Archive | October, 2016

 CVA (quick ED algorithm)

28 Oct

submitted by Amit Kumar, M.D.

Cerebrovascular Accident: First thoughts…

1) Monitor/stabilize ABCs > POCT glucose > rush to neuroimaging

2) CT/MRI DWI: to differentiate ischemic vs hemorrhagic

3a) If ischemic and within 4.5 hours of last normal: tPA (alteplase)

–0.9mg/kg: Load with 10% (0.09mg/kg) as an IV bolus over 1 minute, followed by 90% (0.81 mg/kg) gtt over 1h

3b) If ischemic and within 6 hours of last normal: endovascular thrombectomy

 

*tPA highly suggested for NIHSS 4-22. Check contraindications.

*Use modified NIHSS (on MDCalc, greater inter-rater reliability, easier)

 

Simultaneous thoughts:

-Have broad differential:

  • hypoglycemia
  • seizure/post-seizure todd’s paralysis
  • infection-induced
  • tox-induced
  • cardiogenic (ex: ACS/STEMI)

 

-No need to micromanage glucose. Reduce if >180 mg/dL, obviously treat if <50 mg/dL

-BP management:

  • If giving tPA (maintain BP <180/110), if not giving tPA (don’t treat unless >220/120).
  • Use titratable IV anti-HTN drugs like labetalol pushes or nicardipine gtt

-Other things that need to happen inpatient (not ED!): HLD panel, HbA1c, carotid dopplers, ECHO, counseling to quit smoking, starting anti-platelet agents (if given tPA, 24 hours after)

 

References:

-Ischemic CVA: https://www.uptodate.com/contents/initial-assessment-and-management-of-acute-stroke?source=search_result&search=CVA&selectedTitle=1~150

-Modified NIHSS: http://www.mdcalc.com/modified-nih-stroke-scale-score-mnihss/

-tPA contraindications: https://www.uptodate.com/contents/image?imageKey=NEURO%2F71462&topicKey=NEURO%2F16134&rank=1~150&source=see_link&search=tpa%20contraindications

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Necrotizing Fasciitis (quick-hits)

10 Oct

submitted by Amit Kumar, M.D.

Diagnosis:

1) Physical exam

-pain out of proportion of external appearance of skin, crepitus, dish-water foul-smelling fluid; rapidly progressive

 

2) Criteria: LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) score

  • CRP >/= 150: 4 points
  • WBC 15-25: 1 point; >25: 2 points
  • Hgb 11-13.5: 1 point; <11: 2 points
  • Na <135: 2 points
  • Creatinine >1.6: 2 points
  • Glucose >180: 1 point

General rule of thumb:

-Score <6: Low risk but not “no risk” (use history, PE, and clinical gestalt)

-Score >6: +NF (PPV of 92% and NPV of 96%)

 

3) Imaging

-CT without contrast (best at assessing for gas within fascial planes)

necfasc_abd-wall

 

Treatment:

  1. Early and aggressive surgical exploration and debridement
    • debridement of all necrotic tissue until healthy, viable tissue is reached
    • reevaluate in OR ~24 hours later, redebride as needed
  2. Broad-spectrum empiric antibiotics
    • Acceptable regimen: carbapenem/b-lactam and b-lactamase + clindamycin + anti-MRSA (example: meropenem/zosyn or unasyn + clindamycin + vanc/linezolid/daptomycin)
  3. Hemodynamic support
  4. +/- hyperbaric oxygen, IVIG?

References:
-UpToDate (https://www.uptodate.com/contents/necrotizing-soft-tissue-infections?source=search_result&search=necrotizing%20fasciitis&selectedTitle=1~101)

-MDCalc (http://www.mdcalc.com/lrinec-score-for-necrotizing-soft-tissue-infection/)

-Picture of CT scan of abdominal wall abscess (http://bariatrictimes.com/necrotizing-fasciitis-of-the-abdominal-wall-after-laparoscopic-roux-en-y-gastric-bypass-by-joanna-r-crossett-md-and-william-v-rice-md/)