Conference Notes 5-17-2017

Anderson/Traylor    Oral Boards

Case 1. 56 yo male with shortness of breath. HR 126, BP 88/59,  RR35.  On exam, patient has a diastolic murmur and rales bilaterally.   EKG shows LVH.  Echo shows signs of aortic root dilation and aortic regurgitation.  Diagnosis is aortic dissection with aortic valve failure.  CXR shows pulmonary edema.

Aortic regurgitation can occur due to aortic root dilatation or direct involvement of the aortic valve

Aortic regurgitation can occur due to aortic root dilatation or direct involvement of the aortic valve

 

Case 2. 36yo male with low back pain and bilat lower extremity pain.  Patient is tachycardic. He states he has an aching in his thighs.  Patient gives a history of ETOH and cocaine use the night prior. Urine showed large blood with minimal RBC's.  CK was 24,000.

Cocaine-induced rhabdomyolysis with secondary acute renal failure

By Karthikram Raghuram, MD, Department of Radiology, University of Alabama at Birmingham and Birmingham VA Medical Center, Birmingham, AL

The incidence of rhabdomyolysis in patients who use cocaine varies from 5% to 30% in published reports. It is unclear why cocaine causes rhabdomyolysis. Hypotheses include cocaine-induced vasospasm with resultant muscle ischemia, excessive energy demands placed on the sarcolemma, and direct toxic effects on myocytes. Seizures, agitation, trauma, and hyperpyrexia may also play a role. In general, the severity of the rhabdomyolysis parallels the severity of the cocaine intoxication; patients with very high CK levels tend to have the most severe complications from this disease. Intravenous cocaine use may be associated with a higher incidence of rhabdomyolysis-induced acute renal failure (ARF) compared with smoking cocaine.1

Patients with rhabdomyolysis classically present with complaints of muscle weakness, swelling, and pain. The myalgias may be focal or diffuse, depending on the underlying cause of the disease. The patient may also note dark- or tea-colored urine. However, a high clinical suspicion for rhabdomyolysis must be maintained in patients at risk because up to 50% of those with serologically proven rhabdomyolysis do not report myalgias or muscle weakness.1

 

Case 3. 45 yo male with bilat lower extremity numbness.  Vitals are normal. Numbness is localized to lateral thighs.  Patient is obese.   Neurologic exam shows diminished sensation on the lateral aspect of thighs bilat.  Remainder of motor and sensory exam is normal. Diagnosis is meralgia paresthetica.

Geraghty    Endovascular Treatment of Stroke

The typical stroke patient loses 2 million neurons per minute

Only 8% of stroke patients are eligible for TPA.  Also, TPA does not work well for larger clots.

Patients with life changing or potentially fatal strokes are candidates for endovascular management.   Minimum NIH stroke scale of 6 for considering endovascular therapy.

Stent thrombectomy after TPA resulted in earlier neurologic recovery and improved functional outcome at 3 months compared to TPA alone for patients with proximal clots.   NNT=3. 

Who gets endovascular therapy?   No bleed on plain CT.  CTA shows clot in proximal anterior circulation. Patiet received TPA within 4.5 hours and can get endovascular procedure within 6-12 hours.  New study just released today shows that even patients who wake up from sleep with stroke symptoms can benefit from endovascular therapy without receiving TPA.

If a patient wakes up with stroke symptoms and has an NIH score >6 send them for both plain CT and CTA.  If they have a large vessel occlusion they may be eligible for endovascular therapy without TPA.  Dr. Garaghty will consider patients for endovascular therapy based on imaging and the overall clinical picture not just strictly on time endpoints.  

We had a general discussion of how this new data will affect the ED approach to stroke.  We will need to start considering endovascular therapy for a much larger subset of patients than those that present with stroke symptoms within 4.5 hours. Because evolving evidence is suggesting that patients with proximal clots may benefit from endovascular therapy even if they are not TPA eligible based on time of onset.

Berkelhammer/Carlson     Acute Liver Failure

The INR is the best indicator of liver function/dysfunction.

Acetaminophen overdose is the most common cause of acute liver failure.  Acetaminophen causes centrilobular necrosis due to the concentration of cellular mechanisms to to detoxify acetaminophen in the centrilobular areas. 

Mechanism of acetaminophen detoxification in the centrilobular region of the liver. NAPQI is the toxic metabolite of acetaminophen. NAC/glutathione detoxifies NAPQI.

Mechanism of acetaminophen detoxification in the centrilobular region of the liver. NAPQI is the toxic metabolite of acetaminophen. NAC/glutathione detoxifies NAPQI.

The RM nomogram can only be used for acute single ingestions of acetaminophen.  You don't need to adjust the nomogram for patient factors such as chronic or acute ETOH use, P450 inducing medications, or malnourishment.  There is enough safety built into the nomogram to cover all patients.

The RM nomogram can only be used for acute single ingestions of acetaminophen.  You don't need to adjust the nomogram for patient factors such as chronic or acute ETOH use, P450 inducing medications, or malnourishment.  There is enough safety built into the nomogram to cover all patients.

NAC prevents severe liver injury if given within 8 hours of ingestion.  There are benefits though even if NAC is given later. 

If you use the 21 hour IV protocol you need to verify there is no detectable acetaminophen in the blood and the LFT's are normalizing prior to stopping therapy. If not, then you need to treat beyond 21 hours.  There have been some reported cases of liver failure when the patient was treated with IV NAC for 21 hours only and the acetaminophen level was not 0.

If you use the 21 hour IV protocol you need to verify there is no detectable acetaminophen in the blood and the LFT's are normalizing prior to stopping therapy. If not, then you need to treat beyond 21 hours.  There have been some reported cases of liver failure when the patient was treated with IV NAC for 21 hours only and the acetaminophen level was not 0.

Dr. Berkelhammer only will allow a total of 2 grams of acetaminophen per day in patients with alchoholism or cirrhosis. In patients with cirrhosis he also avoids NSAID's to reduce the risk of GI bleeding and renal failure.   If patient needs more pain control he favors prescribing norco with higher doses of hydrocodone (norco 7.5 or norco 10)

Twanow   5 Slide Follow Up

Erythrodermic Psoriasis

Erythrodermic Psoriasis can look like TEN.  Treatment of Erythrodermic Psoriasis includes IV fluids, systemic steroids, and local wound care.  Care best provided in a burn unit.

Erythrodermic Psoriasis can look like TEN.  Treatment of Erythrodermic Psoriasis includes IV fluids, systemic steroids, and local wound care.  Care best provided in a burn unit.

 

Denk      Trauma Airway

To obtain an airway in this patient, you can cut the vertical wires with trauma shears or wire cutters to open the mouth enough to get a Video or Direct Laryngoscope in the mouth.  If you don't have time to do that you can either attempt nasotracheal intubation or perform a cricothyrotomy.

To obtain an airway in this patient, you can cut the vertical wires with trauma shears or wire cutters to open the mouth enough to get a Video or Direct Laryngoscope in the mouth.  If you don't have time to do that you can either attempt nasotracheal intubation or perform a cricothyrotomy.

Dr. Denk discussed 2 other difficult trauma airway situations.  She discussed a recent EmCrit Podcast "Having a Vomit SALAD"  which discusses using the yankaur suction to lead the laryngoscope blade into the supraglottic space to suction out blood or vomitus.  You can then move the suction catheter to the left side of the mouth and keep the tip in the upper portion of the esophogus.  This way the suction catheter continues to clear blood or vomitus from the airway while you are trying to intubate.

Einstein        Extremity Trauma

Every extremity injury requires an evaluation of vascular status, nerve function, soft tissue injury, and bony injury.

When evaluating for vascular injury in an extremity, examine for hard signs, soft signs, and get ABI's.

When evaluating for vascular injury in an extremity, examine for hard signs, soft signs, and get ABI's.