Torticollis (quick review)

21 Mar

submitted by Christina Brown, M.D. 

 

Definition – “Twisted neck” (L. tortus, twisted + collum, neck).29727

Synonyms: Cervical dystonia, wry neck

Self-limited, symptoms resolve in 1 to 2 weeks

Possible Etiologies:

  • Fracture
  • Dislocation, subluxation
  • Cervical spine disease
  • Infections
  • Spondylosis
  • Tumor
  • Scar tissue–producing injuries
  • Ligamentous laxity in atlantoaxial region
  • Drug induced
  • Otolaryngologic:
    • Vestibular dysfunction, Otitis media
    • Cervical adenitis, Pharyngitis, Retropharyngeal abscess
    • Mastoiditis
  • Esophageal reflux
  • Syrinx with spinal cord tumor

 

Physical Exam

  • Intermittent painful spasms of sternocleidomastoid (SCM), trapezius, and other neck muscles
  • Head is rotated and twisted to one direction

 

Management:

Imaging

  • Plain film if cervical fracture is suspected.
  • CT or MRI of cervical spine if retropharyngeal abscess or tumor suspected

INITIAL STABILIZATION/THERAPY: Cervical spine immobilization if fracture is suspected

ED TREATMENT/PROCEDURES

  • Soft collar and rest,
  • Physical therapy,
  • Massage,
  • Local heat,
  • Analgesics

 

MEDICATION:

  • Diphenhydramine (for drug-related dystonia)
  • Valium: 2–5 mg IV, 2–10 mg PO t.i.d. (peds: 0.1–0.2 mg/kg per dose IV or PO q6h)
  • Botulinum toxin is an option for treating non-drug-induced torticollis, though this is not typically administered in the ED setting.

 

References:
1. Schaider, J. & Barkin, R. & Hayden, S. & Wolfe, R. & Barkin, A. & Shayne, P. & Rosen, P. (2011). Torticollis. Rosen’s and Barken’s 5-Minute Emergency Medicine Consult. http://www.r2library.com.proxy.its.virginia.edu/Resource/Title/1608316300/ch0020s16613
2. Harries PG. Retropharyngeal abscess and acute torticollis. J Laryngol Otol 1997; 111:1183.
3. Soundappan SV, Darwish B, Chaseling R. Traumatic spinal epidural hematoma-unusual cause of torticollis in a child. Pediatr Emerg Care 2005; 21:847.
4. Mutsaers P, Fick M, Plötz FB. Acquired torticollis as the only initially presenting symptom in a child with a brainstem glioma. Eur J Pediatr 2007; 166:1075.
5. Shanker V and Bressman S.: What’s new in dystonia? Curr Neurol Neurosci Rep. 2009; 9:278–284.

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Cauda Equina Syndrome

16 Mar

submitted by Christina Brown, M.D. 

 

Definition – Compression of lumbar and sacral nerve fibers in cauda equina region

back-pain-image-2
RISK FACTORS 

  • Neoplasm
  • IV drug use
  • Immunocompromised state.

ETIOLOGY

  • Herniated disc most common:
    • L4–L5 discs > L5–S1 > L3–L4
    • Most common in 4th and 5th decades of life
    • Mass effect from: Myeloma, lymphoma, sarcoma, meningioma, neurofibroma, hematoma
    • Spine metastases (breast, lung, prostate, thyroid, renal)
    • Epidural abscess (especially in IV drug users
  • Blunt trauma
  • Penetrating trauma

 

SIGNS and SYMPTOMS

  • Low back pain
  • Sciatica/radicular pain (unilateral or bilateral)
  • Lower extremity numbness or weakness
  • Difficulty ambulating owing to weakness or pain
  • Bladder or rectal dysfunction (Retention or incontinence)

 

Physical Exam

  • Lumbosacral tenderness
  • Lower extremity sensory or motor deficits (May be asymmetric)
  • Decreased foot dorsiflexion strength
  • Decreased quadriceps strength
  • Decreased deep tendon reflexes
  • Saddle hypalgesia or anesthesia
  • Decreased anal sphincter tone


Postvoid residual volume (PVR):

  • Estimate by bladder catheterization or using US.
  • >100 mL is considered abnormal.
  • Residual increases with age.

 

Labs – Depends on differential diagnosis. Options include CBC, urinalysis, ESR, and C reactive protein (CRP)

IMAGING – MRI of spine is definitive study. CT myelogram if MRI unavailable

ED Treatment/Procedures:

  • Immediate neurosurgical consultation in all cases
  • Initiate antibiotics for epidural abscess in consultation with neurosurgery.
  • Controversy exists regarding urgency of decompression:
    • Recommendations range from within 6 hr of onset to within 24 hr.

 

Disposition:

  • All patients with acute cauda equina syndrome must be admitted to neurosurgical service.
  • Patients have good prognosis with rapid surgical decompression.
  • Treatment should not be delayed.
  • Patients presenting late (>48 hr) also benefit from surgical decompression.

 

References:

1. Fraser S, Roberts L, and Murphy E.: Cauda equina syndrome: A literature review of its definition and clinical presentation. Arch Phys Med Rehabil. 2009; 90(11):1964–1968.
2. Hussain S A, Gullan R W, and Chitnavis B P.: Cauda equina syndrome: Outcome and implications for management. Br J Neurosurg. 2003; 17(2):164–167.
3. Shapiro S.: Medical realities of cauda equina syndrome secondary to lumbar disc herniation. Spine. 2000; 25(3):348–352.
4. Schaider, J. & Barkin, R. & Hayden, S. & Wolfe, R. & Barkin, A. & Shayne, P. & Rosen, P. (2011). Cauda Equina Syndrome. Rosen & Barkin’s 5 Minute Emergency Medicine Consult.

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Peds “step by step”(for FWS)

27 Feb

submitted by Amit Kumar, M.D.

 

“Step by Step”

-Algorithm to identify pediatric patients (<90 days) with fever without a source (38°C, in patients with a normal PE and no respiratory symptoms or a diarrheal process) as low risk for invasive bacterial infection

-Developed by European group of EPs, validated

-Identifies “low risk” group not requiring LP and empiric antibiotics, and fit to be managed outpatient

-Found to be more sensitive than Rochester Criteria and Lab-score

step-by-step-algorithm

(Pediatric Assessment Triangle = appearance, work of breathing, circulation)

(PCT = procalcitonin)

-There, add it to your toolbox!

References:
Gomez, B., Mintegi, S., Bressan, S., Dalt, L. D., Gervaix, A., & Lacroix, L. (2016). Validation of the “Step-by-Step” Approach in the Management of Young Febrile Infants. Pediatrics, 138(2). doi:10.1542/peds.2015-4381

Pediatric assessment triangle article

NEPHROLITHIASIS (quick review)

10 Feb

submitted by Christina Brown, M.D. 

Kidney stones:anatomy_kidneystones

  • Most common cause of renal colic
  • Stone composition:
    • 80%: Calcium stones (calcium oxalate > calcium phosphate)
    • 5% uric acid
    • Others: Magnesium ammonium phosphate (struvite), cystine
  • Associated with infections caused by urea-splitting organisms (eg, Pseudomonas, Proteus, Klebsiella) along with an alkalotic urine
  • 90% of urinary calculi are radiopaque.

 

Epidemiology and Etiology

  • 1% of the population
  • Twice as common in men as women
  • Theories on stone formation:
    • Urinary supersaturation of solute followed by crystal precipitation
    • Decrease in the normal urinary proteins inhibiting crystal growth
    • Urinary stasis from a physical anomaly, catheter placement, neurogenic bladder, or the presence of a foreign body

 

Pediatric Considerations

  • Rare in children
  • When present, indication of an overt metabolic or genetic disorder
  • Painless hematuria common presentation (up to 30%)

 

Causes of stone formation:

  • Metabolic abnormalities (50%)
  • Urologic abnormalities (20%)
  • Infection (15%)

 

History

  • Sudden onset of severe pain in the costovertebral angle, flank, and/or lateral abdomen
  • Colicky or constant pain: Patient cannot find a comfortable position
  • Hematuria: Gross hematuria in 1/3 of patients
  • Nausea/vomiting

 

ESSENTIAL WORKUP

  • Urinalysis
  • Microscopic hematuria present in >80%
  • Gross hematuria
  • Absent urinary blood in 10–30%
  • No correlation between the amount of hematuria and the degree of urinary obstruction
  • WBC/bacteria suggests infection

 

Imaging – CT:

  • Helical CT has replaced IV pyelogram (IVP) as test of choice.
  • Detects calculi as small as 1 mm in diameter
  • Advantages over IVP:
    • Performed rapidly
    • Does not require IV contrast media
    • Detects other non-urologic causes of symptoms, such as abdominal aortic aneurysms (AAAs)
  • Indications:
    • 1st-time diagnosis
    • Persistent pain
    • Clinical confusion with pyelonephritis

 

Renal Ultrasound:

  • unilateral hydronephrosis suggests possible obstructive stone
  • no radiation involved, but does not eval for non-urologic causes of symptoms

 

ED TREATMENT/PROCEDURES

  • Hydration:
    • Initiate IV crystalloid infusion with 1 L of normal saline infused over 30–60 min followed by 200–500 mL/hr.
    • Bolus volume compromised patients with 500-mL increments until urine output adequate
  • Analgesics (morphine, ketorolac):
    • Combination of IV NSAIDS and opioids decrease ED stay.
  • Antiemetics (prochlorperazine, ondansetron, droperidol, hydroxyzine)
  • α-Blockers (tamsulosin) or calcium-channel blockers (nifedipine) have been shown to decrease time to spontaneous stone passage:
    • Most efficacious for stones <5 mm in diameter
    • Tamsulosin and nifedipine equally effective
    • prescribe on discharge.

 

DISPOSITION

Admission Criteria

  • Obstruction in the presence of infection mandates immediate urologic intervention.
  • Intractable pain with refractory nausea and vomiting
  • Severe volume depletion
  • Urinary extravasation
  • Hypercalcemic crisis
  • Solitary kidney and complete obstruction
  • Relative admission indications (discuss with urologist):
    • High-grade obstruction
    • Renal insufficiency
    • Intrinsic renal disease
    • Stones of size <5 mm usually pass spontaneously; those >8 mm rarely do.

Discharge Criteria

  • Normal vital signs
  • No evidence of concomitant urinary tract infection
  • Adequate analgesia
  • Able to tolerate PO fluids to maintain hydration status

 

PEARLS AND PITFALLS

  • Do not miss a vascular catastrophe mimicking as renal colic.
  • Aggressive pain management and hydration promote passage of stones
  • The absence of hematuria does not exclude the diagnosis of acute renal colic.

 

References:
1. Bartosh S M.: Medical management of pediatric stone disease. Urol Clin North Am. 2004; 31:575–587. [PMID: 15313066]
2. Hollingsworth J M, Rogers M A, and Kaufman S R et al.: Medical therapy to facilitate stone passage: A meta-analysis. Lancet. 2006; 368:1171–1179.
3. Marx J A, Hockberger R S, and Walls R M: eds. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 7th ed.St. Louis, MO:Mosby;2009.

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VASOPRESSORS & INOTROPES (PEARLS)

2 Feb

Submitted by Amit Kumar, M.D.

RECEPTOR PHYSIOLOGY:

Alpha 1: In vascular walls; causes: vasoconstriction

Beta 1: In heart; causes: increased inotropy & chronotropy

Dopamine: In renal, splanchnic, cerebral, coronary vascular beds; causes: vasodilation

Vasopressin: V1 receptors in vessels; causes: vasoconstriction, V2 receptors in kidney; maintains osmolality via ADH

pressors_tintinallis

AGENTS:

VASOPRESSORS (A-1 adrenergic):

Norepinephrine (Levophed):

  • Works on A1 and B1 receptors
  • Causes: Potent vasoconstriction (+reflex bradycardia) and modest increase in CO; latter negated by reflex tachycardia
  • 1st line treatment for septic shock
  • 0.5-10mcg/min, titrate up

Phenylephrine (Neo-Synephrine):

  • Works on A1
  • Causes: Potent vasoconstriction
  • 100-180mcg/min. Once BP stable, titrate down to 40-60mcg/min

Epinephrine (Adrenalin)

  • Works primarily on B1, some on A1 and B2. Increase A1 activity in higher doses
  • Causes: Increased CO. At higher doses causes vasoconstriction as well.
  • 1st line for anaphylactic shock, 2nd line for septic shock
  • 0.1-4mcg/kg/min

Dopamine (Intropin)

  • Doses 2-5mcg/kg/min: dopaminergic (vasodilation);
  • 5-10mcg/kg/min: B1 (increased CO);
  • >10mcg/kg/min: A1 (increased vasoconstriction)

INOTROPE (B-1 adrenergic):

Dobutamine (Dobutrex)

  • Works on B1
  • Causes: Increased CO (+ reflex vasodilation)
  • 2.5-20mcg/kg/min

INOTROPE (PDE-inhibitor):

Milrinone (Primacor)

  • Optional loading dose: 50mcg/kg over 10 mins, followed by 0.125-0.75mcg/kg/min

ADH:

Vasopressin (Pitressin)

  • 0.03-0.04U/min
  • Causes: vasoconstriction

GENERAL CONCEPTS:

-Avoid reflex hypotension by titrating pressors down

-Gold standard: use central lines. For extravasation, use phentolamine 5-10mg SC including through the infiltrated line.

-Hypovolemia should be corrected first to achieve maximal vasopressor efficacy

-Do not use low-dose dopamine solely for “renal protection”/to increase UOP

REFERENCES:

-Dellinger RP, Levy MM, Rhodes A, et al. Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med 2013; 41:580.?

-Hollenberg SM. Vasoactive drugs in circulatory shock. Am J Respir Crit Care Med 2011; 183:847.?

-Picture: Tintinalli’s

ovarian cysts (quick review)

23 Jan

submitted by Christina Brown, M.D.

Follicular cysts:

  • Most common
  • Occur from fetal life to menopause
  • Unilocular; diameter 3–8 cm
  • Thin wall predisposes to rupture, which usually causes minimal or no bleeding.
  • Rupture during ovulation at midcycle is known as mittelschmerz.

Corpus luteal cysts:

  • Most significant
  • Diameter 3 cm, but usually <10 cm
  • Rapid bleeding from intracystic hemorrhage causes rupture.
  • Rupture is most common just before menses begins.
  • Can cause severe intraperitoneal bleeding
  • Gradual bleeding into cyst or ovary distends capsule and may cause pain without rupture.

 

Etiology:fig16

  • Follicular cysts result from non-rupture of mature follicle or failure of atresia of immature follicle.
  • Corpus luteal cysts result from unrestrained growth in early pregnancy or from normal intracystic hemorrhage days after ovulation.
  • Other cysts:
    • Theca lutein
    • Cystic teratoma
    • Endometrioma (chocolate cyst)

History

  • Abdominal pain
    • Sharp, unilateral
    • Intermittent vs. constant
    • Migration
    • Previous episodes
    • May occur with exercise, intercourse, trauma, or pelvic exam
  • Fever is rare.
  • Irregular menses (may suggest polycystic ovary syndrome).

 

Physical Exam

  • Abdominal tenderness (mild to severe with peritonitis)
  • Adnexal tenderness
  • Pelvic mass
  • Hemorrhagic shock possible:
    • Usually from corpus luteal cyst rupture
    • Orthostasis, hypotension, tachycardia

Lab work:

  • Urine or serum human chorionic gonadotropin determination
  • CBC
  • Urinalysis
  • If significant hemorrhage, type and cross packed RBCs
  • Cervical cultures to rule out PID

Imaging
Transvaginal US:

  • Adnexal cysts and masses:
    • Cystic masses <5 cm in premenopausal women generally benign
    • Should be reevaluated at end of menstruation
  • Pelvic free fluid

CT:

  • May demonstrate cysts or evidence of torsion or suggest alternative diagnosis
  • May provide enough information to proceed to laparoscopy if abnormal ovary and no other cause of pain identified
  • Uterus may be shifted to side of torsed adnexa.
  • Ascites may be present.

Disposition – If hemorrhagic conversion due to ruptured ovarian cyst, admit to Gynecology.
FOLLOW-UP RECOMMENDATIONS:  If pain is resolved and cyst is <4–5 cm, close follow-up is recommend with gynecology for further studies.

 

References:
Schaider, J. & Barkin, R. & Hayden, S. & Wolfe, R. & Barkin, A. & Shayne, P. & Rosen, P. (2011). Ovarian Cyst/Torsion. Rosen’s 5-minute EM Consult.
Bottomley C and Bourne T.: Diagnosis and management of ovarian cyst accidents. Best Pract Res Clin Obstet Gynaecol. 2009; 23:711–724.
McWilliams GDE, Hill M J, and Dietrich C S.: Gynecologic emergencies. Surg Clin North Am. 2008; 88:265–283.

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modified valsalva maneuver (quick reference)

12 Jan

for a more in-depth look, check out last May’s ACEP Now article.

brief highlights:

  • 428 patient study
  • modified valsalva maneuver
    • forced strain (e.g. blow into 10 cc syringe)
    • lie patient flat
    • elevate legs to 45 degrees x 15 seconds
  • return to sinus rhythm at 1 minute:
    • 43% with modified valsalva
    • 17% standard valsalva (strain x 15 sec, no position change)
    • NNT = 4

 

quick visual aid (start at the 1:17 mark if short on time):

 

There you go.  Add it to the toolbox.

References: ACEP Now article; video