The Fast Track - Winter 2015

THE FAST TRACK Fall 2014

The Fast Track

AN EMERGENCY MEDICINE PUBLICATION - WINTER ISSUE 2015

Winter

As the temperature drops outside

ERs heat up inside!

CO POISONING!

08

MEDICAL PODCASTS

16

NON-FREEZING COLD INJURIES

38

SNOWSPORT INJURIES

40

ROSH REVIEW

52 page 1

Letter from the Editor

The Track The Fast Fast Track Editors-in-Chief Fall 2014

Tanner Gronowski, DO Jeremy Lacocque, OMS-IV Veronica Coppersmith, DO Danielle Turrin, DO Chris Swyer, OMS-III Ariel Sindel, OMS-III

Editors

Andy Little, DO Drew Kalnow, DO Erin Sernoffsky RC Board Members

Andy Little, DO President Joe Sorber, DO Vice President Drew Kalnow, DO Treasurer Tanner Gronowski, DO Secretary Veronica Coppersmith, DO Gina Moffa, DO Allison Remo, DO John Downing, DO Patrick Cary, DO Chase Ungs, DO Danielle Turrin, DO Daniel Engleberg, DO Steven Brandon, DO Past President

SC Board Members Cameron Meyer Sasha Rihter Timothy Bikman Jeffery Weeks

Deborah Rogers Michael Fucci Ariel Sindel Chris Swyers Chris Falslev Michael Kinghorn Bryant Gray Kaitlin Fries

President Vice President Treasurer Secretary

I

hate New Year’s. The annual hoopla of wiping away the last year to get a clean slate and resolving to change is my least favorite holiday of them all. Every year there is a big build up to the eve of the coming year, plans get made with friends or family, the countdown with hats and champagne commences, and then the ball drops and I am left standing there waiting for something to happen. I like to call it the proverbial “lunchbox letdown,” where in elementary school you opened your lunchbox just knowing there was going to be some kind of dessert packed inside by your mom, only to find carrots and celery. Maybe it’s my ER doc mentality of desire for instant feedback or results, but with such a big buildup I want there to be something, anything, at the end of the line.

I have learned over the course of my adult life that while video games and blood work typically give you the satisfaction of timely feedback, resolutions and goals do not. They require planning, execution, nurturing, endurance, and often a little bit of dreaming. There undoubtedly will be errors and obstacles in your way when you start something new, but if you really want to achieve these endeavors it wont matter because you are dedicated to the bitter end.

Many people around the time of New Year’s look at the past year and feel as if they have failed at something and want to right the ship. Here is my suggestion for you… stop making resolutions once a year and make it a timeless action. If you see a weakness in yourself, address that chink in your armor now. If there is something you have always wanted to do, use that smart phone in your hand to write down the steps to get there and start checking them off. Be the best version of yourself from day to day.

It truly is a pleasure to introduce you to the first issue of the Fast Track with our new editing and production staff for ACOEP this year. We have great things planned for the publication this year and hope you enjoy the continued awesomeness that this magazine has become. We cannot do this without you, so thank you for all your support and contributions!

Tanner Gronowski, DO Doctors Hospital, Columbus, OH Editor-in-Chief, The Fast Track Publication, ACOEP

Past President

Printing of this issue sponsored by:

page Cover photo courtesy of Tanner Gronowski

Interested in contributing?

Let us know: FastTrack@ACOEP.org

CONTENTS Presidential Messages................................04 Rosh Review...................................................06

20

OSBORN WAVES!

by Terrance and Justin

Tricks of the Trade.......................................09 Medical Podcasts..........................................10 What’s New With Croup...........................12 Snowsport Injuries......................................14 CO Poisoning.................................................18

12

GHANA CROUP by Frederick Davis, DO

by Courtney Johnson, DO

Osborn Waves................................................20 Non-Freezing Injuries................................22 Pediatric Obesity In The ER....................25 Diverticulitis.....................................................26 Residency Spotlight.....................................30

14

SNOWSPORT INJURIES

by Sesha Nandyal, OMS-I

30

RESIDENCY SPOTLIGHT St. Luke’s

Pulse Crossover Article..............................32

The Fast Track Winter 2015

PRESIDENTIAL MESSAGE –

Resident Chapter

G

reetings Residents. A Happy New Year to each of you! We hope each of you had a wonderful holiday season with your family and friends, while taking time to reflect on 2014 and all the wonderful things you were able to accomplish. We also hope that each of you have started planning on to make 2015 a big year for yourselves. Make it the year you go the extra mile to accomplish that one thing you’ve been hoping or wanting to do.

After a great 2014, 2015 looks to be a great one for the ACOEP Resident Chapter. Your newly elected officers are working behind the scenes to make sure that your membership in our organization is valuable. We hope over the next 12 months you take the opportunity to utilize your membership in the ACOEP, whether that is coming to a conference, tuning in for an upcoming google chat, submitting a paper to a FOEM competition, joining us for D.O. Day on the Hill, using one of our benefits or simply reading this and other editions of The Fast Track.

Your Resident Chapter officers hope this is the year you decide to become more involved in our ACOEP family and we look forward to meeting and speaking with you at an upcoming conference!

Best Regards, Andy Little, DO ACOEP National Resident Chapter President ACOEP Board of Directors Doctors Hospital Emergency Medicine

page 4

The Fast Track

Student Chapter

Fall 2014

PRESIDENTIAL MESSAGE –

T

hrough my time in medical school I have attended several conferences from different specialties. I have experienced the lectures, labs, and events that are put on for the students from the various colleges. Each one had great things to offer, but one college has always stood out more than others – ACOEP. At ACOEP conferences it is quite apparent that they are dedicated to their student chapter. They make sure that the student chapter has all the resources to put on great lectures and skills labs. They make sure we have opportunities to meet and interact with program directors and residents on a one-on-one basis. ACOEP conferences are a cut above the rest.

While going to conference sounds great, the reality is that attending is challenging.

Students often have to miss class or part of their rotation to go to a conference. This presents logistical obstacles with schools that are sometimes difficult to figure out. Also with airfare, hotels, and food, expenses can pile up quickly. Often students can’t see how the value of going to conference is worth the trouble.

Because of the hard work of the ACOEP Student and Resident Chapters we are now able to provide a way for students to experience the benefits of conference without missing classes and rotations. On Saturday, February 21, 2015 we will be holding the first ACOEP Student Regional Symposium. This will be a one day event of lectures, a skills lab, a resident panel, and will feature Dr. Mark Mitchell - ACOEP President - as the keynote speaker. The symposium will be held at Doctors Hospital in Columbus, Ohio with the help of many other regional residency programs. Our goal is to have frequent symposiums around the country and to provide all osteopathic students an opportunity to attend. Signups for this and other symposiums will be online and will be advertised on Facebook and sent to students in the region.

ACOEP is dedicated to serving all ACOEP students and providing them with high-quality emergency medicine experiences. I encourage you to take advantage of the experiences of the regional symposiums and national conferences. You will not regret it.

Sincerely, Cameron Meyer, OMS-III ACOEP National Student Chapter President West Virginia School of Osteopathic Medicine

page 5

The Fast Track Winter 2015

Emergency Medicine Review with 1. A 41-year-old woman presents with a severe headache that started 10 hours ago. She has never had a headache this intense before. The headache is associated with photophobia and nausea. What management is indicated?

A. Non-contrast head CT and lumbar puncture B. Non-contrast head CT and discharge if normal C. Outpatient MRI D. Symptomatic headache treatment and follow up with neurology if headache resolves

Find more questions like these by visiting roshreview.com

2. A 16-year-old boy presents with headache, nausea and vomiting after a fall.

The patient fell from a tree with a brief loss of consciousness. A minute later he was awake and only complained of a mild headache but he has since worsened. A non-contrast CT scan is shown. What management is indicated?

page 6

A. Admit for repeat non-contrast head CT B. Discharge with follow-up with neurology C. Emergent neurosurgical consultation D. Obtain MRI of the brain 3. For which etiology of cardiac arrest does induced hypothermia carry the best improvement in survival with good neurologic outcome?

A. Hyperkalemia B. Pulmonary embolism C. Pulseless electrical activity D. Ventricular fibrillation 4. A 73-year-old woman with an indwelling Foley catheter is sent for evaluation from the nursing home because of fever. Which of the following is a criterion for systemic inflammatory response syndrome (SIRS)?

A. Heart rate 86 B. Lactic acid 4 mg/dL C. Respiratory rate 22 D. Temperature 37.9째C

Find your Rosh Review Answers at the end of the issue

The Fast Track

Resident Conference

Fall 2014

The Edge: Spring Seminar 2015

Marriott Harbor Beach Fort Lauderdale, FL April 7-9, 2015 Cutting Edge Ultrasound Lab Sponsored by EMP High Impact Lectures Evening Events Networking For more information visit www.acoep.org page 7

The Fast Track Winter 2015

ACOEP Student Chapter

Regional Conference

Doctors Hospital Columbus, OH February 21st, 2015 JOIN US FOR: Lectures Labs and a Resident Panel For more information visit http://acoep.org/pages/stu-mem page 8

Tricks of the Trade

By Veronica Coppersmith, DO @ St. Lukes Hospital and Tanner Gronowski, DO @ Doctors Hospital

Fall 2014

The Fast Track

Makeshift Cric Kit An ED cricothyroidotomy is never a planned procedure, but is often a last resort when your crashing patient requires an emergent airway. In this high stress situation, having someone run to find the cricothyrotomy kit may take a few more seconds than your patient can afford. Be honest, do you even know where the cric kit is kept in your department? Or where a kit is on the floor if you respond to a rapid response? Luckily, with some quick thinking, you can improvise this cric set up from an IV tubing spike, trauma shears, and an ambu-bag. First cut the drip chamber of the IV tubing spike on the skinniest portion, closest to the IV tubing as seen in the picture. This is miraculously the perfect size to fit onto an ambu-bag! Clean the patient’s neck with betadine, chloroprep, or other cleaning agent. Then by making a small incision (or simply by driving the spike through skin), go through the cricothyroid membrane, which is the small divot found between the thyroid cartilage and the cricoid cartilage. Once through the membrane, tilt the cut drip chamber superiorly at a 45 degree angle, staying in line with the trachea. Advance the spike into the trachea so it is secure, attach the ambu bag, and oxygenate. This is a temporizing measure, as there is inadequate ventilation, however it will buy you 15-20 minutes when the patient is crashing. And there you have it, an quick emergency airway with common supplies found in every room in the ED!

McGuyver’ed Eye Wash Station Even though you can find “emergency eye flushes” around most hospitals, their locations are not always convenient or desirable for patients or treatment. Consider the patient who had some chemical irritant blasted in their eyes such as mace - and you want to keep them in their room but still flush their poor flaming orbits. This nifty trick will keep both you and the patients hands free and happy. Simply take two items: a 1L bag of normal saline and one nasal cannula setup. Hang the normal saline bag and spike it with some tubing as if you were going to do an IV line. Before you prime the tubing, take the nasal cannula setup and trim the end that normally fits on the oxygen tree to the size that will fit over the end of the IV tubing. Push two pieces together until they are snug. Fix the nasal cannula over the patient’s superior aspect of the bridge of their nose so that each prong is pointed at the medial canthus of their eye, open the flow to the tubing and BAM... instant gentle flushing for the next 20-60 minutes! page 9

EM Basic www.embasic.org

MedicalPodcasts Special choices, making it even easier to learn Alex Murray, OMS-IV Ohio University Heritage COM

M

edicine is constantly changing and it can feel nearly impossible to keep up with current literature. It is difficult to decide which sources to read, which journals to trust, and determine which evidence should change current practice. Fortunately, there are several online resources that provide up to date information on emergency medicine topics and provide relevant information in a fraction of the time it would take to sort through articles.

Most of these resources are free to use and are supported on a variety of platforms.

This podcast is hosted

by Dr. Steve Carroll, who created EM Basic as a third year EM resident.

EM Basic is geared for medical students and emergency medicine interns to review the basics of emergency medicine. Each podcast is roughly 30 minutes long and is organized by common chief complaints encountered in the Emergency Department. Dr. Carroll reviews important points of the patient’s history and physical exam, the workup, and the basic treatment and disposition of each chief complaint. Each podcast has an associated one to two page summary and is free to download.

EM:RAP www.emrap.org

Emergency Medicine: Reviews and Perspectives (EM:RAP) is a 4.5 hour monthly audio series created

by Dr. Mel Herbert and Dr. Stuart Swadron.

EM:RAP reviews approximately six emergency medicine related articles per month and presents the best speakers from across the country. Each episode is accompanied by an extensive written summary and several pages of board review questions and answers. A yearly subscription to EM:RAP costs $55 for residents and students; however, you can obtain a free membership by belonging to Emergency Medicine Residents’ Association (EMRA) or American Academy of Emergency Medicine Resident and Student Association (AAEM/RSA). EM:RAP has its own app and episodes are supported on a variety of devices.

ERCAST www.blog.ercast.org

ERCast episodes last from five minutes to more than an hour and are comprised of curbside consults with specialists, different takes from ED docs the world over, procedures, product reviews and various topics in emergency medicine. This podcast was created by Dr. Rob Orman and each episode covers a single issue and tries to tease out all the relevant elements that affect your practice. Episodes are free and are accompanied by a written summary.

Some episodes cover advanced topics that are beyond the scope of a medical student; however, there are several episodes that are relevant to medical student listeners.

The Fast Track

www.emcrit.org

This podcast was created by Dr. Scott Weingart and each episode is approximately 20 minutes long. EMCrit is devoted to bringing the best evidence-based care from the fields of critical care, resuscitation, and trauma and translate it for bedside use in the Emergency Department. Every two weeks Dr. Weingart posts a full episode, and in between, the site gets filled with blogposts, links, and EMCrit Wees (miniature podcasts). Episodes are free and accompanied by written show notes.

Some topics discussed by Dr. Weingart are above the level of a medical student but are still useful in learning about current evidence based medicine.

Life In The Fast Lane

Fall 2014

EMCRIT

www.lifeinthefastlane.com

Life in the Fast Lane (LITFL) is a medical blog and website that provides free online emergency medicine and critical care insights and education for everyone. LITFL is spearheaded by Dr. Mike Cadogan, Dr. Chris Nickson, and several other emergency medicine physicians and intensivists based in Australia and New Zealand. This website attempts to harness the power of social media to allow some of the best and brightest emergency medicine and critical care clinicians from all over the world to provide insight into what they think is worth reading. This site also discusses clinical cases, reviews new technology, and has a resource that collates the very best of emergency medicine and critical care audio and video podcasts in a database searchable by keyword, author, source, topic and title.

EKG REVIEW http://ekgumem.tumblr.com/

University of Maryland Emergency Physician and ECG enthusiast, Dr. Amal Mattu presents free emergency ECG videos every week to help you become an expert in ECG interpretation and take better care of your patients. Each episodes is under 20 minutes and is packed with high yield pearls for reading ECG’s. Each episode has an associated written summary that highlights what to look for, how to differentiate arrhythmias, and how to treat patients in each scenario. There are over 170 episodes that can be accessed for free on the website.

page 11

The Fast Track Winter 2015

What’s New with Croup Courtney Johnson, D.O., Adena Regional Medical Center

‘Tis the season for croup! This seasonal illness with a classic presentation is common among the six month to three year old age group. It is predominantly a viral illness and is usually self-limited; but in rare cases it can progress to upper airway obstruction and respiratory failure. So what’s new with this old disease?

Case Presentation: A previously healthy 1-year-old boy presents to your ED on a January evening after the sudden onset of a barking cough and difficulty breathing. His mother is concerned because of a “whistling” sound he is making while crying. Mother notes he has had “cold-like” symptoms and subjective fever at home. At triage, he is tachypneic with a respiratory rate of 34 breaths per minute. His oxygen saturation is 93% on room air, his axillary temperature is 38.4oC, and his heart rate is 142 beats per minute. On exam, he appears in mild distress and is fussy. You can clearly hear inspiratory stridor highlighted by a barking cough. You notice moderate subcostal retractions. The rest of your physical exam is within normal limits.

Croup encompasses a spectrum of diseases involving the upper airway and rarely the lung parenchyma (laryngotracheitis, laryngotracheobronchitis, laryngotracheobronchopneumonitis). No distinction will be made in this article between the different types, as the treatments are similar. Croup affects males more often than females (3:2 ratio) with an overall mortality rate of 1 per 30,000 cases. This is greatly reduced from study estimates in 1991 which calculated mortality at 0.5% [1].

The symptoms of croup are caused by infiltration of the subglottic region of the larynx by a variety of viral pathogens. This infiltration causes erythema, edema, and glandular hypersecretion of the subglottic mucosa. Due to a complete ring of cartilage in the pediatric larynx, it is incapable of expansion.

It cannot accommodate for narrowing of the airway and obstruction may occur quickly with even the smallest amount of swelling. This narrowing is the source for the classic stridor associated with croup.

Diagnosis is made on history and physical exam alone. The illness begins with upper respiratory symptoms and usually a low-grade fever. Hoarseness, stridor and/or the classic “seal-like” barking cough manifests 12-48 after onset of illness. Imaging studies should only be obtained when the history is unclear or there is concern for foreign body aspiration. “Steeple sign” present on AP radiographs of the neck, is due to subglottic edema causing narrowing of the trachea. The presence or absence of steeple sign does not rule in or rule out the diagnosis. Thus making radiographs of little diagnostic use in the setting of croup. Lab studies are not useful when evaluating croup and viral cultures are not recommended for routine use.

Severity scoring: There are two commonly used scoring systems to objectively quantify croup severity: The Westley Croup Score Criteria[2] and the Alberta Clinical Practice Guideline Working Group [3]. Both systems use five physical exam findings to classify severity. these scores are primarily used in clinical research and are rarely used in practice. However, some pediatricians may ask for croup scoring to assess the level of care needed in hospital.

Treatment: Humidified air has historically been used to alleviate croup symptoms. Croup kettles and croup tents were common practice until the early 1990’s, when better treatment modalities went into effect. Neto et al and Bourchier et al both produced randomized control trials that failed to show any benefit between patients receiving humidified air and those who did not [4][5]. Numerous other studies examining vapor particle size and a meta-analysis by Little failed to show benefit of humidified air in the treatment of croup.

page 12

Nebulized epinephrine stimulates alpha & beta adrenergic receptors resulting in vasoconstriction of the laryngeal mucosa and bronchial smooth muscle relaxation and thinning of bronchial secretions. Numerous studies have shown benefit with nebulized epinephrine [6][7][8]. No clinical difference exist between the racemic mixture and the isolated L-isomer forms [9].

Nebulized epinephrine has also been shown to decrease the rate of admission to the hospital and the need for intubation [11]. Up to 2 doses of nebulized epinephrine administered every 15 to 20 minutes within the same hour is most likely safe in an otherwise healthy child. Adverse events are rare and usually occur with more than 2 doses in the same hour [10]. If symptoms persist after repeated doses, consultation with a pediatric intensivist should be made. Intubation should also be considered if impending respiratory failure seems likely. Several studies have demonstrated that patients treated with nebulized epinephrine and therapeutic doses of corticosteroids may be observed for 2 to 4 hours, and, if they remain stable, they may be safely discharged home [12][13][14].

Fall 2014

The Fast Track

There is no single treatment more crucial in the treatment of croup than the administration of corticosteroids. Twenty-four studies involving 2878 patients found that treatment with glucocorticoids is effective in improving symptoms in children as early as 6 hours and up to 12 hours after treatment. It also significantly reduces hospital admissions and return visits to EDs [15]. Oral dexamethasone 0.6 mg/kg, has become the preferred choice of treatment because it is cost effective and is easier to administer to children with croup than budesonide. The parenteral preparation, which is more palatable and less diluted than the oral preparation, can be given in a smaller volume, is rarely vomited, and is recommended for use in children [16][17]. If PO dexamethasone is contraindicated or not well tolerated, nebulized budesonide 2.5 mg can be substituted. To date, there have been no studies to definitively show benefit in using higher doses of corticosteroids of any formula or route [18][19][20][21]. Novel therapies like heliox have been shown to improve croup scores in the heliumoxygen group. However, the studies to date were underpowered and changes did not reach statistical significance [22] [23]. Antipyretics have theoretical benefit by reducing fever and thus reducing fever-associated tachypnea and work of breathing. Antitussives are contraindicated in children under the age of 6 and are discouraged in the treatment of croup [24]. Given that croup is primarily a self-limited viral infection, antibiotics are of little to no use in its treatment.

Disposition: In previously healthy children with mild croup (no stridor, no retractions), they can be safely discharged home without further observation after single dose of dexamethasone. Family should be educated on the anticipated course of the disease, signs of respiratory failure and when to seek medical care. Children with moderate croup (stridor, retractions but no altered mental status) should be treated with single dose dexamethasone and nebulized epinephrine. They should be observed for 2 hours minimum and ideally 4 hours. If child has improved and airway obstruction has resolved, they can be safely discharged home after family education. In moderate-severe cases (stridor, retractions, altered mental status) that do not respond to appropriate therapy (dexamethasone 0.6 mg/kg, requiring > 2 nebulized epinephrine), hospital admission should be considered and consultation with pediatric ICU should be made. Special consideration must be made when dealing with children with known congenital anomalies of the upper airway or those with craniofacial malformations as these can lead to rapid progression of respiratory failure and a need for urgent airway management.

In summary, croup is a clinical diagnosis and ancillary testing, if used, should be used to rule out other more fatal causes of stridor and upper airway obstruction. Oral dexamethasone should be given to all children diagnosed with croup no matter the severity. Those exhibiting signs of upper airway obstruction should be treated with nebulized epinephrine and observed for at least 2 hours post administrations. Children who do not improve with conventional therapy, those with altered mentation or patients with preexisting congenital anomalies should strongly be considered for admission to a pediatric ICU. Case resolution: After your patient received 0.6 mg/kg dexamethasone, a single nebulized racemic epinephrine and two hours of observation, he has now eaten your ED’s stockpile of outdated popsicles. His stridor and retractions have resolved. Pulse ox has improved to 100% on room air. His mother is elated to take her child home with lungs full of epinephrine and a belly full of high fructose corn syrup. page 13

The Fast Track Winter 2015

snowsport injuries

There are over 10 million people who participate in snowboarding and skiing every year page 14

Ski Photo Credits - Claudia Bouvier, DO

from euphoria to doom Snowsport injuries in the United States Sesha Nandyal, OMS-I OU-HCOM

I

magine that you’re an 18 year old

you pause in reflection mid-air over a jump,

snowboarding

is

you ask yourself, could this be the definition

vacationing with his family in Vancouver on

of euphoria? In a split second, a moment

what looks to be a perfect day for “shreddin’

of mild hesitation causes you to land at an

the powder.” You and your brother sneak

awkward ankle and suddenly shooting pains

off to conquer a few routes down the

crawl up your leg. You’re still being propelled

formidable mountain next to your family’s

forward rapidly, and then you’re upside

resort. Today is the day that you will tackle

down; your head has struck something hard

the “Viper,” the most dangerous course on

and unforgiving. All you see is sky, and then

the mountain. Your heart is beating, the

only black.

adrenaline is pumping, and the sun peers

Due to the burgeoning popularity of alpine

menacingly through the pines. You nod to

skiing and snowboarding in the United States,

your brother, and he takes off on his board

the National Sporting Goods Association

first. You see him clear the hill, and you take

(NSGA) estimates that there were 6.5 million

a deep breath as you take the plunge. The

skiers and 5.9 million snowboarders in 2008

view is incredible and you’re hurling down

with on-slope participants in these activities

the mountain and unimaginable speed. As

approaching 10 million per year. The NSGA

enthusiast

who

The Fast Track Winter 2015

reports that the rate of fatality in this group is 3.9 per 1

extremity injuries. The central nervous system injuries were

million on the slope. However, snowboarding injuries

spread evenly throughout both snowboarders and skiers.

doubled from 3.37 injuries per 1000 in 1990 to 6.97 in

The operative injuries in this study population included

2000. According to Shorter Jenson, and Harmon et al, these

extremity injuries, spinal injuries, and splenectomies.

injuries carry a high economic burden with the average

During the 6.5 year duration of the study, 25 deaths due

cost of treatment for skiing injuries being $22,000 per

to skiing and 1 death due to snowboarding occurred in the

patient. The cost and potential debilitating nature of winter

state of Vermont with the cause of death being primarily

sports injuries necessitates further investigation into their

blunt head trauma or blunt chest trauma. The authors

prevention and severity.

recommend prevention programs for safe skiing and safe

According to a 6-year study by Sacco, Sartorelli,

snowboarding practices, recognition of poor conditions

and Vane at the Department of Surgery at the University

and children too young for these activities, and helmet use.

In a retrospective cohort study conducted at the

University of Utah Medical Center, Wasden et al also found that snowboarders were statistically younger than skiers, with the average ages being 23 and 41 respectively. In addition, head injury in snowboarders (27.3%) was higher than in skiers (27.3%). All of the fatalities secondary to of Vermont College of Medicine, snowboarding and alpine skiing yield equal risk of injury. However, snowboarders (average age 20) are statistically younger than skiers (average age 29) and snowboarders have a lower Injury Severity Score (15 vs. 27 in skiers). While 16% of the injured skiers had multiple injuries, only 8% of the snowboarders did. The types of injuries recorded ranged from upper extremity, cruciate ligament, lower extremity, head, spine, and spleen. Snowboarders were more likely to suffer from upper extremity and splenic injuries while skiers were more likely to have cruciate ligament and lower page 16

head injury were found in the injured skier population, while a single fatality due to snowboarding was due to pneumothorax. Skiers were more likely to suffer from facial bone fractures, facial lacerations, and lower extremity injuries, and snowboarders more commonly presented with abdominal injuries as well as injuries to the spleen, liver, and kidney. Both of the winter sport participant groups suffered from spinal injuries but snowboarders were more likely to present with this injury. In terms of hospital stay and operative treatment, skiers spend an average of 3.4 days in the hospital while snowboarders averaged 2.4 days; skiers had more OR admissions and snowboarders had a higher

The Fast Track

likelihood of ICU admission. This group of authors

results showing 74% due to hitting one’s head on the snow, 10%

also highly recommends injury risk minimization

were due to the impact of hitting another skier, and 13% were

via protective equipment and knowledge of proper

due to hitting a fixed object. However, there was a statistically

riding technique.

significant low incidence of loss of consciousness episodes

Williams, et al of the Department of Anaesthesia

in the group of helmet wearers that sustained head trauma

the University of Vermont conducted a study on the

due to hitting a fixed object. In addition, there is a significant

speeds of skiers and snowboarders on non-traditional terrain

increase in risk of head injury at terrain parks versus ski runs.

such as terrain parks and glades versus open slopes. Upon

These conclusions lend weight to the recommendation of

obtaining 113 pieces of speed data via radar analysis of expert

wearing a helmet when engaging in these activities, as shown

level skiers and snowboarders, they found speeds less than 15

by the Williams et al study.

mph in 79% of the gladed terrain cases and in 94% of the terrain

park cases. This led the authors to confirm their theory that the

incidents range from minimal to debilitating. Nevertheless,

risk of traumatic brain injury as a result of these activities (on non-

such injuries are an important portion of hospitalizations in

traditional terrain) could be diminished by the use of a protective

this country as well as sources of significant cost expenditure.

helmet. In general, only a minority of skiers and snowboarders use

The evidence for potential prevention of fatality and disability

helmets; this could be potentially due to knowledge of the futility

by proper protective equipment, i.e. helmets, is mounting. But

of a helmet in a high-speed crash. Thus, the group proposes that

currently, there is no official legislation in the United States as

their data, confirming the low-speeds accomplished on gladed

to the mandatory use of helmets for skiers and snowboarders.

terrain and terrain parks, shows that the use of the helmet is still

an important strategy to reduce traumatic brain injury in this

from your arms. You have a tube down your throat and you

population.

drift in and out of consciousness. Your first thought is for your

In terms of head injuries, a retrospective cohort study

brother; Is he okay? Was he, wait, was I wearing my helmet?

by Greve, et al of the Department of Emergency Medicine at

Your second thought is for you; Will I make it? The worry-ridden

the Warren Alpert School of Medicine compiled data on those

faces of your mother and father blur by in the messy soup that

sustaining a head injury at 9 facilities in Colorado, New York, and

is currently your vision and awareness. You close your eyes

Vermont. In the group of 1013 participants, 52.6% were skiers,

and avoid processing the unfortunate reality in which you

46.7% were snowboarders, and 37.1% were using helmets at the

find yourself, a reality that instantaneously transformed

time of their injury. The mechanism of injury was analyzed with

from euphoric to harrowing.

at

Fall 2014

...snowboarding and alpine skiing yield equal risk...

The injuries resulting from snowboarding and skiing

You wake up in a bustling ER with various lines flowing

page 17

The Fast Track Winter 2015

Carbon Monoxide

CO

By Laura Fil, DO Tox Fellow, North Shore University Every winter there is an increase in the number of cases of patients with carbon monoxide (CO) toxicity compared to the rest of the seasons. CO is the leading cause of morbidity and mortality from poisoning in the United States. Although CO poisoning is treatable, usually the most difficult part of a carbon monoxide case is first considering it as a diagnosis.

Carbon monoxide is a colorless and odorless gas that is formed from the incomplete combustion of carbon-containing compounds. CO binds to hemoglobin with almost 200 times the affinity of oxygen, thus beating out oxygen when competing for hemoglobin binding sites. CO also causes a leftward shift in the oxyhemoglobin dissociation curve, decreasing the ability of oxygen to offload to tissue. An exposed patient will have an adequate supply of oxygen, however it is not able to be transported or used. In essence, CO works to decrease the amount of oxygen that can bind to hemoglobin as well as hinder the release of that oxygen to tissue, thus leading to a functional asphyxiation.

Although CO exposure is a year-round concern, the cold winter months usually create some additional ways for your patients to be unintentionally exposed. Exposure may occur when your patient tries to warm their house up with an unconventional method such as bringing a gas grill into the house or using propane heaters. An indoor fire in a fireplace without proper ventilation is another way CO may accumulate in the home. CO exposure is commonly linked to emissions from automobiles despite the implementation of catalytic converters in the 1970’s. Patients may also run into trouble when they warm their cars with the garage door closed. page 18

CO

a silent attacker, symptoms range from flu-like to death Patients with elevated carboxyhemoglobin (COHb) levels may present with a myriad of vague complaints ranging from a mild headache or nausea to more severe symptoms such as altered mental status, coma and even cardiac arrest. Patients with elevated COHb levels may also present with flu-like symptoms, which may trick many clinicians during flu season. Table 1 is a guide to the types of symptoms to be expected at various COHb levels. However, it is important to note that these levels are guidelines and that patients may present with different symptoms at different levels.

Aside from mortality, the other major concerns for CO poisoning is delayed neurologic sequelae as most patients do not have neurologic symptoms at presentation.

Impairments in concentration and learning, cog-wheel rigidity, dementia, amnesia and depression occur in 23-76% of patients several days to weeks after poisoning.

Considering CO toxicity in your patients is of utmost importance, because a serum COHb level is how CO toxicity is definitively diagnosed. Importantly, a standard pulse oximetry (SpO2) does not distinguish oxyhemoglobin from carboxyhemoglobin, it can only determine if the hemoglobin is bound to something. Therefore a normal pulse ox does not rule out CO poisoning.

You may also have access to a co-oximeter in your emergency department which is not as accurate, but may be used to rule

Fall 2014

The Fast Track

out an elevated COHb level. A normal COHb level is between 0-5%. If the patient is a smoker a normal level could be up to 10%. A special consideration is with the pregnant patient where studies have shown that even low COHb levels may have deleterious effects on the fetus. Therefore it is prudent to treat a pregnant patient even with a low COHb level.

Fire is the most common exposure to CO.

Keep in mind that if a patient was removed from the source of CO the percentage of COHb has had time to drop so they may have had a much higher level. You may be able to back-calculate the level using Table 2. Treatments include using a 100% non-rebreather or sending the patient to the hyperbaric oxygen chamber, ideally within six hours of exposure. All patients who are symptomatic or with elevated COHb levels should be considered for hyperbaric therapy.

Patients with the following may be at increased risk for delayed neurologic sequelae: syncope, seizure, altered mental status or confusion, age >36 years, carboxyhemoglobin level > 25% (or COHb>20% in pregnancy), prolonged CO exposure >24 hours, abnormal cerebellar function or fetal distress during pregnancy.

Finally, with any CO case it is wise to discuss the case with the toxicologist on staff at your hospital or a local poison center. page 19

The Fast Track Winter 2015

Osborn Waves: Not Just for the Cold Hearted Terrance McGovern, DO, MPH and Justin McNamee, DO St. Joseph’s Regional Medical Center, Paterson, NJ, USA

page 20

Hypothermia is known to cause cardiac abnormalities that manifest as changes seen within the electrocardiogram (ECG). These changes include prolonged PR intervals, sinus bradycardia, ventricular dysrhythmias, and perhaps the most characteristic is the Osborn wave. The Osborn wave presents as an upward deflection that immediately follows the QRS complex (Figure 1). Within the winter months it seems that Osborn waves are mentioned far more often than the rest of the year, but don’t they deserve a little bit more respect than that? While most of us associate Osborn waves with hypothermia, they can also be indicative of intracranial pathology, hypercalcemia, idiopathic ventricular fibrillation, Brugada syndrome, or - more optimistically - benign early repolarization.1,2

regulated by the flow of potassium.3 The presence of Osborn waves in hypothermic patients can appear at temperatures as high as 35.6°C and have been shown to be inversely proportional in size with decreasing body temperature.4,5 Osborn waves may persist for 12-24 hours after rewarming the hypothermic patient, with one case that showed persistence of the Osborn wave months after the patient’s hypothermic event.5,6 One of the more lethal dysrhythmias that can occur in hypothermic patients is ventricular fibrillation. In Dr. John Osborn’s original work he felt that the presence of Osborn waves may be a prognostic indicator and may be predictive of patients decompensating into ventricular fibrillation; however, there have been subsequent studies that have disagreed with these claims.7,8,9,10

Osborn waves are thought to be caused by a transmural voltage gradient across both the endocardium and epicardium largely

Emergency medicine physicians have a uniquely difficult task of caring for a multitude of different complaints at a high rate

of speed and must

FIGURE 1

sometimes rely on being “pattern recognizers.”

Osborn waves have been ingrained in our minds as being indicative of “hypothermia,” but putting on our clinical blinders could lead to a delayed, or even worse, a missed diagnosis. Hypercalcemia is classically taught as having a short QT interval and in some circumstances the shortened ST segment of a hypercalcemic patient is misinterpreted as an “Osborn” wave. However, an article by Otero et al. in 2000 opened the eyes of the world’s clinicians to the possibility of an alternative diagnosis when recognizing an Osborn wave on an EKG.11 They described a patient who was normothermic yet hypercalcemic with true Osborn waves on EKG.11 It is important to note, the Osborn waves described in hypercalcemia appear more narrow as compared to those of hypothermia. As if that were not convincing enough to alter ones perception of Osborn waves, a 2009 case series by Milewska et al. was published in the Journal of Electrocardiology discussing the phenomena of Osborn waves presenting themselves in patients with increased ICP secondary to intracranial pathology.12 The Osborn waves noted in elevated ICP are indistinguishable from those in hypothermic patients unlike those founded in hypercalcemia. Many more authors have since followed

suit; a plethora of papers on “normothermic Osborn waves” can be found with a simple search. Commonly cited reasons for normothermic Osborn waves run the gamut from benign early repolarization and left ventricular hypertrophy to cocaine abuse and haloperidol overdose. The job of the clinician is to determine the underlying cause of the Osborn wave on EKG, this task is much more manageable when maintaining a broad differential, such as the examples previously mentioned as opposed to attributing all Osborn waves to being “cold hearted.” Last winter, we had a case of undifferentiated Osborn waves that served to emphasize this very point.

Fall 2014

The Fast Track

A 47-year-old female presented the Emergency Department (ED) with altered mental status due to an apparent overdose as per the family. She was subsequently found to have a rectal temperature of 23°C (74°F), bradycardic and having apparent Osborn waves on her ECG (Figure 1). After rewarming the patient to normothermic temperatures her mental status remained poor and her ECG continued to demonstrate Osborn waves. The thought of persistent Osborn waves due to a delay in normalization after rewarming crept into our minds, but maintaining a broad differential for the J waves was potentially lifesaving. The patient was immediately sent for a head CT, which showed a subarachnoid, epidural and subdural hematoma (Figure 2). It is absolutely possible that this patient’s additional diagnosis could have been missed and proper care delayed if her altered mentation was attributed to the hypothermia instead of an alternative cause. While there are multiple published cases of similar occurrences with hypothermic patients having Osborn waves with concomitant intracranial hemorrhages; it is nearly impossible to determine whether the Osborn waves are due to the intracranial pathology or the hypothermia.

While a patient’s initial presentation may lead us toward a certain diagnosis, it is imperative to create a large differential for other potential causes of findings during the patient’s clinical workup. In the specific instance of having a hypothermic patient present to the ED with Osborn waves it may be prudent to have a very low threshold for obtaining a CT of the head while concurrently rewarming the patient.

We are constantly challenged by these complicated cases, but emergenc y medicine wasn’t designed for the faint of heart.

FIGURE 2

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The Fast Track es th a p ike eel n ju th ed st is! in th e

Ch ec f ro l d w de st b ea k th pa it th r tm e! K er i m en eep ea s o tf n o r yo u s m u t in r e or ju e y

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Winter 2015

Non-

By Joshua Enyart, DO It seems appropriate that as I sit down to write this, the first snow of the year has begun to fall. While I’m fortunate to be tucked away in the warm safety of a hospital call room, now is the time when people are particularly at risk for cold induced injury. Hypothermia and frostbite are always concerns, but there are also several lesser recognized entities, the non freezing cold injuries (NFCI) which have potential for very dangerous outcomes.

NFCI is tissue damage which occurs secondary to exposure to temperatures at or above the freezing point of water (0-15o C, 32-59o F). The skin acts as the primary thermoregulatory organ in humans and does so by exhibiting drastic changes in cutaneous blood flow compensating for alteration in ambient temperature. Cold conditions stimulate increased sympathetic tone. This leads to local arteriovenous constriction and thus, diminished cutaneous blood flow which can cause tissue ischemia and endothelial damage. Further compounding potential injury is direct skin breakdown from cold and moisture as well as nerve damage secondary to cooling which causes sensory impairment. Upon reperfusion, free radical formation actively damages cellular proteins and membranes, possibly acting as apoptotic signals triggering cell death.

01 TRENCH FOOT

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The term “trench foot� originated in WWI when soldiers would fight in trenches and be exposed to cold, wet conditions while wearing boots for prolonged periods of time. Injury has been seen after exposure from 14 to 22 hours and is exhibited in three distinctive phases with variable time courses and possible overlap.

Clinical signs during the post-hyperemic phase are more subtle and may even be absent in less severe cases. The general presentation is for extremities to go from persistent warmth to noted coolness, with continued sensitivity to cold.

Hyperhidrosis may develop as can continued anesthesia and pain, though less severe than during the hyperemic phase.

The Pre-hyperemic phase is characterized by intense vasoconstriction. Clinical presentation includes: blanching, yellowish white or mottled discoloration and muscle cramps.

Capillary refill is decreased and frequently peripheral pulses will only be detectable by doppler. Loss of sensation is a key diagnostic criterion and most commonly manifests as complete local anesthesia. Pain and blistering are typically absent.

Diagnosis is clinical and generally no significant workup is indicated. Very severe cases could lead to gangrene which may necessitate infectious workup or pre-operative testing.

Upon rewarming, pulses return and may be bounding. This is called the hyperemic phase. Extremities become hot, painful, erythematous and swollen. Sensation returns in a proximal to distal pattern and results in burning or throbbing which tends to peak within 24-36 hours. Tense edema may form as could hemorrhagic or serous blisters which are indicative of more severe injury.

In contrast to treatment for hypothermia where the goal is an increase in core temperature, rewarming of extremities with NFCI is undesirable. Rewarming injured tissues may lead to increased metabolic demand which outpaces the supply capability of damaged vessels. This causes further tissue anoxia, endothelial cell damage, reflex vasodilation, edema, skin necrosis and worsening pain. The treatment of choice is to cool the affected extremity by elevating and exposing it to cool air via a fan which should be continued until resolution of pain and hyperemia have occurred, and circulation has recovered.

Severe swelling of the tissues could lead to compartment syndrome which may require fasciotomy.

-Freezing

njuries

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The Fast Track

02 Chillblains (Pernio) Chillblains is a mild form of cold injury which is an abnormal inflammatory response resulting in localized bluish red lesions.

The predominance of cases are in children and adolescents and there seems to be higher incidence in females. Some conditions appear to be predisposing factors for risk of developing pernio.

These include cryoproteinemia, systemic lupus erythematosus with antiphospholipid antibodies, Raynaud syndrome and anorexia nervosa. Other serious conditions that are associated with pernio are chronic myelogenous leukemia and macroglobulinemia. The underlying pathophysiology is thought to be vessel wall inflammation secondary to cold induced vasoconstriction. Symptoms include intense itching, burning and pain which may be worsened with rewarming. The lesions are generally self limited and resolve within a few weeks, though sometimes chronic recurrent cases may cause permanent alteration of skin pigmentation. Commonly affected sites include fingers, toes (dorsum and sides), Chillblains is a mild form of cold injury which is an abnormal inflammatory response resulting in localized bluish red lesions. The predominance of cases are in children and adolescents and there seems to be higher incidence in females. Some conditions appear to be predisposing factors for risk of developing pernio. These include cryoproteinemia, systemic lupus erythematosus with antiphospholipid antibodies, Raynaud syndrome and anorexia nervosa. Other serious conditions that are associated with pernio are chronic myelogenous leukemia and macroglobulinemia. The underlying pathophysiology is thought to be vessel wall inflammation secondary to cold induced vasoconstriction. Symptoms include intense itching, burning and pain which may be worsened with rewarming. The lesions are generally self limited and resolve within a few weeks, though sometimes chronic recurrent cases

may cause permanent alteration of skin pigmentation. Commonly affected sites include fingers, toes (dorsum and sides), lower legs and heels, thighs, nose and ears. Lesions can sometimes mimic bruises, and thus should be considered in the differential when seeing apparent bruising in an individual recently exposed to cold conditions.

Diagnosis is clinical, with key diagnostic and differentiating factors being rapid onset, pruritus and development of lesions after exposure to cold. Useful tests include CBC with peripheral smear and ESR to rule out leukemia or other blood disorder and antiphospholipid antibodies to rule out SLE. Though unlikely to be performed in the emergency department, further testing may include cryoglobulins, cryofibrinogen, cold agglutinins, and serum protein electrophoresis. Pernio can in sometimes appear similar to polyarteritis nodosa and in these rare cases, a biopsy may be necessary to differentiate the two entities.

Treatment is accomplished by drying and gentle massage of the affected area. As with trench foot, active re-warming could exacerbate pain and should be avoided. There are few proven medical treatments for pernio, however case reports indicate some utility in symptomatic management with potent topical corticosteroids such as mometasone. Small studies have shown treatment with nifedipine to be helpful, possibly because of it’s vasodilatory function leading to increased cutaneous blood flow. In one randomized controlled trial, 20-60 mg daily significantly reduced the time for clearing of lesions.reduced occurrence of new lesions and decreased pain.

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The Fast Track Winter 2015

BRRRRRR! AVOID THESE INJURIES BY KEEPING SKIN COVERED AND WARM

03 COLD URTICARIA Cold urticaria has similar epidemiology as pernio most frequently affecting females and young adults. The presentation includes generalized wheals that occur after exposure to cold air, water or objects.

The lesions are frequently idiopathic, however may be associated with infections, arthropod bites/stings or HIV. The mechanism appears to be an IgE-mediated, mast cell degranulation resulting in release of histamine, leukotrienes and other mast cell mediators.

Symptoms are usually localized and include erythema, edema, and pruritus of affected area, though systemic reactions can occur which in the most severe cases may present as anaphylactic shock. Cold water swimming is most closely related to these severe systemic reactions.

Other potentially dangerous complications could include pharyngeal angioedema after ingestion of cold beverages. Ninety-five percent of cases are primary idiopathic cold urticaria, though there is also a rare familial form which is inherited in autosomal dominant fashion and tends to respond poorly to antihistamines.

Thus, knowledge of the early signs as well as efforts to minimize injury are essential. Keeping feet as dry as possible, and changing socks frequently when conditions are likely to cause injury are important.

Materials made of cotton, or containing down feathers retain a lot of moisture and can lose 90% of their insulating properties when wet. Moisture wicking materials such as wool and synthetics are a good options, as are Gore-Tex fabrics which can be expensive but are moisture proof and breathable.

Any wet clothing should be removed if possible as it pulls heat away from the body. Proper fitting of footwear and not tying shoelaces too tightly helps to avoid restriction of blood flow to the feet. Finally, if injury does occur, appropriate treatment allowing for gradual rewarming while minimizing metabolic demands help mitigate pain as well as tissue damage.

In the case of cold urticaria, particularly with systemic reactions, avoidance of triggers is key. In the event of exposure, a plan of action involving foreknowledge of increased antihistamine dosing and potential need for epinephrine self administration should be made clear, as well as the fact that patients should present to the ED anytime anaphylactic type Most of the time, treatment with antihistamines is sufficient and the reaction occurs. most effective option, though required dosages may be up to four times the usual dose. In severe systemic reactions presenting as anaphylaxis, These entities, while uncommon, present unique treatment would consist of early use of epinephrine, antihistamines diagnostic and treatment challenges and thus and corticosteroids. Patients should be prescribed epinephrine auto it is important to be armed with the knowledge injectors on discharge and educated in their usage. Familial type is to recognize their presence, and intervene unique in that it may respond poorly to antihistamines and is treated appropriately. with the IL-1 receptor antagonist, anakinra (Kineret).

This is a clinical diagnosis based on history. Confirmation may be obtained with the ice cube test, where an ice cube is placed on the forearm for 3-5 minutes and the area monitored for development of wheals. It should be noted that in certain cases, such as the familial type, this test may be negative, and thus doesn’t absolutely rule out cold urticaria as a diagnosis.

As with many injuries and illnesses, the best cure for NFCI’s is a good plan for prevention. Of course, while avoidance of cold wet conditions is ideal, this may not always be an option. For example, those in the military, and those pursuing extreme recreational activities are particularly at risk. page 24

Relationship between Pediatric Obesity and Injuries in the Emergency Department

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The Fast Track

MONICA J. ANKOLA B.S., OMS-III AND JOHN WM. GRANETO, D.O., M.ED. MIDWESTERN UNIVERSITY, CHICAGO COLLEGE OF OSTEOPATHIC MEDICINE, DOWNERS GROVE, IL

Introduction: The purpose of the study is to determine whether pediatric obesity risk factors are translated to increased injuries of specific types, and to identify changes in proportions of obese and overweight children presenting to the emergency department.

Hypothesis: The hypothesis of the research is that the proportion of obese and overweight children treated in the Emergency Department has increased over the years, as obesity risk factors have become more prevalent in society. Furthermore, the research hypothesis is that obese children are more likely to have more musculoskeletal injuries, with a larger proportion of lower extremity and upper extremity injuries than their non-obese counterparts. However, obese children may be less likely to sustain head and trunk or intra-abdominal injuries.

Methods: The study is an IRB approved retrospective review of medical records to examine weights and injuries in children ages 2 to 16 years presenting to the Emergency Department in 2005 and 2013. The data collected determines the Weight Classifications and the Injury Classifications of each individual for analysis within the study. The patients in the study are split into four categories: Underweight, Average, Overweight, and Obese. The patients are further grouped into injury classifications: Head, Upper Extremity, Lower Extremity, Trunk, and Unknown.

Results: The results of this study show no significant changes in weight patterns from 2005 to 2013. Minor changes include an increase in overweight patients, a decrease in average greater than 50th percentile patients, and a decrease of obese patients. The overall injury pattern regardless of gender, weight, or year is: lower extremity, upper extremity, and head, with trunk and unknown injuries at a minimum. However, obese and overweight patients do have a larger proportion of lower extremity injuries 50% and 46% respectively, in comparison to the 35-43% of lower extremity injuries in other weight groups, true to the hypothesis. Multiple chi-square analyses show p-values >0.05, thus accepting the null hypothesis that the different weight classifications are not independent in determination of type of common injuries in the ED. Conclusions: The study will aid in providing education on healthy habits, weight reduction, and injury prevention to parents and children to avoid common injuries and promote a healthier lifestyle and allow physicians to effectively diagnose and treat pediatric patients.

Keywords: Pediatric, Obesity, Trauma, Injury, Weight Monica J. Ankola was supported by the Kenneth A. Suarez Summer Research Fellowship. page 25

The Fast Track Winter 2015

Emergent Management of Acute Abdomen Due to Complicated Diverticulitis Theresa Hsiao, OMS IV @ Touro University Nevada Joshua Batt, DO @ Arrowhead Regional Medical Center ABSTRACT: The authors present the case of a 68-year-old woman with worsening abdominal pain over a period of two weeks. Clinical examination revealed an abdomen that had diffuse tenderness to palpation, significant distention, and hypoactive bowel sounds. Imaging depicted a thickwalled colon with free air. The patient was taken to the operating room for an exploratory laparotomy. The diagnosis of perforated diverticulitis was made, and the patient had minor complications during recovery that were resolved surgically. The authors review etiologies of abdominal pain and diverticular disease, clinical findings, and various treatment options.

INTRODUCTION: Abdominal pain is one of the most common complaints presenting to the emergency department (ED) every year. The number of noninjury visits for which abdominal pain was the primary presenting complaint increased 31.8% from 5.3 million in 1999-2000 to 7.0 million in 2007-2008.1(Figure 1) Evaluation of the emergency department patient with acute abdominal pain is sometimes difficult. Various factors can obscure the presentation, delaying or preventing the correct diagnosis, with subsequent adverse patient outcomes.2 The abdominal cavity houses a multitude of organs, thus the differential diagnosis for abdominal pain is vast. Many times, patients present with similar, nonspecific complaints such as nausea, vomiting, diarrhea, rebound or guarding. Typically a thorough history and physical will help to narrow possible etiologies. Abdominal pain is the presenting issue in a high percentage of medicolegal actions against both general and pediatric emergency physicians.2 Due to this and the increasing incidence of abdominal pain, it is crucial as an emergency physician to be familiar with and comfortable in correctly diagnosing and managing this condition.

Figure 1. Emergency Department visits for abdominal pain aged 18 years and over: United States, 1999-2008.1 Patients with serious abdominal pathologies typically present to medical page 26

personnel upon having acute onset of unrelenting pain. While frequently due to organ dysfunction, other contributory causes of abdominal pain include increased age, the use of non-steroidal anti-inflammatory medications (NSAIDs), alcohol and drug abuse, associated comorbidities and diet. It is not uncommon for older patients to have atypical presentations.

Serious causes of abdominal pain generally present early in their course; however, delays in presentation commonly occur in the elderly.2 Acute-onset pain, especially if severe, should prompt immediate concern for a potential intra-abdominal catastrophe.2 In this manuscript, we describe the case of an elderly woman with a perforated diverticulitis diagnosed and resolved with surgical exploration.

Fall 2014

The Fast Track

CASE REPORT: A 68-year-old African American female presented with the chief complaint of abdominal pain for two weeks. The patient stated that she thought it was initially a benign stomach ache or indigestion. With time, however, she had been experiencing an increasing amount of pain. At its onset, the pain was localized to the right-lower quadrant, yet was now situated at the left-lower quadrant. The patient described her pain as sharp and intermittent, rating it a 10 on a 10-point scale. Resting and limiting her movements gave minimal relief as the pain sporadically waxed and waned throughout the day. Prior to the event, the patient had no change in her diet. She had decreased oral consumption as a result of feeling nauseated. At the time of presentation, she had developed non-bloody vomiting and diarrhea for one day.

Figure 2. Computed tomography of the abdomen and pelvis showing small bowel edema, free air, thick-walled colon and a small ventral hernia.4 page 27

The Fast Track Winter 2015

She denied any recent travel, and has not been exposed to ill contacts. While typically active, she felt limited by the pain which made doing daily activities increasingly difficult.

The patient’s past medical history includes diabetes, hypertension, congestive heart failure, myocardial infarction, breast cancer, chronic kidney disease and a previous stroke. She had a cesarean section, bilateral breast mastectomy and right breast reconstructive surgery in the past.

The patient takes carvedilol, lovastatin, furosemide and losartan daily. Upon taking penicillin and sulfa-based medications the patient develops a rash. She denies drug use but admits to tobacco and alcohol use.

On arrival, the patient had a blood pressure of 80/49 mmHg, a heart rate of 88 beats per minute, a respiratory rate of 18 and a temperature of 97.3F. Her electrocardiogram showed normal sinus rhythm at a rate of 85 beats per minute with no ST changes. Focused physical examination revealed a significantly distended abdomen with decreased bowel sounds. There was diffuse tenderness to palpation that was worse in the left-lower and right-lower quadrants. Further examination demonstrated no costovertebral angle tenderness, no rebound or guarding, a negative Murphy’s sign and no hepatomegaly. The patient had a negative heme-occult examination with good rectal tone. Laboratory analysis and radiographic imaging were significant for an elevated white count of 17.0, bandemia of 41 %, BUN of 30, creatinine of 2.5, lactate of 3.59, total bilirubin 0.5and an albumin of 3.0. Computed tomography (CT) of the abdomen and pelvis revealed small bowel edema, free air, a portion of thick-walled colon and a small ventral hernia (Figure 2).

After careful review of the history, physical examination, laboratory results, and imaging, the authors suspected an acute abdomen with possible etiologies of mesenteric ischemia or diverticulitis. Ciprofloxacin and metronidazole were empirically administered after the labs were resulted. While the abdomen was the main focus, the patient’s low blood pressure of 80/49 upon presentation led the authors to initiate intravenous (IV) hydration. Upon revaluation an hour after arrival in the emergency department, the patient was smiling, conversing and appeared to be in no distress. Her systolic blood pressure was persistently less than 90 mmHg despite her initial bolus of fluid. Another liter of normal saline bolus was given in an attempt to raise her blood pressure. This was met with little success. General surgery was consulted, who decided to take the patient emergently to the operating room for an acute abdomen with generalized peritonitis. As a result of her persistently low blood pressure, the authors placed a central venous line before exploratory laparotomy to start vasopressor agents in the emergency department.

During surgery, the patient was noted to have gross peritonitis with a significant amount of purulent fluid which was suctioned out. An end-ostomy was created and two drains were placed in the abdomen. The postoperative diagnosis was peritonitis secondary to perforated diverticulitis. The patient was placed on IV antibiotics for an anticipated ileus and started on a norepinephrine drip to maintain hemodynamic stability. Following surgery, the patient was unable to tolerate a regular clear liquid diet. There were no indications of ostomy function on post-operative day 10. The decision was made to take her back into the operating room for revision of the ostomy. She was found to have an obstruction proximal to the colostomy with dense adhesions. A second ostomy was created which allowed for proper bowel flow a day after the revision. Her regular diet was resumed and well tolerated. She made an otherwise uncomplicated recovery from this point forward and was discharged home in a stable condition.

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DISCUSSION: In older patients with pain localized to either lower quadrant, diverticular disease should be

considered. One of the more common etiologies of abdominal pain in Western countries is Diverticular Disease with 80% of patients being 50 years or older.5 Colonic Diverticular Disease is acquired by herniation of the colonic wall through low resistance sites in areas of vascular passage, resulting in protrusions of small outpouchings of the mucosa.5 (Figure 3) These herniations can be due to a low-fiber diet, as it results in less bulky stools that retain less water which may alter gastrointestinal transit time. The increasing intracolonic pressure then leads to mucosal protrusions.7 Diverticulosis refers to presence of diverticula in colon, without associated inflammation.8 Once diverticula are present, particles of undigested food may become inspissated within them and this obstruction can Figure 3. Diverticula are sac-like pouches that cause distention and overgrowth of colonic bacteria.7 Diverticulitis occurs protrude from the normally smooth muscular layer 6 when this distention becomes inflamed of the colon. or infected, and if it worsens, a complicated diverticulitis will involve an obstruction, free perforation, fistula, or an abscess.8,9

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The Fast Track

Patients with diverticular disease typically present with symptoms of abdominal pain localized to the lower quadrants, nausea, vomiting, dysuria or have changes in bowel movements. Many times, an accurate diagnosis is made based off history, physical examination and imaging.

Low-grade fever and leukocytosis are generally present.5 Most patients with acute diverticulitis respond to conservative medical management, although 15 to 30 percent may require surgery during hospital admission due to a lack of response to treatment or from the development of complications.10 The ill-appearing patient with abdominal pain requires immediate attention which is particularly so in the elderly, as the overall mortality rate for older patients with acute abdominal pain ranges from 11%-14%, and those presenting in an unstable fashion have an even poorer prognosis such was the case presented here.2 A complication of diverticulitis is perforation, which can incite somatic changes and induce diffuse sharp abdominal pain. Patients with intra-abdominal free air may have peritoneal irritation, including marked abdominal tenderness that begins suddenly and spreads rapidly to involve the entire abdomen.5 These symptoms are similar to how our patient presented. With suspicion of perforated viscous, a CT scan may be paramount in diagnosis. CT with intravenous and oral contrast is the test of choice to confirm a suspected diagnosis of diverticulitis.10 If scan results indicate the need for surgery, several surgical options are available, including the following: resection with primary anastomosis, resection with colostomy and closure of the rectal stump, transverse colostomy with drainage and laparoscopic colectomy.10 Ultimately, it is the choice of the patient and surgeon as to which surgery they would like to have performed.

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The Fast Track Winter 2015

Residency Spotlight

St. Luke’s University Hospital – Bethlehem, PA –

Size: 40 EM residents (16 osteopathic, 24 allopathic) Total ED visits per year: over 100,000 between all sites Hospital size: Level I trauma with 500 beds, stroke center, and cardiac cath center

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What is unique about your program?

St. Luke’s is truly a special

hospital for many reasons. We have the dynamic of a level 1 trauma center and university academic institution, intermixed with the feel of a tight-knit, family-oriented, community-based hospital; in fact, the hospital’s motto accurately used to be ”Big city medicine, home-town feel.”

The hospital is staffed by friendly, happy people, who are genuinely excited to be teaching residents medicine. This is true at all levels of health-care providers. Our program is also unique in that we have two parallel EM programs, an osteopathic and an allopathic program, which suprisingly does not take away from the family feel in our program. The different medical backgrounds amongst our residents push us to consider different approaches, and to work both harder and smarter. As a level 1 center we have all the things needed to help train strong EM doctors; sick patients, technology, well-trained staff, and research. Our programs’ real strength, however, cannot be measured as easily as our trauma census or number of ultrasound machines.

Instead, it is the relationships and comradery between the residents and staff that help make St. Luke’s the great residency that it is.

What do you do outside the hospital?

We are the definition of ”work hard, play hard.” We work hard everyday in the hospital to deliver quality patient care. We study a lot outside of work, and we keep up with the latest literature and are strong residents because of it. We also do a good job of keeping our lives in balance by with adequate ”relaxation and recreation” when we are not doing medicine. We have a good mix of residents who are married with children, in relationships, and single, and we all get along in and out of the hospital. We often go out for happy hours together to ruminate our medical stories.

We also enjoy a wide range of activities to get a break from medicine, such as: outdoor activities (skiing/snowboarding, rock climbing, surfing), traveling new places, running races, going to the gym, video games, and trying new things. We are lucky to live in the small, up and coming city of Bethlehem with some great restaurants, bars, and other activities, but we are also a short drive from NYC, Philly, local lakes and rivers, and the beaches of NJ. It is a great mix.

Fall 2014

The Fast Track

What three words describe your residency?

Comradery, Innovative, Lively

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The Fast Track the PULSE | JANUARY 2015

Winter 2015

The Pulse Crossover Article

Are You Really Listening to Your Patient?

It turns out that the patient, who is a regular patient of the agency who made the report, had called several times the morning of her visit to speak with her counsellor. She was very anxious about a job interview later in the day and her regular therapist was not immediately available.

The patient became frustrated that she couldn’t access her provider and voiced her frustration, making a statement somewhat to the effect of, “what do I need to do to speak with someone, take some pills?” That was all the secretary needed to hear. The next thing you know the supervisor was calling the police and EMS to go get her. Now she’s here.

The Editor's Desk

Tim Cheslock, DO, FACOEP

W

e all like to think that we’re doing what’s best for our patients. We read their complaint and order an array of tests in order to diagnose a condition or ensure their safety for discharge. We base our decisions on a brief interview, sometimes with input from a family member or EMS provider.

But are we really listening to what the patient is telling us? Does the physical exam corroborate with what we’re told?

I recently encountered a patient brought in

by EMS for a potential overdose and presumed involuntary mental health evaluation. Slam dunk, or so I thought. The patient was visibly emotional and EMS reported that the patient called the local mental health provider line stating that she overdosed on her Depakote.

As the EMS provider continued her hand off to the nursing staff, the patient became increasingly irate and boisterous insisting that is not what happened.

I now have a dilemma to say the least. Do I take the word of the EMS crew, or do I listen to what the patient has to say in her obvious state of distress and emotional breakdown?

As I continued to get an earful on each side, I thought it might be prudent to listen to the patient and see what she had to say. I’m glad I did!

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Now, another dilemma. Do I pursue the toxicology workup even though this sounds like a big miscommunication? You bet I do, I value my license too much to ignore a potential overdose situation. But what’s more important, how do I interact with the patient? The patient was obviously distraught about not being able to speak with someone about her anxiety.

Did she make a potentially suicidal gesture?

I’m not sure. She denied being suicidal, rather she wanted to speak with her therapist. Not really an unrealistic request. She told me that the secretary told the patient didn’t have time to deal with her issue and she needed to stop calling. This only infuriated the patient, with a history of mental health issues, even more.

I needed to get to the bottom of this situation and hopefully help the patient in the process.

After calming the patient down and assuring her that I would try to help her come to terms with her issues, she became much more relaxed and compliant. We did the obligatory tests and observation period. It turns out all her medication was accounted for and she never exhibited any signs of overdose. I spoke with the mental health provider who wanted to know if she was being committed for a 72 hour hold. I explained the situation and they had a plan in place to send a crisis worker to meet with her for a face-to-face visit upon discharge. Deep down I think they realized that the situation was handled poorly and the desired outcome was going to occur regardless of the ED work up.

It turns out that if they had just put that plan in place originally, before the patient became irate and infuriated, the whole ED visit and situation

5

could have been avoided. It just goes to show that you need to be responsive to your patient’s needs and to help provide them with the services they need.

It’s important to listen to your patient, for a lot of information can be obtained that may result in an entirely different work up plan.

Case in point—I recently had an oncology patient come in for nausea and vomiting. The only thing she required was an anti-emetic and some fluids. The meds she had at home were not helping and she ran into this situation in the past with her chemotherapy. Had I not listened to the patient I would have begun an extensive work up to determine why this patient was vomiting. Was she dehydrated, suffering from a bowel obstruction? Was she merely out of her anti-emetic? A liter of fluids and two doses of Zofran later she was much improved. The family was grateful and the patient disposition was to home with a new script, after her basic chemistry results came back as normal. The family and the patient did not want an extensive work up. No CT needed to be done. They simply wanted help in stopping her vomiting.

They just wanted her to feel better. Sometimes more is not better.

It is so important in this day and age of patient care that we truly listen and provide what is needed for our patients rather than the knee-jerk reaction to a chief complaint. It saves time, money, and will ultimately result in higher patient satisfaction. It may take a few extra minutes on the front end to hear your patient out, but in the end the payoff will far outweigh the perceived delay. A visit does not always need to be the endless laundry list of tests yielding a non-specific diagnosis. More often than not, a positive outcome can be obtained by listening to the patient and providing what they truly need – an engaged provider, willing to go the extra mile to assist them in finding the solution that they really need.

Emergency Medicine Review with

Elevate your knowlege, rock the inservice exam and blow away the boards! www.roshreview.com

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FA LL 20 C 14 O -L N as Ve F ga E s, R Ne va E da N CE

The Fast Track

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Sacco DE, Sartorelli DH, Vane DW. Evaluation of alpine skiing and snowboarding injury in a northeastern state. J Trauma. 1998 Apr; 44(4): 654-9.

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Williams R, Delaney T, Nelson E, Gratton J, Laurent J, Heath B. Speeds associated with skiing and snowboarding. Wilderness Environ Med. 2007 Summer; 18(2): 102-5.

Non-freezing Cold Injuries Auerbach, P. (2011). Ch 7 - Non Freezing Cold Induced Injuries. In Wilderness medicine (6th ed.). Philadelphia: Mosby Elsevier.

Knoop, K. (2010). Ch 16 - Environmental Conditions. In Atlas of emergency medicine (3rd ed.). New York: McGraw-Hill, Medical Pub. Division.

Rustin et al. (1989). The treatment of chilblains with nifedipine: The results of a pilot study, a double-blind placebo-controlled randomized study and a long-term open trial. British Journal of Dermatology, 120(2), 267-75.

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Thom, Stephen R., Veena M. Bhopale, and Donald Fisher. “Hyperbaric Oxygen Reduces Delayed Immune-mediated Neuropathology in Experimental Carbon Monoxide Toxicity.” Toxicology and Applied Pharmacology 213 (2006): 152-59.

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Osborne Waves Maruyama M, Kobayashi Y, Kodani E, Hirayama Y, Atarashi H, Katoh T, Takano T. Osborn Waves: History and Significance. Indian Pacing and Electrophysiology Journal. 2004; 4(1): 33-39 Patel, Archana, John P. Getsos, Ghias Moussa, and Damato Anthony N. “The Osborn Wave of Hypothermeia in Normothermic Patients.” Clinical Cardiology. 1994; 17(5): 273-76.

Dedeoglu E, Bayram B, Dedeoglu B. Osborn wave in a patient with intracranial haematoma and hypothermia. Hong Kong Journal of Emergency Medicine. 2012; 19:130-132 Thompson R, Rich J, Chmelik F, Nelson W. Evolutionary changes in the electrocardiogram of severe progressive hy-pothermia. J Electrocardiol.

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Vassallo, Susi U., Kathleen A. Delaney, Robert S. Hoffman, William Slater, and Lewis R. Goldfrank. “A Prospective Evaluation of the Electrocardiographic Manifestations of Hypothermia.” Academic Emergency Medicine. 6(11): 1121-126.

Matei, Veronica A., Holli A. Barth, John A. Elefteriades, and Paul G. Barash.

“Hypothermia-related Electrocardiographic Abnormalities: Osborn Waves.” Anesthesiology 112(6): 1518 Kraus F: Ueber die Wirkung des Kalziums auf den Kreislauf. Dtsch Med Wochensch. 1920; 46: 201-203.

Gussak I, Bjerregaard P, Egan TM, Chaitman BR: ECG phenomenon called the J wave: history, pathophysiology, and clinical significance. J Electrocardiol 1995; 28: 49-58.

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Otero, Javier, and Daniel Lenihan. “The “Normothermic” Osborn Wave Induced by Severe Hypercalcemia.” Texas Heart Institute Journal. 2000; 27(3): 316-17.

Milewska, Agata, Przemyslaw Guzik, Magdalena Rudzka, Rafal Baranowski, Roman Jankowski, Stanislaw Nowak, and Henryk Wysocki. “J-wave Formation in Patients with Acute Intracranial Hypertension.” Journal of Electrocardiology. 2009; 42(5):420-23.

Acute Abdomen from Diverticulitis Bhuiya F, Pitts SR, McCaig LF. Emergency department visits for chest pain and abdominal pain: United States, 1999-2008. NCHS data brief, no 43.

Hyattsville, MD: national center for health statistics. 2010 Macaluso C, Mcnamara R. Evaluation and Management of Acute Abdominal Pain in the Emergency Department.” Int J Gen Med. 2012;5:789-797.

Ambrosetti P, Robert JH, Witxig JA, Mirescu D, Mathey P, Borst F, et al.

Acute left colonic diverticulitis: a prospective analysis of 226 consecutive cases. Surgery 1994;115:546-50 Figure 2. CT Abdomen Pelvis with IV and PO contrast Liu C, Hsu H, Cheng S. Colonic Diverticulitis in the Elderly. Division of Colorectal Surgery, Department of Surgery and Department of Radiology.

International Journal of Gerontology March 2009, Vol 3 No1; 1-15 Figure 3. Diverticular Disease of the Colon. Harvard Men’s Health Watch.

Aug 2010.

Ferozoco, LB, Raptopoulos V, Silen W.. Acute Diverticulitis. N Engl J Med1998;338-1521-6.

Wong W, Wexner S, Lowry A, et al. Practice parameters for the treatment of sigmoid diverticulitis-supporting documentation. Diseases of the Colon and Rectum. March 2000, Volume 43, Issue 3. Pp 290-297.

Thompson DA, Bailey HR. Management of Acute Diverticulitis with abscess. Semin Colon Rectal Surg 1990;1:74-80.

Salzman H, Lillie D. Diverticular Disease: Diagnosis and Treatment. Am Fam Physician. 2005 Oct 1;72(7):1229-1234 Pediatric Obesity Abstract References Lazar-Antman MA, Leet AI. Effects of obesity on pediatric fracture care and management. J Bone Joint Surg Am. 2012;94(9):855-861.

Skelton JA, Cook SR, Auinger P, Klein JD, Barlow SE. Prevalence and trends of severe obesity among US children and adolescents. Acad Pediatr.

2009;9(5):322-329.

Brown CV, Neville AL, Salim A, Rhee P, Cologne K, Demetriades D. The impact of obesity on severely injured children and adolescents. J Pediatr Surg. 2006;41(1):88-91; discussion 88-91.

Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of obesity and trends in body mass index among US children and adolescents, 1999-2010.

JAMA. 2012;307(5):483-490.

Centers for Disease Control and Prevention. Progress on Childhood Obesity. Vital Signs August 2013; http://www.cdc.gov/VitalSigns/ ChildhoodObesity/.

Centers for Disease Control and Prevention. Childhood Data and Statistics.

Overweight and Obesity January 2013; http://www.cdc.gov/obesity/data/ childhood.html.

Vaughn LM, Nabors L, Pelley TJ, Hampton RR, Jacquez F, Mahabee-Gittens EM. Obesity screening in the pediatric emergency department. Pediatr Emerg Care. 2012;28(6):548-552.

Thundiyil JG, Christiano-Smith D, Greenberger S, Cramm K, LatimerPierson J, Modica RF. Trimming the fat: identification of risk factors associated with obesity in a pediatric emergency department. Pediatr Emerg Care. 2010;26(10):709-715.

Whitaker RC, Wright JA, Pepe MS, Seidel KD, Dietz WH. Predicting obesity in young adulthood from childhood and parental obesity. N Engl J Med. 1997;337(13):869-873.

Prendergast HM, Close M, Jones B, et al. On the frontline: pediatric obesity in the emergency department. J Natl Med Assoc. 2011;103(910):922-925.

Sayegh R, Bradley D, Vaca F. Pediatric obesity: implications for fall injuries. J Emerg Nurs. 2010;36(2):175-177.

National Conference of State Legislatures. Childhood Overweight and Obesity Trends. 2007; http://www.ncsl.org/research/health/childhoodobesity-trends-state-rates.aspx.

Centers for Disease Control and Prevention. Childhood Obesity Facts. Adolescent and School Health July 2013; http://www.cdc.gov/ healthyyouth/obesity/facts.htm.

Pomerantz WJ, Timm NL, Gittelman MA. Injury patterns in obese versus nonobese children presenting to a pediatric emergency department. Pediatrics. 2010;125(4):681-685.

Rana AR, Michalsky MP, Teich S, Groner JI, Caniano DA, Schuster DP. Childhood obesity: a risk factor for injuries observed at a level-1 trauma center. J Pediatr Surg. 2009;44(8):1601-1605.

Choudhary AK, Donnelly LF, Racadio JM, Strife JL. Diseases associated with childhood obesity. AJR Am J Roentgenol. 2007;188(4):1118-1130.

Backstrom IC, MacLennan PA, Sawyer JR, Creek AT, Rue LW, Gilbert SR. Pediatric obesity and traumatic lower-extremity long-bone fracture outcomes. J Trauma Acute Care Surg. 2012;73(4):966-971.

About Pediatrics. BMI Calculator. http://pediatrics.about.com/cs/ usefultools/l/bl_bmi_calc.htm.

Centers for Disease Control and Prevention. Growth Charts. 2001; http://www.cdc.gov/growthcharts/html_charts/wtage.htm.

Centers for Disease Control and Prevention. About BMI for Children and Teens. Healthy Weight September 2011; http://www.cdc.gov/ healthyweight/assessing/bmi/childrens_bmi/about_childrens_bmi. html.

Centers for Disease Control and Prevention. Basics about Childhood Obesity. Overweight and Obesity April 2012; http://www.cdc.gov/ obesity/childhood/basics.html.

Preacher, K. J. (2001, April). Calculation for the chi-square test: An interactive calculation tool for chi-square tests of goodness of fit and independence [Computer software]; http://quantpsy.org.

What’s New With Croup 1. McEniery J, Gillis J, Kilham H, et al. Review of intubation in severe laryngotracheobronchitis. Pediatrics. 1991;87(6):847- 853.

(Retrospective chart review; 208 patients) 2. Westley CR, Cotton EK, Brooks JG. Nebulized racemic epinephrine

by IPPB for the treatment of croup. Am J Dis Child. 1978;132(5):484487. (Randomized controlled trial; 20 patients) 3. Alberta Clinical Practice Guideline Working Group. Guideline for diagnosis and management of croup. 2007 Update. Available at: http:// www.albertadoctors.org/bcm/ama/ ama-website.nsf/AllDoc/87256DB0 00705C3F87256E0500553 4E2/$File/CROUP.PDF. Accessed October 2, 2011. (Clinical guidelines) 4. Bourchier D, Dawson KP, Fergusson DM. Humidification in viral croup: a controlled trial. Aust Paedatr J. 1984;20(4):289- 291.

(Randomized controlled trial; 16 children) 5. Neto GM, Kentab O, Klassen TP, et al A randomized controlled trial of mist in the acute treatment of moderate croup. Acad Emerg Med. 2002;9(9):873-879. (Randomized controlled trial; 71 patients 6. Westley CR, Cotton EK, Brooks JG. Nebulized racemic epinephrine

by IPPB for the treatment of croup. Am J Dis Child. 1978;132(5):484487. (Randomized controlled trial; 20 patients) 7. Corkey C, Barker G, Edmonds J, et al. Radiographic tracheal diameter

measurements in acute infectious croup: an objective scoring system.

Crit Care Med. 1981;9(8):587-590. (Randomized controlled trial; 14 patients) 8. Kristjansson S, Berg-Kelly K, Winso E. Inhalation of racemic adrenaline in the treatment of mild and moderately severe croup.

Clinical symptom score and oxygen saturation measurements for evaluation of treatment effects. Acta Paediatrica. 1994;83(11):11561160. (Randomized controlled trial; 54 patients) 9. Waisman Y, Klein BL, Boenning DA, et al. Prospective randomized double-blind study comparing L-epinephrine and racemic epinephrine aerosols in the treatment of laryngotracheitis (croup). Pediatrics.

1992;89(2):302-306. (Randomized controlled trial; 28 patients) 10. Butte MJ, Nguyen BX, Hutchison TJ, et al. Pediatric myocardial infarction after racemic epinephrine administration. Pediatrics.

1999;104(1):e9. (Case report; 1 patient) 11. Bjornson C, Russell KF, Vandermeer B, et al. Nebulized epinephrine for croup in children. Cochrane Database Syst Rev. 2011,16;(2): CD006619. (Systematic review; 8 studies; 225 patients) 12. Ledwith CA, Shea LM, Mauro RD. Safety and efficacy of nebulized racemic epinephrine in conjunction with oral dexamethasone and mist in the outpatient treatment of croup. Ann Emerg Med. 1995;25(3):331337. (Prospective interventional study; 55 patients) 13. Kelly PB, Simon JE. Racemic epinephrine use in croup and disposition. Am J Emerg. 1992;10(3):181-183. (Retrospective chart review; 50 patients) 14. Thomas LP, Friedland LR. The cost-effective use of nebulized racemic epinephrine in the treatment of croup. Am J Emerg Med. 1992;10(3):181-183. (Cross-sectional study; 23 hospitals) 15. Russell KF, Liang Y, O’Gorman K, et al Glucocorticoids for croup.

Cochrane Database Syst Rev. 2011,19;(1):CD001955. (Systematic review; 24 studies; 2878 patients) 16. Alberta Clinical Practice Guideline Working Group. Guideline for diagnosis and management of croup. 2007 Update. Available at: http:// www.albertadoctors.org/bcm/ama/ ama-website.nsf/AllDoc/87256DB0 00705C3F87256E0500553 4E2/$File/CROUP.PDF. Accessed October 2, 2011. (Clinical guidelines) 17. Klassen TP, Craig WR, Moher D, et al. Nebulized budesonide and oral dexamethasone for treatment of croup: a randomized controlled trial. JAMA, 1998;21(6):359-362. (Randomized controlled trial; 198 patients) 18. Geelhoed, GC. Oral dexamethasone in the treatment of croup: 0.15 mg/kg versus 0.3 mg/kg versus 0.6 mg/kg. Ped Pulmonol.

1995;20(6):362-368. (Randomized controlled trial; 120 patients) 19. Geelhoed CC, Macdonald WBS. Oral and inhaled steroids in croup: a randomized, placebo-controlled trial. Pediatr Pulmonol.

1995;20(6):355-361. (Randomized controlled trial; 80 patients) 20. Parker C. “ToPDog” is in progress. Emerg Med J. 2010;27(12):961.

(Letter) 21. A comparison of oral prednisolone and oral dexamethasone in children with croup: a prospective, randomised, double blinded multicentre trial, Australian New Zealand Clinical Trials Registry, ACTRN12609000290291. (Randomized controlled trial, unpublished data) 22. Terregino C, Nairn S, Chansky M, et al. The effect of heliox on croup: a pilot study. Acad Emerg Med. 1998;5(11):1130- 1133. (Randomized trial; 15 patients) 23. Weber JE, Chudnofsky CR, Younger JG, et al. A randomized comparison of helium-oxygen mixture (heliox) and racemic epinephrine for the treatment of moderate to severe croup. Pediatrics.

2001;107(6):E96. (Randomized controlled trial; 33 patients) 24. US Food and Drug Administration. News & Events. FDA releases recommendations regarding use of over-the-counter cough and cold products. Products should not be used in children under 2 years of age; evaluation continues in older populations. Available at: www.fda.gov/ NewsEvents/Newsroom/PressAnnouncements/2008/ucm116839.htm.

Accessed October 26, 2011.

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References

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Review Answers

The Fast Track Winter 2015

Question 1: Answer A. This patient presents with a severe headache unlike prior headaches raising the suspicion for a subarachnoid hemorrhage (SAH). SAH is defined as the extravasation of blood into the subarachnoid space. Approximately 1-4% of patients presenting to the ED for headache will have a SAH. The classic presentation of SAH is a patient presenting with a “thunderclap” headache or “the worst headache of life.” However, it should be suspected in any patient who presents with an acute, severe headache that reaches maximal intensity in a short period of time or is different than prior headaches. Although some patients will present with traumatic SAH, the most dangerous form is SAH related to berry aneurysms. These aneurysms are prone to catastrophic rupture. Many patients who have large berry aneurysm bleeds will report a sentinel headache, which may or may not have prompted a doctor visit. It is vital to diagnose patients presenting with a sentinel bleed as neurosurgical intervention for berry aneurysms can avoid catastrophic events. Noncontrast CT scan of the head should be ordered in any patient with a presentation concerning for SAH. The sensitivity of CT within the first 6 hours of headache onset is extremely high (> 95%) but the sensitivity decreases with time. Overall sensitivity is about 93%. A negative CT scan should be followed by a lumbar puncture (LP). The LP is performed looking for the presence of blood in the CSF or xanthochromia (the yellowish pigmentation of CSF secondary to hemoglobin metabolism). Xanthochromia takes approximately 12 hours to develop.

Non-contrast head CT scan (B) alone is highly sensitive for the diagnosis of SAH if performed within the first 6 hours. However, because SAH is a life-threatening disease if missed, current guidelines recommend against using non-contrast head CT to rule out the diagnosis. An MRI of the brain (C) can be helpful in detecting berry aneurysms as the cause of SAH but the workup should not be delayed when SAH is suspected. Symptomatic treatment (D) should be given to all headache patients regardless of etiology. However, response to treatment does not rule out dangerous pathology.

References Kwiatkowski T, Alagappan K: Headache, in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 7. St. Louis, Mosby, Inc., 2010, (Ch) 101: p 1356-1366.

Question 2: Answer: C. This patient presents with a classic story for an epidural hematoma confirmed by imaging and requires immediate evaluation for prompt surgical hematoma evacuation. Epidural hematoma results from trauma leading to rupture of the middle meningeal artery. Classically, patients report a brief loss of consciousness followed by a lucid period and then a precipitous decline. Non-contrast head CT (NCHCT) scan is diagnostic for this disease. A NCHCT will show a biconvex or lens shaped hyperdense area in the temporal region of the side of trauma in the epidural space. Depending on the size of the hematoma, there may also be midline shift and compression of the ventricles. As the hematoma continues to expand, it can cause uncal herniation leading to brain compromise and respiratory arrest. In an obtunded patient, the physical examination may reveal a unilateral dilated and unresponsive pupil (aka “blown pupil) on the side of the hematoma. Emergency management of an epidural hematoma should focus on airway protection if necessary and emergent neurosurgical consultation for hematoma evacuation. In patients with signs of increased intracranial pressure or impending herniation, hyperventilation should be initiated followed by osmotic agents like mannitol.

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Stable patients with traumatic subdural or subarachnoid hematomas may be admitted for serial NCHCT (A) after neurosurgical evaluation. These intracranial hematomas may not increase in size and may not require surgical intervention. However, this does not apply to epidural hematomas. In the absence of an intracranial hematoma, the patient’s symptoms may be consistent with a concussion, which would require outpatient neurology follow up (B).

MRI of the brain (D) is not necessary in epidural hematoma

as the NCHCT is diagnostic.

References Kwiatkowski T, Alagappan K: Headache, in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 7. St. Louis, Mosby, Inc., 2010, (Ch) 101: p 1356-1366.

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Question 3: Answer: D. Therapeutic hypothermia has become the standard of care in the care of postarrest patients who achieve return of spontaneous circulation but remain comatose. The original trials showed significant survival benefit in patients whose initial rhythm was either ventricular fibrillation or pulseless ventricular tachycardia. Additional observational data has suggested a modest benefit in the other rhythms and the American Heart Association now recommends therapeutic hypothermia in all unresponsive post-cardiac arrest patients. In the first hours after cardiac arrest, the core temperature of the body is lowered and maintained there for 12 to 24 hours. Recent data suggests that the most important element in post-cardiac arrest care is avoidance of fever.

Hyperkalemia (A) may lead to cardiac arrest. In most cases the rhythms associated with hyperkalemia are either asystole or pulseless electrical activity, which appear to have slightly worse outcomes when compared with ventricular fibrillation or ventricular tachycardia in therapeutic hypothermia. Pulmonary embolism (B) may lead to cardiac arrest with significant proximal clot or overwhelming clot burden. However, outcome data of therapeutic hypothermia looks at primary rhythm in arrest, and most commonly pulmonary embolism is associated with pulseless electrical activity or asystole. Patients found in pulseless electrical activity (C) may derive some survival benefit from therapeutic hypothermia but the benefit is not as strong as ventricular fibrillation or ventricular tachycardia.

References http://www.uptodate.com/contents/post-cardiac-arrest-management-in-adults?source=search_result&s earch=therapeutic+hypothermia&selectedTitle=1~32#H9724176 Question 4: Answer: C. Systemic inflammatory response syndrome (SIRS) is the systemic inflammatory response syndrome occurring most commonly in response to an infection. SIRS plus a source of infection is the definition of sepsis. Sepsis is an increasingly common cause of ED visits and the tenth leading cause of death in the US. In response to the infectious insult, the host’s body activates a number of inflammatory cascades as part of the host response. As patients become sicker, severe sepsis develops with the presence of organ dysfunction in the setting of an infection. The respiratory rate of 22 above fulfills one of the SIRS criteria.

The heart rate of 86 (A) and temperature of 39.7°C (D) do not meet criteria for SIRS. Lactic acid (B) has become an important laboratory value in the management of septic patients. Lactic acids greater than 4 are associated with worsened outcomes. Aggressive resuscitation in the early stages of sepsis includes large volumes of intravenous fluid and early antibiotics. A goal of resuscitation is lactate clearance.

Reference: Shapiro NI, Zimmer GD, Barkin AZ: Sepsis Syndromes, in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 8. St. Louis, Mosby, Inc., 2013, (Ch) 138: pp 1864-1866.

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The Fast Track Winter 2015

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