases of UTI’s.

Critical Thinking and Take-home Tips

What is PUBS?

  • PUBS stands for Purple Urinary Bag Syndrome, first described in 1978.(1)
  • It is characterized by purple-colored urine collecting in urinary catheterization bags in patients known to prolonged urinary catheters. 
  • It presents asymptomatically and it is associated with urinary tract infections.
  • PUBS presents alarmingly to patients and family members, yet it is a benign phenomenon.

What causes the purplish discoloration of the urine in PUBS?

  • PUBS is associated with alkaline urine with a high bacterial load. 
  • It results due to UTI with certain bacteria producing sulphatases and phosphatases, which lead tryptophan metabolism to produce indigo (blue) and indirubin (red) pigments, a mixture of which becomes purple. (2)
  • Several bacterial species have been reported in association with PUBS including Providencia stuartii, Providencia rettgeri, Klebsiella pneumoniae, Proteus species, Escherichia coli, Enterococcus species, Morganella morganii, and Pseudomonas aeruginosa. (3)

What are the PUBS risk factors?

  • Female gender
  • Bedridden status or immobility
  • Chronic constipation leading to bacterial overgrowth
  • Renal disease
  • Prolonged urinary catheterization

What is PUBS management?

  • The reassurance of patient and family
  • Regular changing of urinary catheter
  • UTI Antibiotics coverage

What other urine colors should we be aware of?

  • Urine discoloration if a fairly common sign and indicates a certain pathology often that would need your attention as a physician.
  • Most urine discoloration is caused by food intakes, medications, dyes, or specific disease pathologies.
  • Red-colored urine is often related to hematuria, caused by multiple pathologies, including kidney stones, urinary tract injury or infection or cancer, amongst others.
  • Pink colored urine is often related to certain medications or dietary intake, i.e. beetroots and berries.
  • Brown or tea-colored urine indicates hepatobiliary disease or obstruction.
  • Green Urine can result due to medications such as Propofol.

What should I do when I encounter a discolored urine finding in my patient?

  • Remember always to have a systematic approach. 
  • Take a full history, including types or changes in medications history, diet changes, past medical history, and a full review of systems.
  • Keep in mind, some patients who are bedridden or elderly, communication and history taking might be limited; hence you will have to do your due diligence in gathering all the information you can get from family members, or available medical charts.
  • Your physical exam is a great asset as well in collecting information that can help you 

References and Further Reading

  1. Khan F, Chaudhry MA, Qureshi N, Cowley B. Purple urine bag syndrome: An Alarming Hue? A Brief Review of the Literature. Int J Nephrol 2011. 2011 419213. [PMC free article] [PubMed] [Google Scholar]
  2. Kalsi DS, Ward J, Lee R, Handa A. Purple Urine Bag Syndrome: A Rare Spot Diagnosis. Dis Markers. 2017;2017:9131872. doi:10.1155/2017/9131872
  3. Dilraj S. Kalsi, Joel Ward, Regent Lee, and Ashok Handa, “Purple Urine Bag Syndrome: A Rare Spot Diagnosis,” Disease Markers, vol. 2017, Article ID 9131872, 6 pages, 2017. https://doi.org/10.1155/2017/9131872.
  4. Al Montasir A, Al Mustaque A. Purple urine bag syndrome. J Family Med Prim Care. 2013;2(1):104–105. doi:10.4103/2249-4863.109970
  5. Traynor B P, Pomeroy E, Niall D. Purple urine bag syndrome: a case report and review of the literature. Oxford Medical Case Reports, Volume 2017, Issue 11, November 2017, omx059, https://doi.org/10.1093/omcr/omx059
  6. Lin CH, Huang HT, Chien CC, Tzeng DS, Lung FW. Purple urine bag syndrome in nursing homes: Ten elderly case reports and a literature review. Clin Interv Aging. 2008;3:729–34. [PMC free article] [PubMed] [Google Scholar]
Cite this article as: Shaza Karrar, UAE, "Purple Rain: A Rare Spot Diagnosis," in International Emergency Medicine Education Project, September 20, 2019, https://iem-student.org/2019/09/20/purple-rain-a-rare-spot-diagnosis/, date accessed: March 29, 2020

Febrile Seizures

febrile seizures

A 20 Month-Old Male

It is a busy Wednesday afternoon in your pediatric emergency department. You work at a tertiary center, so you are used to receiving transfers from other hospitals for further evaluation and management. You see a new patient on the board. It is a 20 month-old male who came in as a hospital transfer for evaluation of first-time seizure. You go to bedside to start your evaluation. Parents tell you that he had three episodes of seizures in the past 6 hours. All of them lasted for less than 15 minutes, did not require medication for cessation, one of them was described as partial-focal and two were described as generalized tonic-clonic seizures, and the patient had complete return to baseline behavior a few minutes after each episode. Mom says that the patient had his axillary temperature taken by her at home and by the staff at the outside hospital and he had no fever on these measurements. However, she did notice some runny nose in the past 24 hours. As soon as the mom tells you that information, the nurse looks at you and says that the patient’s rectal temperature is 40.1 C.

Febrile Seizures

The first-step in the management of febrile seizures is to understand its definitions. Following that, we need to appropriately classify the patient’s presentation within one of the two types of febrile seizure.

Definition

  • Age greater than six-months-old and lower than five-years-old
  • Seizure in a patient with a temperature higher than 38 C
  • No inflammation or infection of the central nervous system
  • No metabolic abnormality that may cause seizures
  • No history of afebrile seizures

Two Types of Febrile Seizures

Class Age Number of seizures in 24h Duration Type of seizure Resolution Return to baseline
Simple
6 mo to 5 yo
1
< 15 min
No focal features
No meds required
Yes
Complex
6 mo to 5 yo
> 1
> 15 min
Focal features
Med required
No return to baseline in a reasonable time

You must note that you will be able to easily identify those patients who fit the criteria for simple febrile seizures and those who fit the criteria for complex febrile seizures. However, there will be a group of patients that fill one or two criteria for complex febrile seizure, but are extremely well-appearing. We will talk more about that later on during the discussion.

Workup

Simple Febrile Seizures

The evaluation of a child with a simple febrile seizure should focus on the underlying febrile illness. In the vast majority of the cases the cause for the fever will be a viral infection that does not require further evaluation and treatment other than some acetaminophen (paracetamol), ibuprofen, and oral hydration.

However, as part of your job, you need to think outside of the box and have a broad differential diagnosis for your patient’s presentation. Make sure to rule out signs of CNS infection (altered mental status, nuchal rigidity, petechial rashes, and prolonged, focal or multiple seizures); risk factors, symptoms, and signs of systemic conditions that could be causing a seizure; and, history of afebrile seizures. Special factors that increase the risk for CNS infections and that you should consider in your evaluation are age 6 -12 months with incomplete immunization status (Haemophilus influenzae type b (Hib) or Streptococcus pneumoniae) and pre-treatment with antibiotics for another disorder (which could mask meningitis).

Complex Febrile Seizure in Ill-Appearing Child

The workup in this situation is simple. The patient has meningitis until proven otherwise. You should consider starting antibiotics immediately and obtaining a full sepsis workup including complete blood cell count, urinalysis, urine culture, blood cultures, chest x-ray, and lumbar puncture for cerebrospinal fluid analysis. In addition to the infectious work-up, the differential also includes epileptic seizures, toxic ingestion, metabolic disorders, head trauma, and intracranial hypertension.

Complex Febrile Seizure in Well-Appearing Child

Now we reached the tricky part of the discussion. There are no consensus guidelines for the workup of patients with complex febrile seizures in the well-appearing child. As stated in the simple febrile seizure section, you should consider further workup if any concerns for CNS infection, systemic conditions causing seizures, or history of afebrile seizures. You should decide which workup to perform on a case by case basis. In a perfect scenario, these cases should be evaluated in conjunction with specialist consultation (e.g. with pediatric neurology) for guidance with work-up and treatment.

Case Resolution

After you finish your assessment, you make the diagnosis of complex febrile seizure because the patient had multiple seizures in less than 24 hours and had one episode with focal features. The patient is well-appearing, is fully vaccinated, has not used antibiotics recently, returns to baseline completely soon after an episode, and has no findings concerning for CNS infection on his exam. Therefore, you think that a CNS infection is less likely. Since you are facing a case of complex febrile seizure in a well-appearing child, you consult pediatric neurology for guidance with the workup and treatment. They agree with the low likelihood of CNS infection and recommend symptomatic treatment for the patient’s likely upper respiratory infection with observation during six hours in the ED. The patient has no problems during the period of observation. You re-discuss the case with pediatric neurology and they recommend discharge home with close follow-up on their clinic for further workup of other causes of seizure. A couple days later, you check the patient’s records and find that he had a spot EEG done, which was negative for epileptiform waves, and a brain MRI performed, which was unremarkable. Patient was diagnosed with complex febrile seizure and recommended to keep follow-up with his primary care physician with no need for further follow-up with pediatric neurology.

Take-Home Points

  • Always obtain a temperature from a core source, in the ED the most feasible source is a rectal temperature
  • The differential diagnosis for febrile seizures includes CNS infections, epileptic seizures, toxic ingestion, metabolic disorders, head trauma, and intracranial hypertension
  • There is no consensus about the workup and treatment of the well-appearing patient with a complex febrile seizure

References and Further Reading

  1. Festekjian A. Seizures and Status Epilepticus in Children. In: Cydulka RK, Fitch MT, Joing SA, Wang VJ, Cline DM, Ma O. eds. Tintinalli’s Emergency Medicine Manual, 8e New York, NY: McGraw-Hill; . http://accessemergencymedicine.mhmedical.com/content.aspx?bookid=2158§ionid=162271372. Accessed May 12, 2019.

  2. https://www.emrap.org/episode/kiddos/febrileseizures

  3. https://www.emrap.org/episode/c3seizuresin/seizuresin 

  4. John J Millichap. Clinical features and evaluation of febrile seizures. Mar 25, 2019. https://www.uptodate.com/contents/clinical-features-and-evaluation-of-febrile-seizures?source=history_widget

Cite this article as: Henrique Puls, Brasil, "Febrile Seizures," in International Emergency Medicine Education Project, September 9, 2019, https://iem-student.org/2019/09/09/febrile-seizures/, date accessed: March 29, 2020

An upside-down cake: the EM differential diagnosis

An upside-down cake: the EM differential diagnosis

How we’re different

When I was rotating on surgery as a medical student, our attending once asked of our small group what may be concerning in the differential for right upper quadrant abdominal pain. A very eager and a somewhat brash student blurted immediately: “Echinococcal cyst!” The attending replied, “Well, that’s true, but if Echinococcal cyst is the first thing you think of as a surgical consultant, you’re crazy!”

On the other hand, take a practicing internal medicine physician like my Dad. He formulates his differentials with a very different strategy, which is: what is the most likely? A chronic cough is bronchitis (even with hemoptysis), pneumonia, GERD or postnasal drip. Shoulder pain is, of course, a sprain, bursitis, or some referred cervical impingement. And so on.

Unfortunately, neither hunting for zebras (an unofficial US name for exciting but rare diagnoses) nor settling for the most common works for emergency medicine. In fact, that is how true diagnoses may get missed and patients may start dying. 

Why we are different

The EM differential diagnosis is a pyramid tipped on its head. It is therefore different from how differentials are approached by many other specialties.

In EM, we first have to think of and rule out the most severe or threatening pathology. That’s a given. But our choices have to come from among the common killers, not Martian viruses or unheard of tumors from a medical encyclopedia. 

Amoebic meningitis is exciting to encounter in your practice. But guess what? Your patient won’t have it. At the same time, for EM physicians things like pulmonary embolus, aneurysm of the abdominal aorta, subarachnoid hemorrhage and necrotizing fasciitis are everyday icons on our cognitive desktops. While less common than a common cold, these things are by no means rare.

Why it is difficult

In EM, one can rest assured that common pathology will present atypically and not quite like the textbook.

Things are further complicated by confounders, mimics and the disjunction of concern.
 
Confounders are concurrent pathologic processes that the patient already has, which tend to get worse due to any new significant disease process or general body stress. CHF and COPD get exacerbated, kidneys become insufficient, anxiety and psychoses go florid and atrial fibrillation accelerates to rapid. How do you spot sepsis or an MI, which is the true cause of it all, underneath layers and layers of abnormal vitals and test results?
 
Mimics are things that pretend to be other diseases. PE presenting with a low-grade fever and a cough, carbon monoxide poisoning posing as geriatric altered mental status, and severe sepsis arriving as chest pain, dizziness and a bumped troponin. Such has happened many times in the past and continues to happen daily at all EDs globally.
 
The disjunction of concern is when your patient is not worried about what you are worried about. They don’t want to get cancer like their neighbor, but they have never heard of a TIA or an AAA. Kawasaki disease? Why don’t you just give my daughter better antibiotics? My uncle died of a heart attack at 35, not a “bisection” or whatever you called it…So I don’t want a CT scan!
 
An EM physician’s focus on ruling out worst-case scenarios may paradoxically contribute to a patient’s distrust at the end of the encounter. The patient’s agenda is to leave knowing what disease they have, while we are often satisfied knowing which horrible things a patient does do not have.

It may take years of practice to be able to persuade someone that you have done due diligence and your professional duty by excluding a whole lot of deadly things, while the exact diagnosis still remains elusive.

Secretly paranoid, openly confident and always nice

We are confident, but also afraid. We have to think of the worst yet possible scenario for any complaint, yet of course anticipate that the actual diagnosis will hopefully be something less severe and quite common – like a migraine. After all, after most CT scans and lumbar punctures, it is not a subarachnoid hemorrhage.

In EM, we are in this perpetual struggle with having to be professionally pessimistic and paranoid on the one hand, yet emotionally supportive and reassuring for the patient on the other. I always teach my students, even nursing trainees, that no one should be leaving an emergency department more scared or anxious than when they came in.

Your job as a rotating trainee in EM is to understand and learn this exact interplay.

Homework

For your attending, but more importantly for yourself and your patients, you have to be as concerned with sepsis from PID on a 16-year-old young woman with fever and abdominal pain as you are with appendicitis. The 86 year old grandmother with Afib but on no anti-coagulation, because she falls a lot is not just TIA or CVA prone. Her embolic clots may just as well be traveling downstream, causing that intermittent or out of proportion abdominal pain called mesenteric ischemia – for which you do not have a good lab test or imaging, by the way.

Here is a brief checklist:

  • For any anatomic complaint or a chief complaint type

    think of several real worst-case scenarios that are not zebras. Can something horrible yet by no means unheard of be presenting atypically? What steps can you take to prove or disprove it?

  • Think of confounders and mimics.

    What else could be going on? Like a stack of dominoes: what happened first, what happened next?

  • Address the patient’s concerns

    while carefully and patiently pursuing your own professional agenda.

  • When it turns out to be something common or benign,

    don’t forget to discuss worrisome signs for which to return. What if you’re still wrong?

If you liked this story, you may like these too!

Cite this article as: Anthony Rodigin, USA, "An upside-down cake: the EM differential diagnosis," in International Emergency Medicine Education Project, August 26, 2019, https://iem-student.org/2019/08/26/an-upside-down-cake-the-em-differential-diagnosis/, date accessed: March 29, 2020

The ABCDE Approach for Medical Students

The ABCDE Approach

Emergency Medicine Is a Dynamic Specialty

Emergency medicine is a dynamic specialty which mainly focuses on the rapid assessment and intervention of life-threatening conditions. It is well known that emergency patients are undifferentiated and mostly they come for unscheduled care. This is usually a new environment for a medical student in clinical years. Facing many undifferentiated patients and understanding the situation requires an initial standardized approach. There is an “ABCDE” approach which is universally accepted and applicable in all clinical emergencies for immediate assessment and intervention (1).

The Summary of ABCDE Approach for Medical Students

ABCDE assessment, which is also called primary survey is all about looking for immediately life-threatening conditions while at the same time doing lifesaving interventions. Rapid intervention usually includes O2 Support, IV access, the fluid challenge with or without specific treatment. The approach should take no longer than 5 min. It can be repeated as many times as necessary, depending on patient condition. During the ABCDE phase, you may recognize that the situation needs much more experience than critical but straightforward life-saving maneuvers. So, get experienced help as soon as you need it. Because resuscitation efforts need a team approach, If you have one, delegating jobs can help to move steps faster and smoother.

A - Airway

Acute Problems

  • Decreased GCS
  • Excessive secretions
  • Foreign body
  • Inflammation
  • Infection
  • Trauma, and so on.

Assessment

  • Unresponsive patient
  • Added sounds
    • Snoring, wheeze, stridor
  • Accessory muscles use
  • Irregular respiratory pattern

Interventions

  • Head tilt chin lift
  • Jaw thrust
  • Suction
  • Oral airway application
  • Nasal airway application
  • Advanced airway interventions (endotracheal intubation, surgical airway, etc.)

B - Breathing

Acute Problems

  • Decreased GCS
  • Respiratory depressions
  • Muscle weakness
  • Exhaustion
  • Asthma/COPD
  • Sepsis
  • Cardiac event
  • Pulmonary edema
  • Pulmonary embolus
  • ARDS
  • Pneumothorax
  • Haemothorax
  • Flail chest

Assessment

Look

  • Respiratory rate (Apnea/Bradypnea/Tachypnea), symmetry, effort, SpO2, color

Listen

  • Talking: sentences, phrases, words
  • Air entry, wheeze, silent chest other added sounds

Feel

  • Central trachea, percussion, expansion

Interventions

  • Consider ventilation with BVM (Bag-Valve-Mask Ventilation)
  • Consider ventilation with BVM
  • Position upright if struggling to breath (be careful in trauma patient)
  • Specific treatment like β agonist for wheeze, chest drain for pneumothorax

C - Circulation

Acute Problems

  • Loss of volume/Hypovolaemia
  • Pump failure (Myocardial & non-myocardial causes)
  • Vasodilatation (Sepsis, anaphylaxis, neurogenic)

Assessment

  • Look at color
  • Examine peripheries
  • Pulse, BP & CRT
  • Hypotension (late sign)
  • Decreased urine output

Interventions

  • Position supine with legs raised (shock position)
  • Left lateral tilt in pregnancy
  • IV access – 16G or larger x2 (+/- bloods if new cannula
  • Fluid challenge
  • ECG Monitoring
  • Specific treatment

D - Disability

Acute Problems

  • Inadequate perfusion of the brain
  • Sedative side effects of drugs
  • Toxins and poisons
  • Cerebrovascular accident (CVA)
  • Increased ICP

Assessment

  • AVPU (Alert, responds to Voice, responds to Pain, Unresponsive) or GCS
  • Pupil size/response
  • Posture
  • Pain relief

Interventions

  • Optimize airway, breathing & circulation
  • Treat underlying cause (i.e., naloxone for opiate toxicity)
  • Control seizures
  • Seek expert help for CVA or high ICP

E - Exposure

  • Remove clothes and examine head to toe, including patients front and back. 
  • Look for hemorrhage, rashes, swelling, sores, syringe drivers, catheter, etc.
  • Keep the patient warm.
  • Maintain dignity

Reference

  1. Thim T, Krarup NH, Grove EL, Rohde CV, Løfgren B. Initial assessment and treatment with the Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach. Int J Gen Med. 2012;5:117–121. doi:10.2147/IJGM.S28478

Further Reading

Cite this article as: Temesgen Beyene, Ethiopia, "The ABCDE Approach for Medical Students," in International Emergency Medicine Education Project, August 18, 2019, https://iem-student.org/2019/08/18/the-abcde-approach-for-a-medical-students/, date accessed: March 29, 2020

Some Hints About Airway!

Some Hints About Airway!

Introduction

The airway is one of the most critical topics in the ER. Read everything about the airway; it is not a waste of time. Even if you have to spend one year just for airway, it is worth it. You will always be confident in dealing with whatever situation that might come to you. Although reading is essential, practicing and getting experience on airway issues is essential too. So, reading along with exposing many patients is a great combination to achieve good skills.

Build your own skills by reading then summarizing your own words. As long as it is correct and safe, the way accomplishing or securing the airway may not be important in many patients.

Here are some tips in airway management at the Emergency Department (ED)

I will mention some points that might help in the management of typical scenarios at the ED. They might look random, but trust me, it is the real deal.

  • Preparations

  • Attach the patient to monitor
  • Check the vitals,
  • Check saturation continuously,
  • Open IV lines (2x) and attach a bag of normal saline,
  • If the blood pressure is low use pressure cuff on the fluid’s bag,
  • If the patient maintains oxygenation don’t bag, just leave the mask on. Moreover, do not forget; bagging is not a safe procedure.
  • Your equipment’s; choose your tube size depending on the patient’s size, size of the laryngoscope
  • Make capnography ready
  • Call the respiratory therapist, if you don’t have one, you check the ventilation machine by yourself
  • Keep bougie on the side, and SUCTION! Doesn’t matter Yankuer or not anymore, as long as it takes away whatever is on your way. Don’t go too deep to avoid vomiting.
  • Raise the bed highest, keep the level of the patient up to your chest or even higher, the higher the better.
  • Have someone on your side in case you needed tracheal manipulation or pressure to facilitate the view.
  • Pay attention to hemodynamic parameters

  • Never intubate before knowing the blood pressure readings.
  • Never intubate with low blood pressure below 90 systolic.
  • Resuscitate then intubate.
  • Neutral hemodynamic resuscitation (some studies tried the use of paralytic agent alone, with local anesthetic on the glottis, the same idea as awake intubation, in case of hemodynamic instability to avoid the use of induction agents that might decrease hemodynamics). The risk of using multiple doses of an induction agent can cause hemodynamic instability.
  • However, if there is no contraindication, you can think of using ketamine to help boost the blood pressure.
  • Double the dose of your medication if the patient has low cardiac output. As with low cardiac output, the medication won’t reach fast; it might take longer than 4 min. There is no harm in increasing paralytic agents ONLY IF THE AIRWAY IS NOT DIFFICULT. Induction agents can be used as boluses also, but again be careful if the patient is unstable as it might worsen the condition.

Here is a great video summarizing hemodynamic issues in airway management

  • Intubation and beyond

  • Use direct laryngoscopy first, use the old school equipment to keep your skills fresh, but keep the video laryngoscope ready on the side. Some experts recommends using video laryngoscope blade for direct laryngoscope and if you need, just look to the screen.
  • Still failed multiple trials with the laryngoscope? Consider difficult airway. One of the recommendations is to “leave the tube in the esophagus and insert another tube; the other opening is definitely the trachea.” By the way, there are tools to understand the difficulty of the airway, so know and use it.
iEM-infographic-pearls-airway - Assessing Airway Difficulty
  • Rapid Sequence Intubation (RSI) and Delayed RSI: Delayed RSI used mainly in the ICU, and many authors hate this term. However, there is no harm if the patient is maintaining oxygenation, you can give a sedative and look before proceeding to RSI. Just don’t call this approach “RSI.”
  • Rocuronium or Succinylcholine; both will paralyze the patient; it is not about which one is better; it depends on the type of airway you are dealing with. If it is a difficult airway, you do not want to use rocuronium and end up bagging the patient for one hour. Using a short-acting agent is a smart move.
  • However, if it is easy, use it as it would help in paralyzing the patient for an hour, but doesn’t mean the patient is fine, do not forget analgesia/sedation!
  • The tube is in, yay! Good for you, but your work is not done yet. All of us been through the situation where we jump into the airway, insert the tube and leave. This is not a skill lab; it is a real patient. The patient is not moving does not mean he is fine, you paralyzed him but he can still feel. Insert the tube, attach capnography, bag, auscultate, make sure of the level of the tube’s depth, order x-ray STAT then start analgesia/sedation infusion! No matter how naive you are or had a blackout, use midazolam and fentanyl! However, please learn other options too, because different patients may require different agents.
  • Propofol infusion, the bright side of Propofol is its analgesic and sedative effect, although it has a high risk of causing hypotension.
  • The dilemma of which medication to use, as for induction or paralyzing. No one can tell you that one medication is better than the other. Read everything about each medication, understand it, then you make your own mixture.

As long as you keep reading, and updating your knowledge, with of course practice and exposure to different type of situations, you will always know how to deal with every situation.

Further Reading

Cite this article as: AlHanouv AlQahtani, KSA, "Some Hints About Airway!," in International Emergency Medicine Education Project, July 17, 2019, https://iem-student.org/2019/07/17/some-hints-about-airway/, date accessed: March 29, 2020

A 19-year-old female presents with sharp right flank pain and shortness of breath

by Stacey Chamberlain

A 19-year-old female presents with sharp right flank pain and shortness of breath that started suddenly the day prior to arrival. The pain is worse with deep inspiration but not related to exertion and not relieved with ibuprofen. She denies anterior chest pain, cough, and fever. She denies leg pain or swelling and recent travel, immobilization, trauma, or surgery. She has no anterior abdominal pain, no dysuria or hematuria and no personal or family history of gallstones, kidney stones, or blood clots. She’s never had this pain before, has no significant past medical history and her only medication is birth control pills. On exam, her vital signs are within normal range, she has normal cardiac and pulmonary exams, no costovertebral angle tenderness, no chest wall or abdominal tenderness and no leg swelling.

Do you need to do any studies to evaluate this patient for a pulmonary embolism?

Pulmonary Embolism Rule-Out Criteria (PERC)

  • Age ≥ 50
  • Heart rate ≥ 100
  • O2 sat on room air < 95%
  • Prior history of venous thromboembolism
  • Trauma or surgery within 4 weeks
  • Hemoptysis
  • Exogenous estrogen
  • Unilateral leg swelling

The PERC CDR was originally derived and validated in 2004 and with a subsequent multi-study center validation in 2008. In the larger validation study, the rule was only to be applied in those patients with a pre-test probability of < 15%, therefore incorporating clinical gestalt prior to using the rule. PERC is a one-way rule, as mentioned above, which tried to identify patients who are so low-risk for pulmonary embolism (PE) as to not require any testing. It does not imply that testing should be done for patients who do not meet criteria, and it is not meant for risk stratification, as opposed to the Wells’ and Geneva scores.

Case Discussion

In order to apply the PERC CDR to the case study patient, the ED physician pre-supposes a pre-test probability of < 15%. If the ED physician has a higher pre-test probability than that, he/she should not use the PERC CDR. If the ED physician, in this case, did indeed have a pre-test probability of < 15%, the case study patient would fail the rule-out due to her use of oral contraceptives. In that case, the ED physician would need to determine if he/she would do further testing which could include a D-dimer, CT chest with contrast, ventilation/perfusion scan, or lower extremity Doppler studies to evaluate for deep vein thromboses (DVTs). The PERC CDR gives no guidance in this case.

Cite this article as: iEM Education Project Team, "A 19-year-old female presents with sharp right flank pain and shortness of breath," in International Emergency Medicine Education Project, June 17, 2019, https://iem-student.org/2019/06/17/a-19-year-old-female-presents-with-sharp-right-flank-pain-and-shortness-of-breath/, date accessed: March 29, 2020

A 57-year-old man fell from a height comes with neck pain

by Stacey Chamberlain

A 57-year-old man fell from a height of 12 feet while on a ladder. He did not pass out; he reports that he simply lost his footing. He fell onto a grassy area, hitting his head and complains of neck pain. He did not lose consciousness and denied headache, blurry vision, vomiting, weakness, numbness or tingling in any extremities. He denies other injuries. He was able to get up and ambulate after the fall and came in by private vehicle. He has not had previous spine surgery and does not have known vertebral disease. On exam, he is neurologically intact with a GCS of 15, does not appear intoxicated and has moderate midline cervical spine tenderness.

Should you get imaging to rule out a cervical spine fracture?

C-spine Imaging Rules

Canadian C-spine Rule

NEXUS Criteria for C-spine Imaging

  • Age ≥ 65
  • Extremity paresthesias
  • Dangerous mechanism (fall from ≥ 3ft / 5 stairs, axial load injury, high-speed MVC/rollover/ejection, bicycle collision, motorized recreational vehicle)
  • Focal neurologic deficit present
  • Midline spinal tenderness present
  • Altered level of consciousness present
  • Intoxication present
  • Distracting injury present

Both the Canadian C-spine Rule (CCR) and NEXUS Criteria are widely employed in clinical practice to reduce unnecessary cervical spine imaging in trauma patients with neck pain or obtunded trauma patients. The CCR uses mechanism and age criteria, whereas the NEXUS Criteria incorporates criteria including midline tenderness and additional factors that might limit a practitioner’s exam. The CCR can be difficult for some practitioners to remember all the criteria that qualify as a dangerous mechanism and is limited to ages > 16 and < 65. However, it can be used in intoxicated patients if the patients are alert and cooperative, allowing a full neurologic exam. The NEXUS Criteria are applicable over any age range (> 1 year old), but the sensitivity may be low in patients > 65 years of age. A single comparison study found the CCR to have better sensitivity (99.4% versus 90.7%); however, the study was performed by hospitals involved in the initial CCR validation study.

Case Discussion

By applying either criteria to this case, the patient would require C-spine imaging as by CCR, the patient would meet criteria for dangerous mechanism, and by NEXUS, the patient has midline tenderness to palpation.

Cite this article as: iEM Education Project Team, "A 57-year-old man fell from a height comes with neck pain," in International Emergency Medicine Education Project, June 14, 2019, https://iem-student.org/2019/06/14/a-57-year-old-man-fell-from-a-height-comes-with-neck-pain/, date accessed: March 29, 2020