EM Quick Hits 53 Postpartum Hemorrhage, Serotonin Syndrome, TBI Herniation Syndromes, Ulcerative Colitis, Pediatric C-Spine Immobilization, Global EM

Topics in this EM Quick Hits podcast

Anand Swaminathan on update to ED management of postpartum hemorrhage (1:11)

Nour Khatib on serotonin syndrome and its mimics (6:09)

Katie Lin on an approach to recognition and management of severe TBI and brain herniation syndromes (15:28)

Hans Rosenberg on ED recognition and management of ulcerative colitis  (24:35)

Heather Cary on pediatric c-spine immobilization controversies and techniques (30:00)

Navpreet Sahsi on the difference between humanitarian and development work (38:03)

Podcast: Play in new window | Download (Duration: 53:18 — 48.9MB)

Subscribe: Apple Podcasts

Podcast production, editing and sound design by Anton Helman

Written summary & blog post by Shaila Gunn, edited by Anton Helman

Cite this podcast as: Helman, A. Swaminathan, A. Khatib, A. Rosenberg, H. Cary, H. Sashsi, N. EM Quick Hits 53 – Postpartum Hemorrhage, Serotonin Syndrome, TBI Herniation Syndromes, Ulcerative Colitis, Pediatric C-Spine Immobilization, Global EM. Emergency Medicine Cases. November, 2023. https://emergencymedicinecases.com/em-quick-hits-november-2023/. Accessed April 23, 2024.

An Update to ED management of postpartum hemorrhage and the 4 Ts DDx

1. Recognition of postpartum hemorrhage is by gestalt
   • Defined as more bleeding than expected after vaginal delivery or abortion (classically defined and >500 mL blood loss but difficult to measure accurately – if it looks bad/blood filling the vaginal vault, start resuscitation).
2. As soon as postpartum hemorrhage is identified, activate the team
   • Call OBGYN but if unavailable, call general surgery
3. Identify the cause(s) of the hemorrhage: 4 Ts differential diagnosis of postpartum hemorrhage
   • Tone (uterine atony) *most common cause post-delivery
   • Tissue (retained placenta or clots) *most common cause post-abortion
   • Trauma (large vaginal or cervical tears, uterine rupture)
   • Thrombin (pre-existing or acquired coagulopathy i.e. DIC)
4. Blood products (RBC +/- platelets, FFP, fibrinogen); consider massive hemorrhage protocol
   • Postpartum patients who are hemorrhaging tend to have low fibrinogen with an increased risk for DIC, so have a low threshold to give fibrinogen
5. If atony, give 4 uterotonics (oxytocin, misoprostol, methergine, and carboprost)
   • If the pregnancy was <20 weeks, oxytocin is still recommended but does not play a major role
   • If bleeding persists despite the uterotonics, consider direct tamponade with a Bakri balloon.
   • If there is concern for uterine inversion stop uterotonics
6. Consider TXA as per WOMAN Trial
7. Consider developing a mother-child care set for efficient management of postpartum hemorrhages

Recognition of Serotonin syndrome and its mimics

Serotonin syndrome develops as the result of the increased concentration of serotonin  serotonin agonists. It usually occurs shortly after an increase in dose of a serotonergic agent or after the addition of another serotonergic agent.

There are many agents in addition to SSRI’s/SNRI’s/TCA’s/MAOi’s that can contribute to serotonin syndrome

• Synthetic opioids including tramadol, meperidine, methadone, and dextromethorphan
• Antibiotics including linezolid and isoniazid
• Herbals i.e. St. John’s wart
• Anti-epileptics
• Anti-emetics i.e ondansetron
• Illicit drugs including ecstasy, cocaine, and amphetamines.

Physical exam findings clues to serotonin syndrome:

• Autonomic dysfunction: tachycardia, hypertension, or hyperthermia, mydriasis, flushed skin with diaphoresis, dry mucous membranes.
• Altered mental status/agitation.
• Neuromuscular abnormalities: ocular clonus, tremor, hyperreflexia, muscle clonus

Hunter criteria for serotonin syndrome

The patient must be using a serotonergic agent and have one of the following:

• Spontaneous clonus
• Inducible clonus + agitation or diaphoresis
• Ocular clonus + agitation or diaphoresis
• Tremor + hyperreflexia
• Hypertonia + T>38C + ocular or inducible clonus

Consider a broad differential diagnosis for serotonin syndrome

• Mild cases are often mistaken for psychiatric presentations and severe cases may be mistaken for neuroleptic malignant syndrome.
• Rule out infections including meningitis or sepsis and drug overdoses including cocaine, ecstasy, lithium, and anticholinergics.

The treatment of serotonin syndrome is largely supportive

• Recognize and discontinue all serotonergic agents
• Supportive care:
  • IV fluid hydration
  • Benzodiazepines (act as a non-specific serotonin antagonists); may improve myoclonus, hyperreflexia, and seizures
  • Aggressive cooling if hyperthermic (antipyretics are not effective as it is due to increased muscle tone and not central thermoregulation)
• Cyproheptadine is an H1 antihistamine that blocks serotonin receptors and can be considered as a second line agent in moderate to severe cases
• Avoid physical restraints; the neuromuscular activation makes these patients prone to rhabdomyolysis and restraints can make this worse

A bit about THC toxicity

• THC can activate serotonin receptors and inhibit serotonin reuptake, creating a condition that resembles a mild form of serotonin syndrome. Features include tachycardia, hypertension, hyperthermia, tremor, clonus, and lower extremity rigidity. Treat this the same way you would treat serotonin syndrome with supportive care.

Bottom line => Many agents can contribute to serotonin syndrome. Serotonin syndrome can be diagnosed using the Hunter Criteria, but ensure you consider a broad differential diagnosis. The treatment for serotonin syndrome and THC toxicity is largely supportive.

Neuroresuscitation pearls in recognition and management of traumatic brain injuries and herniation syndromes 

1. Don’t forget the glucose
   • Hypoglycemia can mimic neurologic disasters and can be the cause trauma
   • If you cannot get a glucose rapidly or it is not possible, empirically treat with 1 amp (50 cc) of D50W.
2. Consider a 3-step neurologic exam to focus on time-sensitive critical findings.
   • Identify signs of herniation and major focal neurologic deficits and communicate the neurologic status of the patient prior to intubation.
   • Step 1: GCS. What is the LOC and is it dropping?
   • Step 2: Eyes. Are the pupils equal and reactive? Are they deconjugate or deviated? Are the corneal reflexes in tact?
   • Step 3: Lateralizing motor response: Purposeful movement equally bilaterally?  Is there asymmetry or posturing present?
3. Recognize signs of herniation and act fast – do not wait for imaging confirmation
   • A blown pupil is often considered a cardinal sign, but not all herniation syndromes come with a blown pupil.
     • Uncal herniations classically come with a blown pupil
     • Subfalcine herniations are too high up to cause a blown pupil
     • Central herniations cause small pinpoint pupils
     • Tonsillar herniations cause mid-fixed pupils
   • Herniation is dynamic and serial assessments to recognize a change in status is critical
     • Symptoms of rising ICP include worsening headache, worsening or refractory nausea/vomiting, evolving focal deficits especially involving cranial nerves, motor, or speech, and dropping GCS
     • Late herniation results in Cushing response (hypertension, bradycardia, irregular respirations including pauses of apneic spells) and pupillary changes
4. Resuscitate the body to resuscitate the brain
   • The 2 biggest priorities are avoiding hypoxia and hypotension
   • Start O2 early with a low threshold for airway capture and support
   • There is no role for permissive hypotension; target a MAP >80 with blood product transfusions and vasopressors.
   • Resuscitate before you intubate with pre-oxygenation and hemodynamic support to avoid peri-intubation hypoxia and hypotension.
   • Start ICP lowering therapies prior to imaging
     • Raise the head of the bed to 30 degrees
     • 250cc bolus of 3% hypertonic saline
     • Mannitol 1g/kg or 50g empiric bolus or 1 amp sodium bicarbonate

Bottom line => Always check a glucose. It is important to complete a focused neurologic  exam prior to intubation and this can be done rapidly in 3 steps: GCS, the eyes, and a lateralizing motor response. Watch for signs of early herniation – not all herniation syndromes have a blown pupil and the Cushing’s response indicates late herniation. Maintain MAP >80 and avoid hypoxia at all costs.

Review: recognition and management of ulcerative colitis in the ED

• The hallmark feature of ulcerative colitis is bloody diarrhea
• Other features may including non-bloody diarrhea in milder cases, increased stool frequency, urgency, tenesmus, abdominal discomfort, or proctitis (urgency + tenesmus)
• Ulcerative colitis can also have extra-intestinal manifestations:
  • Derm: pyoderma gangrenous, erythema nodosum.
  • MSK: arthritis.
  • Eyes: uveitis, episcleritis, iritis.
• Ulcerative colitis is associated with a number of complications including VTE, severe bleeding, toxic megacolon, and bowel perforation
• Mimics of ulcerative colitis exacerbations include infections (i.e. C. difficile, E. Coli, Salmonella, Campylobacter), ischemic colitis, STI proctitis, medication colitis, radiation proctitis, diverticular disease, and colorectal cancer
• Work-up ulcerative colitis flare:
  • Bloodwork: CBC, electrolytes, creatinine, liver enzymes, albumin, ESR, CRP
  • Stool studies: C. diff, C+S, O+P; if available, fecal calprotectin
  • Imaging studies: routine use of CT is not recommended unless suspected bowel perforation or obstruction
• The treatment of ulcerative colitis includes the following and should involve a gastroenterologist:
  • Correct fluid and electrolyte balances.
  • Stopping offending agents i.e. NSAIDs
  • Identify and treat concomitant infections and complications i.e. toxic megacolon
  • Control intestinal inflammation
    • Moderate to severe cases often require steroids, usually oral prednisone or budesonide
    • Mild to moderate cases can be treated with 5-ASA
    • Patients on existing treatment may need the dose and/or agents modified
• Indications for admission in patients with ulcerative colitis include:
  • Severe exacerbation
  • Presence of complications
  • Lack of response to corticosteroid therapy

Bottom line => The hallmark of ulcerative colitis is bloody diarrhea, but there are many other ways this may present. Keep an eye out for mimics. The mainstay of treatment is identifying and treating the complications and controlling the inflammation, usually with 5-ASA or steroids. Treatment should be done in collaboration with a gastroenterologist.

Pediatric C-Spine immobilization controversies

Suggested indications for using c-spine precautions in pediatrics

1. Symptomatic children such as those with focal neurologic deficits, spinal tenderness, anatomical deformity, or torticollis
2. A reliable history and physical cannot be obtained such as in the case of altered LOC, intoxication, significant pain medication use, or a significant distracting injury
3. High risk mechanisms such as diving, an axial load, a clothesline injury, or a high risk MVA
4. Conditions that predispose spine instability such as trisomy 21 or osteogenesis imperfecta
5. Substantial torso injury

Two controversial topics for c-spine immobilization in pediatrics are using a 20-degree tilt and the use of hard collars.

20-degree tilt in pediatric trauma

• Rationale according to APLS: avoid disrupting a clot and an unstable pelvis in blunt trauma by ensuring minimal handling; this is also the maximum angle required to use a scoop stretcher
• Ensure to tell your team you are only rolling to 20 degrees
• Then bring eyes down to the level of the bed to look for step deformities

Manual in-line stabilization followed by the application of blocks and tape

• The benefits of manual in-line stabilization prior to applying blocks include the ability to examine the neck for JVD tracheal deviation, laryngeal crepitus, and subcutaneous emphysema first
• 2 exceptions to using blocks and tape are:
  • Overzealous immobilization of the head and neck can paradoxically increase leverage of the head and neck if the child is struggling; treat severe pain and hypoxia first
  • A child with traumatic torticollis should have manual in-line stabilization used to maintain their current position.

There is substantial evidence supporting the use of using blocks and tape over hard collars; hard collars do not have proven benefit and may cause harm

• Evidence that hard collars do not provide benefit
  • Dixon et al. 2015: self extrication from a vehicle caused less movement than 5 immobilization techniques
  • Holla 2012: the addition of a collar to blocks did not improve restriction and blocks are significantly better than a collar alone
  • Wampler et al. 2016: transporting a patient using a long board and blocks demonstrated more movement than a just a stretcher and blockers
  • Hauswald et al. 1998: no difference in clinical outcome with restriction vs no restriction during transport
• Evidence that hard collars may cause harm
  • Yuk et al. 2018 and Durga et al. 2014: Collars impact airway and neck assessment, limit exposure for vascular and front of neck access, increase the difficulty in airway management
  • Yard et al. 2019: hard collars may raise ICP evidence by increased optic nerve sheath diameter on POCUS
  • Hard collars compromise respiratory function with decreased lung capacity and spirometry parameters
  • March et al. 2002: in 20 healthy volunteers in a hard collar on back board, 1 had point tenderness after 30 minutes and 18 had point tenderness after 60 minutes
  • Holla et al. 2012: increased in high c-spine motion, especially when the mouth is open (C1-C3 is where children are most commonly injury)
• Hard collars provide incomplete stabilization due to mobility of shoulders
• Hard collars limit imaging as odontoid views are difficult to obtain and there is decreased image quality of lateral films
• Hard collars are uncomfortable (put pressure on the mandible, rib, and clavicle)

Bottom line => Hard collars are not as effective as blocks and tape for c-spine immobilization and may be harmful. Employ a 20-degree tilt for spine/back assessment in pediatric trauma.

Global EM: Humanitarian work vs. development work

Dr. Sahsi discusses the key points of his GEM blog “So you want to be a humanitarian doctor?”

None of the authors have any conflicts of interest to declare