Archive | May, 2013

Infective Endocarditis (quick review)

31 May

RAGING HYPOTHETICAL:

your next patient is a 67 year old man with a fever.  previous blood cultures grew out pseudomonas on a recent admission, there’s a nice diastolic murmur, and a CT Chest shows emphysematous changes and one cavitary lesion concerning for hematologic seeding infection.  Can you officially diagnose this as….endocarditis?

 

Duke Clinical Criteria for the Diagnosis of Infective Endocarditis:

(2 major, 1 major and 3 minor, or 5 minor)

Major Criteria:

 • Typical microorganism (Strep Bovis, HACEK group, Staph Aureus, Staph Enterococci) consistent with IE from 2 separate blood cultures

• Microorganism consistent with IE from persistent positive cultures

    •  (2 positive >12 hours apart or all 3 or 3 of 4 drawn 1 hour apart)

Minor Criteria:

• Predisposition: predisposing heart condition or IV drug use

• Fever: temp > 38.0

• Vascular Phenomena: major arterial emboli, septic pulmonary infarcts, mycotic aneurysm, intracranial hemorrhage, conjunctival hemorrhage, and Janeway lesions

• Immunologic Phenomena: glomerulonephritis, Osler’s nodes, Roth spots, and rheumatic fever

• Microbiological Evidence: positive blood cultures not meeting major criteria

• Echocardiographic findings: consistent with IE but not meeting major criteria

 

Indications for Surgery:

• Heart Failure

• Uncontrolled Infection

• Prevention of Embolism

 

Key Points:

• Staph and strep account for a majority of IE cases

• Cerebral complications are the most frequent and most severe extracardiac complications.

• Antibiotics should be held if clinically possible until blood cultures are collected

• ECHO should be performed as soon as possible when IE is suspected

• Indications for surgery include heart failure, uncontrolled infection, and prevention of embolic events.

• Treatment should involve a multidisciplinary team with expertise in cardiology, cardiac surgery, and infectious disease.

• Indications for antibiotic prophylaxis have been restricted to invasive dental procedures in select patients

 

Submitted by K. Dabrowski.

 

References:  Hoen, Bruno, M.D, Ph.D, and Xavier Duval, M.D., Ph.D. “Infective Endocarditis.” N Engl J Med 368: 1425-33.; picture

will you fail to diagnose an epidural abscess?

30 May

According to an article by Davis, et al., the odds are stacked against you.

of 63 spinal epidural abscess patients, diagnostic delays were present in 75%

 

–diagnostic delays, defined as:

1) multiple ED visits before diagnosis

2) admission without a diagnosis of SEA and >24 h to a definitive study.

–Residual motor weakness was present in 45% of these patients vs. only 13% of patients without diagnostic delays

–during the initial visit, “classic triad” of spine pain, fever, and neurologic abnormalities present in:

    • 13% of SEA patients
    • 1% of controls 

SO, HOW DO WE AVOID MISSING THIS?

stay on high alert.  the odds may be stacked against you, but when has that ever stopped us?

 

Tang HJ, et al. article reviewing 46 cases

The initial accurate diagnostic rate was 11%.

 

common history details:

    • diabetes (46%),
    • frequent venous puncture (35%)  — such as with IV drug abuse
    • spinal trauma (24%),
    • history of spinal surgery (22%).

 

common symptoms:

    • Localized spinal pain (89%),
    • paralysis (80%),
    • fever/chills (67%),
    • radicular pain (57%)

erythrocyte sedimentation rate (ESR) was elevated uniformly (mean, 86.6 mm/h) when measured.

Staphylococcus aureus was the most common cause 

BOTTOM LINE:

epidural abscess is tough to diagnose early. 

good luck. stay on high alert.

References: J Emerg Med. 2004 Apr;26(3):285-91. The clinical presentation and impact of diagnostic delays on emergency department patients with spinal epidural abscess. Davis DP, et al.; J Infect. 2002 Aug;45(2):76-81. Spinal epidural abscess–experience with 46 patients and evaluation of prognostic factors. Tang HJ, et al.; picture

pneumothorax from mother’s kiss?

29 May

Recently heard someone mention they stopped using the Mother’s Kiss technique for nasal foreign bodies due to risk of pneumothorax.  

QUICK REVIEW OF MOTHER’S KISS TECHNIQUE:

  • parent places mouth over the child’s open mouth, forming a firm seal as if about to perform mouth-to-mouth resuscitation
  • While occluding the unaffected nostril with a finger, the adult then blows until they feel the resistance caused by closure of the child’s glottis
  • at which point the adult gives a sharp exhalation to deliver a short puff of air into the child’s mouth
  • hopefully, nasal foreign body (and some snot–messy) comes flying out

 

While this idea makes sense as a possibility (sudden positive pressure from mom without a release valve–though its not usually a perfect seal–might pop a lung in theory), wondered if there’s any data out there that addressed this theoretical risk.
PUBMED SEARCH:

yielded not a ton. pretty much this:

Efficacy and safety of the “mother’s kiss” technique: a systematic review of case reports and case series, by Cook S, et al.

review of 8 articles

overall success rate: 59.9% (91/152)

No adverse effects were reported.

“a ruptured tympanic membrane or pneumothorax resulting from this technique has never been reported” (article published Nov 2012)

  • glottis is closed during the technique, so there is little risk of barotrauma to the lungs
  • the pressure used is low, comparable with that generated during sneezing (about 60 mm Hg)

possible confounder: reporting bias (Positive results tend to be published more frequently than negative results)

 

BOTTOM LINE:

according to the data we have, mother’s kiss seems safe.  worth keeping in the toolbox.

 

References: article; pic 1; pic 2

face mask ventilation: 2 hands are better than 1

28 May

from May’s JEM:

 

comparison of 3 techniques for face-mask ventilation:

one-handed C-E

    • median volume 428.4 mL
    • median peak pressure  54.6 cm H2O

tw0-handed C-E

    • median volume 550.8 mL
    • median peak pressure 66 cm H2O

two-handed V-E

    • median volume 538 mL
    • median peak pressure 66.6 cm H2O

 

BOTTOM LINE:

two handed techniques had better median volume & peak pressure than one-handed

if you have the extra hands, two seems to be better than one, for bag-mask ventilation

V-E seems to work as well as C-E; would be a nice addition to your toolbox

 

References: JEM article; ACEP focus; one-handed picture, two-handed picture

stress and burnout

24 May

something light for the weekend.  

nice quick read in the AAEM Common Sense mag on stress and burnout.  

basic concepts, but never hurts to be reminded to find a good work/life balance. 

 

CHOICE QUOTES:

live on less than you bring home

 

value your free time…if it helps, schedule the time and do not cancel that “appointment”

 

make that day off count!

 

do not work for those that…take all you have to give yet give nothing back

 

References: article; picture

lipohemarthrosis by ultrasound

23 May

JEM article covers the basics, with some nice visual aids:

WHY DO I CARE?

lipohemarthrosis suggests intraarticular fracture

sometimes hard to see on X-ray (can miss up to 21% of fx’s)

also, what if X-ray’s are down/unavailable?

 

WHERE TO PUT THE ULTRASOUND:

suprapatellar bursa

 

WHICH PROBE?

linear transducer (we’re not looking too deep here)

 

WHAT TO LOOK FOR:

a = fat (anechoic spheres of fat help identify this layer)

b = serum

c = blood cells

probably is better seen the more time has passed after trauma (takes time to layer out)

 

 

 

 

 

 

 

References: article; x-ray; picture 1; picture 2

Venomous Snakes – Part 2: what do they do, and what should I do?

22 May

Venom

-Local effects mainly secondary to enzymatic action on various structures; Hemorrhage, coagulation, anticoagulation, hemolysis, cell lysis, can all occur.

-Systemic effects can include

  • disruption of the coagulation cascade,
  • increased capillary membrane permeability,
  • DIC,
  • pulmonary edema,
  • shock.
  • Some patients can even develop allergic reactions to venom.

 

Clinical Course

Severe pain around site of bite is common

-Edema surrounding the bite generally increases spreading proximally

Compartment syndrome is highly unlikely since most fangs DO NOT penetrate fascial compartments

Petechiae, ecchymoses, and even hemorrhagic bullae can all occur

Systemic symptoms: nausea, vomiting, sweating, numbness, muscle fasciculations, and hypotension can all occur

 

Grading Envenomation

-Grade 0- Snakebite suspected but no evidence of envenomation with minimal swelling

-Grade 1- Minimal envenomation with surrounding 1-5 inches of edema/erythema, and NO systemic involvement

-Grade 2- Moderate envenomation with more severe edema spreading toward trunk; petechiae/ecchymoses around the area of edema.
Nausea/vomiting possible.

-Grade 3- Severe envenomation. Rapidly worsening course with edema spreading up the extremity to the trunk. Generalized petechiae/ecchymoses possible. Labwork anomalies including thrombocytopenia/coagulation factors.

-Grade 4- SEVERE envenomation. The most severe type. Similar to Grade 3 but more severe systemic effects including hypotension, coma.

 

Labwork

-Assess for CBC (looking at platelets)

-Assess coagulation factors (PTT, INR)

-Consider fibrinogen/D-dimer

-Consider CK

-Consider CMP

 

Treatment

-Great history is essential

Try to determine type of snake

Time of bite

-Location of bite or bites

Last tetanus?

Measure circumferences to determine changes in swelling and effectiveness of antivenin

-Assess whether this was a wet or dry bite

-Look for signs of swelling, ecchymoses, systemic signs/symptoms

Consider use of CroFab based on grade of envenomation

Clean the wound, elevate and immobilize the extremity

-Physical therapy may be needed to prevent contractures

-Patients are generally admitted for observation

 

Submitted by J. Grover. 

 

References: Rosen’s Emergency Medicine. 7th Edition.; picture