Monthly Archives: December 2023

Conference Notes December 2023

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Conference notes 12/6

  • Ovarian cysts, rupture, and torsion (Dr. Williams)
    • Ovarian cysts: If cyst size is greater than 10cm consider OB consult for potential surgery
    • Infundibulopelvic ligament (suspensory ligament) contains the ovarian aa, vv, nn and is cause of ovarian torsion
    • If concerned for torsion and US inconclusive can get MRI
  • PID (Dr. Mattingly)
    • Most common in 18-44 yo F
    • Physical exam findings: lower abdominal tenderness, cervical motion tenderness, cervical purulent drainage, adnexal tenderness or mass
    • Admission criteria: severe n/v, fever, pelvic abscess ruptured TOA, need for invasive diagnostic eval, unable to tolerate PO, concern for nonadherence
    • IP Tx: ceftriaxone and doxycycline+ flagyl, OP: ceftriaxone 1x then doxycycline + flagyl x 14d
  • Perimortem C Section (Dr. Boland)
    • Gravid uterus can compress IVC impeding venous return> compressions w L lateral uterine displacement can alleviate this pressure
    • If fundus height at or above the umbilicus and ROSC is not achieved> recommend perimortem c-section (estimated gestational age >24wks)
    • Should be considered at 4 minutes after the onset of maternal cardiac arrest or resuscitative efforts
    • Do not attempt to take to the OR for the procedure
  • Operations Update (Dr. Ross)
    • If an abortion presents to ED and ‘fetal tissue’ is removed, a series of forms regarding remains, cremation, and ‘death certificate’ must be completed by nursing staff.
    • Minors cannot give consent for cremation/disposal of fetal remains. If the patient refuses to tell their guardian about the pregnancy and abortion- ULH will manage tissue. ** Dr. Ross is in the process of confirming this.
    • ‘Fetal tissue’ must be sent to pathology.
    • CAR T-Cell Therapy Adverse Events: CRS (cytokine release syndrome- patients appear septic, fever, tachy, hypoxic, dyspneic, hypotensive) vs ICANS (Immune-effector cell-associated neurotoxicity syndrome- AMS, seizures, cerebral edema). Will be admitted to BMT. BMT Cytokine release syndrome and ICANS management order set on Cerner
  • Preeclampsia and Eclampsia (Drs. Huttner and Stults)
    • HTN in pregnancy = >140/90 (gestational = diagnosed >20wks gestation and resolves after 12 wks post partum)
    • Pre-eclampsia: HTN w proteinuria (protein/Cr ratio >0.3 or 2+ protein on urine dipstick) or evidence of end-organ damage
      • PLT< 100,000
      • Cr> 1.1
    • Ecclampsia:
    • Pathophys- abnormal placentation leading to poor placental perfusion and hypoxia-reperfusion injury. Inflammatory markers target maternal endothelium.
    • Sxs: elevated BP, SOB, rapid weight gain, pitting edema (hands/face), decreased UOP, AMS, RUQ/epigastric pain, HA
    • Labs: thrombocytopenia, incr Cr/AST/ALT (HELLP), LDH (hemolysis), coagulopathy
    • Severe Pre-E management:
      • Seizure ppx: Magnesium
      • BP management
        • Labetalol, hydral, nifedipine
      • BP goal: decrease MAP by 20% in the first several hours
      • Labetalol 20 mg IV  q30 min total 300 mg
      • Hydral 10 mg IV q 20 min total 30 mg
      • Mag 4-6 g IV
      • Deliver at 37 weeks if regular pre-e; if severe: deliver at 34 wks
    • Eclampsia management
      • L Lat decubitus position
      • RSI if needed
      • Seizure treatment
        • Mag 4-6g bolus (over 20 min) followed by 1-2 g/hr infusion
        • Benzos if refractory
      • Delivery of fetus
    • Complications: pulmonary edema, MI, stroke, ARDS, coagulopathy, renal failure, retinal injury
    • Dispo: pre-e wo severe features likely dc, severe or eclampsia: admit

Conference 12/13

  • Hyperemesis Gravidarum (Dr. Taylor)
    • Severe nausea/vomiting
    •  Weight loss >5% of pre-pregnancy weight
    • Onset <9 weeks gestation
    • Occurs in 0.3-3% of pregnant patients
    • Symptoms resolve 20-22 weeks
    • Risk factors
      • Family hx
      • Prior pregnancy with hyperemesis gravidarum
      • Hx of motion sickness, migraines
      • N/v related to estrogen medications
    • PUQE score to determine severity, based on duration, number of episodes of emesis
    • Complications
      • Dehydration
      • Electrolyte derangements
      • Mallory Weiss tear/esophageal injury
    • Treatment
      • For DC: Pyridoxine +/- doxylamine
      • In ED: IVF, diphenhydramine, metoclopramide, promethazine, prochlorperazine, Zofran is controversial
  • Labor (Dr. Blair)
    • Shoulder Dystocia
      • HELPERR mnemonic
        • Help (call for help)
        • Empty bladder
        • Leg- McRoberts
        • Pressure- Suprapubic
        • Enter- Rotational maneuver
        • Remove posterior arm
        • Roll the patient onto her hands and knees
    • Umbilical cord prolapse
      • Have mom stop pushing
      • Use hand to elevate presenting part and decrease compression of cord
      • Attempt to not manipulate cord> can lead to vasospasm
    • Post-Partum Hemorrhage
      • Most common> uterine atony
        • Fundal massage
        • Oxytocin 10u IM/40 u in 1 L
        • Misoprostol 800-1000 mcg rectal or buccal
        • Methergine 0.2 mg IM/IV q2-4hr PRN
  • Neonatal (Dr. Bhargava)
    • Neonatal conjunctivitis
      • Often without fever, just discharge
      • Ddx: gonorrhea vs chlamydia
        • Gonorrhea- first week of life
        • Chlamydia- day 7-14 of life
          • Pneumonia is common complication
      • Management:
        • Admit for abx
    • Neonatal mastitis
      • Etiology staph aureus
      • Dispo: admit for abx, drain abscess if present
      • Peak incidence at 2wks of life
      • Complications: cellulitis, necrotizing fasciitis, osteomyelitis
    • Neonatal seizures
      • Often focal- lip smacking or leg pedaling
      • Causes: hypoxic-ischemic encephalopathy, infection, ICH, metabolic abnormality, meningitis
      • First line tx is phenobarbital
    • Inconsolable infant
      • Easily consoled without source of crying> can be discharged
      • IT CRIES, causes for crying infant
        • Intussusception
        • Trauma
        • Cardiac
        • Rectal/anal fissures/reflux
        • Ingestion
        • Exposure, eyes (corneal abrasion, FB)
        • Sepsis, strangulation (hernia)
      • Hair tourniquet
        • Try application of Nair (less than 10 mins)
        • If color of extremity/ physical exam does not improve> cut down to bone with scalpel
    • Newborn rashes
      • Erythema toxicum neonatorum:
        • papules, pustules, erythema
      • Herpes simplex:
        • lesions are vesiculopustular on ill appearing neonate
      • Milia:
        • 1-1 mm pearly keratin plugs
      • Neonatal cephalic pustulosis:
        • unclear etiology, can be inflammatory reaction.
        • Tx daily cleaning with soap and water ***
      • Seborrheic dermatitis
        • Yellow flaky, often starts in scalp
        • Typically resolves in weeks to month
        • Can use emollient or low potency steroid
        • Ketoconazole shampoo if severe
    • Hypoglycemia
      • Rule of 50s
        • < 1 year old use D10 (5 mL/kg)
        • 1-8 years old use D25 (2mL/kg)
        • Greater than 8 years old D50 (1mL/kg)
    • Jaundice
      • ABO incompatibility: first day of life. Typically, mother’s blood type is O and Baby is A or B
      • Physiologic jaundice: seen at day 2-3 due to decreased conjugation of bilirubin due to immature liver
      • Severe neonatal hyperbilirubinemia
        • T bili > 25 mg/dL
        • Bili crosses BBB and causes neurologic dysfunction
    • Lower GI bleed
      • Meckel diverticulum is most common cause at 2y of age
      • Milk protein allergy should be suspected after introduction of new formula
      • NEC is complication of premature infants and presents with. Abdominal distension, bloody stools and feeding intolerance
      • To eval for swallowed mother’s blood as cause of blood in stool can use Apt Test
    • Pediatric vital signs
      • For children >1 y old SBP= 70+2x age (lower limit of normal)
    • Abdominal wall defects
      • Omphalocele
        • Often with other congenital defects
        • Membranous covering over abdominal contents
      • Gastroschisis
        • Direct exposure of abdominal contents
    • Omphalitis
      • Most often cause s. aureus
      • Presents before 14 days of life
      • Can become necrotizing fasciitis or sepsis
      • High morbidity and mortality rates
    • Intestinal malrotation
      • AXR: double bubble sign
      • Upper GI series: corkscrew sign
      • AIR in biliary tree is most often seen with NEC

Respiratory Distress 102: The Land Between NC and ETT

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ABCs. Airway and breathing are two-thirds of that three letter dogma we etch into our brain. It should make sense then that as EM physicians we pride ourselves on managing them. We’ve probably all patted ourselves or our colleagues on the back for that difficult intubation. It is sometimes the tendencies of younger physicians to jump for the video scope and intubate that patient who seems to be struggling. While I think we do a wonderful job mastering this, the point of this post is to promote mastery in avoiding having to use this skill.

Simple Oxygen Delivery

“Simple” oxygen refers to non-invasive delivery of an increase in FiO2. This can mean anything from a nasal canula, to tents, masks, trach masks, and non-rebreathers. This should be your first choice for hypoxemia but likely won’t help much in someone who needs a little extra pressure support (ex. COPD exacerbation, CHF exacerbation, flash pulmonary edema). This means that while the oxygen being delivered is increased, the flow and pressure won’t be.

There are a few points to make note of when using simple oxygen. Generally speaking, “room air” is around 21% oxygen. With each liter of oxygen via NC, you add around 4%. I note this because some of our adjuncts provide 100% FiO2, which would require 20 L via NC to equate, which is impossible. If you move up the oxygen ladder to simple masks, they follow the same rules with one exception: you must maintain at least 5 L of flow to prevent rebreathing. Similarly, a non-rebreathing mask must maintain usually around 8 L, or at least enough to keep the bag inflated. There are other modes available and variable, but we will move on.

High Flow Nasal Cannula

High flow nasal cannula, or HFNC, is like simple oxygen’s big brother. Its primary use is again hypoxemic respiratory failure, but with the added benefit of flow. Contrary to simple oxygen, you set both an FiO2 and flow. The benefit of this is that for every 10 L/min of flow, you get approximately 1 mmHg of PEEP. This may not seem much, but considering that CPAP/BiPAP oftentimes start at 5 mmHg of PEEP, and that HFNC can max at 60 L, this can actually add up. Generally speaking, in adults we start at 0.5 L/kg/min to a max of 60 L, and start at 100% FiO2 and wean as able. In children, FiO2 starts at 40% and flow is based on weight.

A benefit of HFNC, apart from the oxygen, is that it affords a way of delivering pressure to someone who might either benefit from a small amount of support, or who could otherwise tolerate a more invasive way of delivering it (CPAP and BiPAP). It isn’t uncommon that patients who are in respiratory distress also do not want a tight mask over their face. While there are ways of easing this anxiety with verbal coaching or anxiolytics, it isn’t a guarantee that they’ll be able to tolerate the mask and this may be a more comfortable option.

CPAP/BIPAP

The final section in this short overview is CPAP/BPAP. Where HFNC provides a small amount of PEEP, CPAP and BPAP exist to provide pressure to aid in respiration. This helps to recruit alveoli, increase lung compliance, and increase oxygenation. It would explain why COPD/CHF exacerbations do well with it. It simply takes more pressure to overcome their disease process, but oftentimes with a little extra help the patient can do this without an ET tube. Studies have shown that CPAP/BPAP decrease both intubation and mortality in cardiogenic pulmonary edema and COPD exacerbation.

The best way of explaining the difference between the two is to look at the names. CPAP stands for continuous positive airway pressure. It would make sense then that you would set a pressure (the PEEP) and that would be the setting. Building on this, it would mean that this pressure is being delivered throughout the respiratory cycle, with no difference between inspiratory and expiratory. So, CPAP is beneficial for hypoxia in CHF exacerbation because this pressure works to stent open alveoli that pulmonary edema may have impacted, to improve oxygenation, but may not do much to help with work of breathing since there is no additional inspiratory pressure.

This is where BiPAP comes in. BiPAP stands for bilevel positive airway pressure. Bilevel insinuates two levels, which is exactly the benefit of BiPAP. Those two levels are IPAP (inspiratory pressure support) and EPAP (expiratory pressure support), which is PEEP. By convention these numbers are given as IPAP over EPAP, i.e. 10 over 5. The benefit of BiPAP is that it decreases work of breathing to increase ventilation in addition to oxygenation. It aids with inspiration and expiration, providing support throughout the respiratory cycle to aid in compensation while the underlying disease process is treated.

Conclusion

The emergency room is a place equipped to deal with any situation, filled with people equipped to deal with any situation. When it comes to respiratory distress, this should be no different. Intubation in the setting of respiratory distress should be last resort. Many of these patients have multiple medical comorbidities and may never come off of a ventilator. For as much as we strive for excellence in intubating, we should strive even more so to be experts, masters, in avoiding intubation.

To tube or not to tube, that is the question

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I always say that it takes more skill to NOT intubate a patient. That is especially the case with severe CHF, where BiPAP, nitro and a couple of hours can turn them around completely. Intubation is a dangerous procedure, and I think we have come a long way in EM from the days when we had a low threshold to intubate intoxicated patients.

The TL;DR is that in patients suspected of “poisoning” (which to them means alcohol, drugs or medication), an expectant approach of “restricted intubation” led to improved outcomes of shorter ICU stay, shorter hospital stay, less pneumonia, and of course less adverse events from intubation.

Read this article and the commentary (both linked below). I thought this was too important to wait for Journal Club, but we could still cover it at JC in the near future. 20 different EDs, RCT, 225 total patients, excluded some poisonings that had easy reversal or needed antidotes. No patients died.

Here is the original research article. Here is the accompanying editorial.