UCONN Emergency Medicine Interest Group

Archive for August, 2011|Monthly archive page

Off Service #2: Heme/Onc

In OFF SERVICE on August 26, 2011 at 7:00 AM

Dr. Gilcrease, Heme/Onc Fellow, University of Utah/Huntsman Cancer Institute

Approach towards neutropenic fever

1. Identify using definitions:

  • ANC < 500 (or will be <500 in 48 hrs, but this is difficult for EPs to determine). Profound neutropenia is ANC < 100. Note: this count includes neutrophils and bands (but not more immature cells).
  • Fever = any T>38.3 (101 F), or T>38 (100.4) for >1 hr. Note: the elderly and pts on corticosteroids may not mount a fever! Also, remember that not all fever = infection.

2. Risk stratify

  • Hisk risk by IDSA 2010 criteria: ANC<100 for >7 days, comorbidities (including GI sx, neuro sx, central venous catheter infection, etc.), hepatic injury (transaminases >5x upper limit of normal), renal insufficiency (CrCl<30)
  • Alternative risk stratification is the MASCC score, but this is more complicated; if used, score >=21 is high risk.
  • If high risk, hospitalize and give IV abx.
3. Initial management
  • Exam- be thorough, do not forget skin, mucosal, port-a-cath, central lines, wounds, abdominal exam. Remember that neutropenic pts frequently will not show signs of infection (eg. abscess, induration, warmth, pulmonary infiltrate). DO NOT do a rectal exam (may cause a bacteremia).
  • Labs- CBC, CMP, UA, directed imaging, blood cx from central venous catheter if present and 2 peripheral sites, directed tests as needed (eg. LP, wound cx, CDiff toxin, stool cx).
  • Abx: within 2 hrs of presentation.
    • Outpatient: cipro/augmentin or levofloxacin
    • Inpatient: meropenem +/- vancomycin
      • If any mucosal breakdown, skin breakdown, concern for central-line infection, pneumonia, give a dose of vanco.
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Upcoming meeting

In ANNOUNCEMENTS on August 26, 2011 at 1:44 AM

The next EMIG meeting has been scheduled for Monday, August 29th from 6-8 PM at Dr. Regan’s. Further details available by contacting lburns@up.uchc.edu. Presenters will be Katherine Farmer, MSIV and Colin Huguenel, MSIV.

 

Book Review: Avoiding Common Errors in the Emergency Department

In REVIEWS on August 20, 2011 at 2:25 PM

This review is for the book Avoiding Common Errors in the Emergency Department edited by Amal Mattu, which can be purchased here. The reviewer has received no financial renumeration for this review.

I purchased this book for my second EM rotation after having finished an introductory textbook to emergency medicine (review forthcoming) based on good reviews and the strength of the editor’s name, who I had listened to several lectures from. My goals were to get into more EBM and learn about subjects that I hadn’t necessarily been exposed to or taught thus far. The initial management of chest pain, trauma, abdominal pain, and so forth are all crucial topics in EM, but we do get exposed to them quite frequently. What about the other areas that we don’t necessarily get taught?

The text of the book is 928 pages (not including the index). It is divided into 28 sections covering the gamut of EM, from airway to wound care, which are subdivided into 400 chapters, each of which range from about 2-5 pages in length, with associated references. Each chapter is written by a separate author. Consequently, there is not a lot of homogeneity in the style of the book, and the quality of each chapter does vary somewhat, although most of them are quite good. I would liken the experience of reading the book to having a short discussion with a different respected attending about a particular point of interest. Occasionally, there does appear to be some overlap in material covered, which is probably to be expected given the number of authors. Some of the chapters end with a “key points” section, but the majority do not, which is a shame, since I found that quite helpful as a succinct summary of the material. The material itself, as I alluded to earlier, does cover some of the basics, but also explores in brief many subjects that I would consider more advanced or technical. For example, how to evaluate children for spinal cord injury without radiographic abnormality (SCIWORA)- clearly, a high risk area, but one that I had not previously heard about. Similarly (and appropriately, given the title), the book frequently warns against errors that rely on the “common wisdom” handed down from generation to generation of physician, such as ignoring troponins in renal failure patients or avoiding epinephrine use in digital blocks. Short of reading an actual full-blown comprehensive EM textbook such as Tintinalli’s or Rosen’s, these topics probably wouldn’t routinely be encountered in a didactic way- but surely do in a clinical setting.

Strengths of the book included the overall comprehensiveness and wide range of topics discussed, as well as the brevity of the writing. Each chapter can easily be read less than 10 minutes, and most in significantly shorter than that time period. Weaknesses included the disjointedness of the writing style (again, probably to be expected in a book written by this many authors), and probably less forgiveably, the number of typos and spelling errors (which sometimes gave me pause to wonder if the actual information being presented was correct). Some more images to illustrate the more visual parts would probably also improve the book. As a final side note, although the publisher promotes this as a “pocket book” for reference, although this book might technically fit into a lab coat pocket, it is rather large and heavy to make that really practical.

Overall score (out of 5 stars):

Venous Thromboembolism in Pregnancy

In BRIEFING on August 14, 2011 at 3:20 PM

Overview
Venous thromboembolism is a life threatening condition that has the unfortunate combination of both increased occurrence and increased difficulty of diagnosis in pregnancy. It is the leading cause of maternal mortality in the developed world (20%), greater than both maternal hemorrhage and pregnancy associated hypertension. As such it is very important to have a high index of suspicion in any pregnant patient seen in the emergency department in distress.

Risk Factors in Pregnancy:
Every pregnant woman is at increased risk of venous thromboembolus due to normal pregnancy changes influencing Virchow’s triad of stasis, hypercoagulability, and endothelial damage.

Stasis

  • Reduction in venous flow velocity in the legs by 50% by 25-29 weeks
  • IVC compression by gravid uterus
  • Compression of left iliac vein by right iliac artery (70-90% of DVTs found in left leg in the pregnant population!)

Hypercoagulability

  • Fibrin generation ↑, fibrinolytic activity ↓, Coagulation factors II, VII, VIII and X ↑, free protein S ↓, resistance to Protein C.

Endothelial damage

  • Delivery associated with vascular injury and changes at uteroplacental surface.
Signs and Symptoms
Unfortunately, many of the classic signs and symptoms of pulmonary embolism and deep vein thrombosis are very similar to the symptoms of normal pregnancy.  Lower extremity swelling, pain in lower abdomen, tachycardia, tachypnea, and dyspnea can all be found in both normal pregnancy and venous thromboembolus.
So when should we work patients up? 

Predictive Scoring Systems
Unfortunately the Well’s criteria has not been validated in pregnancy and is often unhelpful.
A small pilot study (n=194 pregnant women with 17 documented DVTs) described  the LEFt criteria. (Chan et al. Ann Internal Med 2009)
The LEFt Criteria assigns one point to each of the three following criteria:
  • L: Symptoms in the left leg
  • E: Calf circumference difference ≥ 2 cm
  • Ft: First trimester Presentation
This study demonstrated that risk could be stratified based on number of positive criteria. In the group with 0 points, there were no documented DVTs. In the group with one or more points, there were 16% with documented DVT, and in the group with 2 or 3 points there were 58% documented DVT.
While these results are from a small study, it may be helpful in increasing level of suspicion for further workup.

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EM Images #6

In IMAGES on August 13, 2011 at 7:22 PM

Syndicated from the UCONN EM Residency website; credit to Dr. London, Dr. Bolton, Dr. Hitesh Shah for images and text.

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History:
A 25 year old male presented to HH ED in May 2009 complaining of 5 days of an itchy, scattered, worsening rash over his entire body. The rash began on his back and scalp, then spread to his arms, and is now everywhere. He was seen at a nearby clinic 5 days ago and sent home with Benadryl and Hydrocodone. He saw the PMD again 2 days ago and was also given Prednisone, Keflex, Permethrin, and Triamcinolone without relief. The rash was pruritic; he reported a sore throat and dysphagia from pain of oral lesions. He denied fever, cough, SOB, URI, conjunctivitis, congestion, runny nose, difficulty breathing, sick contacts, alleviating factors, exacerbating factors. Pt is an immigrant from Honduras and lives with his parents and his 1 year old child; he has been in the US for 4 years.

Physical Exam:
Vital Signs –T 98.2, P 111, R 16 –BP 146/89, O2 Sat 98%
Gen: Hispanic male, sitting, NAD
HEENT: NC/AT, MMM, PERRL, sclera anicteric, – JVD/LAD
Chest: Tachycardic, + S1/S2, CTAB
Back: No CVAT
Abdomen: + normoactive BS, soft, NTND, no r/g/HSM
Neurological: Awake, alert, oriented, cogent, nonfocal, MAE
Extremities: wwp, no c/c/e
Skin: see images

What is the diagnosis?

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Journal Article Synopsis: β-hCG, Ultrasound, and Ectopic Pregnancies

In JOURNAL CLUB on August 8, 2011 at 3:32 PM

Summary of “Use of a β-hCG Discriminatory Zone With Bedside Pelvic Ultrasonography” By Ralph Wang et al, Annals of Emergency Medicine vol 58: pp. 12-20. 2011.

What is already known on this topic:
Currently, pregnant women presenting to the ED with abdominal pain, vaginal bleeding, or syncope are assessed with pelvic ultrasonography and quantitative serum β-human chorionic gonadotropin (β-hCG) to rule out the possibility of an ectopic pregnancy. In 10-30% of these cases pelvic ultrasound is unable to reveal either an intrauterine (IUP) or ectopic pregnancy- an “indeterminate result”. A level of β-hCG above the “discriminatory zone” of 1500-3000 mIU/mL, in combination with an indeterminate ultrasound, has been shown to be associated with ectopic pregnancy.

What question this study addressed:
What is the utility of the β-hCG discriminatory zone in differentiating between ectopic and intrauterine pregnancies after an indeterminate bedside pelvic ultrasonography in symptomatic pregnant patients presenting to the ED?

What was the study design:
Cross-sectional study of 256 first-trimester pregnant patients presenting to ED with symptoms of abdominal pain or vaginal bleeding. All pelvic ultrasonography was performed by emergency physicians who were blinded to the patient’s β-hCG levels. Research assistants (blinded to the ultrasound results) contacted and performed a standardized interview with all enrolled patients at 8 weeks.

What this study adds to our knowledge:
A β-hCG cutoff of 3000 mIU/mL is not acceptable for use in clinical practice when attempting to identify ectopic pregnancy in symptomatic patients with an indeterminate result on bedside pelvic ultrasonography (sensitivity of 35% and specificity of 58%). On follow up, it was found that 65% of patients with an ectopic pregnancy have a β-hCG < 3000 mIU/mL.

How this is relevant to clinical practice:
When pelvic ultrasound is indeterminate for intrauterine pregnancy, serum β-hCG level alone does not differentiate intrauterine and ectopic pregnancy. A β-hCG cutoff of 3,000 mIU/mL will not aid with the exclusion of ectopic pregnancy and will cause 65% of cases to be missed.

Other considerations:
In the future the discriminatory zone of β-hCG must be re-evaluated. The bedside pelvic ultrasound can reliably exclude ectopic pregnancy only when they demonstrate a clear intrauterine pregnancy in symptomatic pregnant ED patients. Practitioners should avoid an inappropriate interpretation of β-hCG levels in patients without a clear diagnostic result.

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