Conference Notes 11-11-2015

Nejak        Adrenal Crisis and Thyroid Storm


Adrenal Crisis is a life-threatening exacerbation of adrenal insufficiency.  The most common cause worldwide is TB.  The most common cause in the western hemisphere is autoimmune. HIV is another common cause.   The most common cause of secondary adrenal insufficiency is withdrawal of steroid therapy (both oral and inhaled steroids).  Also be aware of post-partum adrenal insufficiency (Sheehan’s syndrome) and post-head trauma adrenal insufficiency.


Adrenal crisis can present with hypotension, altered mental status, abdominal tenderness, hyponatremia/hyperkalemia, hypoglycemia, fever, and hyperpigmentation (hyperpigmentation only with primary adrenal insufficiency).   These are all signs that can be easily attributable to other diseases.  So it is a difficult diagnosis to make.


Treat adrenal crisis with D5.9NS and hydrocortisone 100mg IV bolus Q 6 hours for first 24 hours.  Use pressors as needed.


Thyroid Storm presents as hyperthermia, tachycardia, and altered mental status.



*Diagnostic Scoring for thyroid storm.  There was a discussion that this scoring system may have difficulty differentiating sepsis and thyroid storm.



*Treatment of thyroid storm.  Dan recommended: IV fluids, cooling, PTU followed Iodine, esmolol drip, steroids, and cholestyramine.  Cholestyramine interrupts enterohepatic circulation of thyroid hormone.



Parker          Pearls from Podcasts


Braden played an excerpt of “This American Life” podcast describing a haunting of a house.  This description was reported in a 1921 case report in the Journal of Ophthalmology.   The experiences  (strange sounds, visions, tactile sensations)the family had were due to CO toxicity in the house.


CO toxicity can present with headache, nausea, and a myriad of other nonspecific symptoms.   You have to have a high index of suspicion for CO toxicity especially in the cold weather months when people are using their furnaces. A CO level over 9% is indicative of CO poisoning. Use to the finger probe device to check the level.  It is accurate and painless.   Treatment is O2 and consider hyperbaric O2.    Andrea comment:  Headache is usually present with CO poisoning.  In the winter ask the patient if other people in the house are also having headaches. CO toxicity will affect everyone in the house.


SMARTEM Podcaston who needs LP to identify SubArachnoid Hemorrhage.


CT negative/LP positive SAH are aneurysmal and amenable to neurosurgical intervention.  The problem is identifying these patients.


*SubArachnoid Hemorrhage


Using CTA to screen for aneurysmal hemorrhage are problematic because 3% of the population have asymptomatic aneurysms that don’t require intervention. 


Doing an LP with every bad headache is also problematic.  It is estimated you will have to do  about 1500 LP’s to identify 1 patient who has a negative CT and a SAH due to aneurysm that is amenable to clipping.


Only 20% of SAH have sentinel bleeds.  If the sentinel bleed is missed the patient’s subsequent morbidity and mortality is 45%.  If the diagnosis is made at the tiem of the sentinel bleed,  the patient’s  morbidity and mortality is marginally better at 33%.


CT is very sensitive (99%) for picking up SAH within 6 hours of headache onset.   After 6 hours the sensitivity drops to 86% .  The other factor is that patients who present after 6 hours from the onset of headache have half the risk of SAH compared to patients who present within 6 hours of onset of headache.


Basically a negative CT within 6 hours of onset of headache effectively rules out SAH.   If the patient presents after 6 hours of onset of headache and the CT is negative, look for high risk features that would increase a patient’s risk and use shared decision making with the patient  to decide whether to do the LP.


Elise comment: Be careful.  This can be a tricky diagnosis.  If you are worried do an LP.   Harwood comment:  Be alert for the thunderclap headache.  If the patient reports that the headache became maximal within one hour after onset, that is considered a thunderclap headache.  There are a lot of urban legends about LP’s and patients in general will choose not to have an LP.  If you want to work the patient up further and they are refusing LP you can skip to CTA.  There is however a risk of finding asymptomatic aneurysms as noted earlier.   Girzadas comment: I recall a patient with a severe headache who had a negative CT and LP but still had a really bad headache. We next did a CTA and found an intracranial carotid dissection.  Be aware that this diagnosis is also lurking out there.  If the patient looks bad and the ED work up is negative use your tools to keep looking (neuro consult, CTA, MRA, etc.)


*Carotid dissection


Munoz     Pediatric Rashes



*Roseola   Fever usually starts after fever goes down.  Kid is usually happy.  Can be associated with febrile seizures.


* Pityriasis Rosea   Thought to be due to virus.  Can be mildly pruritic.  Has a larger herald patch.  Can last 2-3 months.



*Chicken Pox   Pruritic vesicles in various stages of evolution.







*Scarlet fever    Due to GABS. More common under 10 years old.  Sandpaper feel to the rash.



*Pastia Lines of Scarlet fever and Sandpaper texture



*Rocky Mountain Spotted Fever



*Erythema Chronicum Migrans Rash of Lyme Disease



Urumov/Navarette     Oral Boards


Case 1.  39 yo male with history of HIV presents with altered mental status. Exam shows evidence of Kaposi’s sarcoma on the skin.  LP studies are positive for india ink and cryptococcal antigen.  Treatment is active rewarming, IV anti-fungal therapy (Amphoterecin B and flucytosine).  In immunocompromised patients always do a CT prior to LP to identify an potential mass lesions.  The cryptococcal antigen study is more sensitive than an india ink test.  You need to do that test on all HIV patients with altered mental status who you tap.

Elise comment: You have to know to do CT/LP and crypto antigen studies in HIV patients who have headache or have altered mental status.  Prior to LP, do CT with and without contrast to look for ring enhancing lesions.  If the patient has Cryptococcus and their opening pressure is high you need to remove fluid to lower ICP.  Harwood comment: You can fill your LP tubes to take off fluid.   No one knew the exact amount of fluid to take off but most felt thatif you took off 20-40 ml that should help a lot.

“CSF pressures should be reduced by therapeutic CSF removal when the opening pressure exceeds 250 mm H2 O. Following removal of CSF, the closing pressure should be less than 200 mm H2 O or at least 50% of the elevated opening pressure.  Medscape Reference”


Case 2.  68 yo female with headache and vomiting.  Patient became ill whe she attended a movie with her husband.   On exam patient is found to have one eye with a poorly reactive pupil and elevated intraocular pressure.  The diagnosis is acute angle closure glaucoma.


*Angle closure glaucoma


*Angle closure glaucoma treatment


Case3.   14 month old child who abruptly started coughing while playing.  No fever or URI symptoms.   CXR shows coin in esophagus.


*Coin in the esophagus (at the clavicles, george washington facing forward).   To be honest, I could not find a picture of a coin in the trachea (coin sideways, overlaying trachea).  It must be pretty rare.  The coin size must not fit thru the chords readily.  Tracheal foreign bodies probably have to be generally smaller than a coin.

ENT usually removes a FB lodged in upper esophagus and airway.  GI usually removes FB’s lodged in the lower esophagus.



Kristen Dibenedetto     Labeling Specimens


Bring the lpatient labels into the patient room prior to obtaining the sample or doing the procedure. Verify that the label matches the patient.  Ask the patient their name, then look at their wrist band.  Check that their name, birthdate, and medical record number all match the labels you have in your hand.  

Be sure you put your initials, date, and time on the label at the bedside. 


Lastly when you put the specimens in the specimen bag at the bedside say out loud the last three numbers of the MR number and match them to the patient’s wrist band at the bedside.


We wrapped up with a robust discussion about the difficulties with patient labels in the ED.



Tekwani       Study Guide   GI


Acute cholangitis: Fever/Pain/Jaundice=Charcot’s Triad.   Add in hypotension and altered mental status and that=Reynold’s Pentad.    Most common causative organisms are ecoli and other gram negatives.


Spontaneous bacterial peritonitis is identified by ascites fluid showing WBC>1000 or polys >250.  Enterobacter is the most common causative organism.   Treat with Rocephin or Zosyn.



*Acetaminophen metabolism pathway.  Acetaminophen overdose is the most common cause of liver failure in the US.


*Amebic Liver Abscess

Amebic liver abscess is caused by entamoeba histolytica.  E histolytica exists in 2 forms. The cyst stage is the infective form, and the trophozoite stage causes invasive disease. People who chronically carry E histolytica shed cysts in their feces; these cysts are transmitted primarily by food and water contamination. Rare cases of transmission via oral and anal sex or direct colonic inoculation through colonic irrigation devices have occurred. Cysts are resistant to gastric acid, but the wall is broken down by trypsin in the small intestine. Trophozoites are released and colonize the cecum. To initiate symptomatic infection, E histolytica trophozoites present in the lumen must adhere to the underlying mucosa and penetrate the mucosal layer.

Liver involvement occurs following invasion of E histolytica into mesenteric venules. Amebae then enter the portal circulation and travel to the liver where they typically form large abscesses.

The right lobe of the liver is more commonly affected than the left lobe. This has been attributed to the fact that the right lobe portal laminar blood flow is supplied predominantly by the superior mesenteric vein, whereas the left lobe portal blood flow is supplied by the splenic vein.   Medscape Reference.




*Hepatitis B Serology:  HBS AG is on the surface of the virus.   HBS AB is the antibody to HBS AG.    HBC AG is in the core of the virus.  HBCAB is the antibody to the core.  HBE AG is the degredation of the core and only seen in acute infection.   Anti-HBC IGM is also only seen in acute infection.

Irritable Bowel Syndrome pain is relieved by defecation.

Large bowel obstruction is most commonly caused by malignancy.

Most common cause of massive lower GI bleeding is diverticulosis.

For the diagnosis of pancreatitis, amylase and lipase have similar sensitivities but lipase is more specific.  So most clinicians order a lipase and pass on the amylase.

Toxic megacolon is more common in ulcerative colitis.  Ulcerative colitis almost always involves the rectum.  Crohn’s disease more commonly has peri-anal involvement.

Hart     Safety Lecture

We discussed issues with safe disposal of sharps.

If you identify that a sharps bin is full and needs to be replaced, call EVS at 41-5958 and they will come and replace the bin.

Do not try to force sharps into a full sharps bin.  Call for a replacement bin or carry your sharps carefully to another bin.   We discussed the possibility of having a large sharps bin on wheels that we could move to where a procedure is performed in case there is not an easily available, not completely full sharps container.

Don’t recap needles.  If you do recap a needle, use a one-handed technique.

To more easily dispose of a guide wire, you can coil up a central line guide wire with the rubber band that you used for the ultrasound probe cover.   Christine comment: Alternatively you can use the plastic guidewire sheath to replace the wire.