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 February 20, 2024.
An Update to ED management of postpartum hemorrhage and the 4 Ts DDx
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).
As soon as postpartum hemorrhage is identified, activate the team
Call OBGYN but if unavailable, call general surgery
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)
WOMAN Trial Collaborators. Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): an international, randomised, double-blind, placebo-controlled trial [published correction appears in Lancet. 2017 May 27;389(10084):2104]. Lancet. 2017;389(10084):2105-2116. doi:10.1016/S0140-6736(17)30638-4
Lew GH, Pulia MS: Emergency Childbirth, in Roberts JR, Hedges JR, Custalow CB, et al (eds): Clinical Procedures in Emergency Medicine, ed 6. Philadelphia, Saunders, 2013, Ch 56:p 1155-82.
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-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.
The patient must be using a serotonergic agent and have one of the following:
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
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.
Baltz JW, Le LT. Serotonin Syndrome versus Cannabis Toxicity in the Emergency Department. Clin Pract Cases Emerg Med. 2020;4(2):171-173. Published 2020 Mar 2. doi:10.5811/cpcem.2020.1.45410
Foong AL, Grindrod KA, Patel T, Kellar J. Demystifying serotonin syndrome (or serotonin toxicity). Can Fam Physician. 2018;64(10):720-727.
Neuroresuscitation pearls in recognition and management of traumatic brain injuries and herniation syndromes
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.
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?
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
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.
Patel S, Maria-Rios J, Parikh A, Okorie ON. Diagnosis and management of elevated intracranial pressure in the emergency department. Int J Emerg Med. 2023;16(1):72. Published 2023 Oct 13.
Kareemi H, Pratte M, English S, Hendin A. Initial Diagnosis and Management of Acutely Elevated Intracranial Pressure. J Intensive Care Med. 2023;38(7):643-650.
Manley G, Knudson MM, Morabito D, Damron S, Erickson V, Pitts L. Hypotension, hypoxia, and head injury: frequency, duration, and consequences. Arch Surg. 2001;136(10):1118-1123.
Fisher C. Brain herniation: a revision of classical concepts. Can J Neurol Sci. 1995;22(2):83-91.
Stevens R, Shoykhet M, Cadena R. Emergency Neurological Life Support: Intracranial Hypertension and Herniation. Neurocrit Care. 2015;23 Suppl 2:S76-82.
Carney N, Totten A, O’Reilly C, et al. Guidelines for the Management of Severe Traumatic Brain Injury, Fourth Edition. Neurosurgery. 2017;80(1):6-15.
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.
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
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:
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.
Yarur et al. Predictive Factors for Clinically Actionable Computed Tomography Findings in Inflammatory Bowel Disease Patients Seen in the Emergency Department with Acute Gastrointestinal Symptoms. J Crohns Colitis. 2014;8(6): 504-512.
Panes et al. Imaging techniques for assessment of inflammatory bowel disease: Joint ECCO and ESGAR evidence-based consensus guidelines. J Crohns Colitis. 2013;7(7):556-585.
De Simone, B., Davies, J., Chouillard, E. et al. WSES-AAST guidelines: management of inflammatory bowel disease in the emergency setting. World J Emerg Surg 16, 23 (2021).
Rosiou K, Selinger CP. Acute severe ulcerative colitis: management advice for internal medicine and emergency physicians. Intern Emerg Med. 2021;16(6):1433-1442.
Pediatric C-Spine immobilization controversies
Suggested indications for using c-spine precautions in pediatrics
Symptomatic children such as those with focal neurologic deficits, spinal tenderness, anatomical deformity, or torticollis
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
High risk mechanisms such as diving, an axial load, a clothesline injury, or a high risk MVA
Conditions that predispose spine instability such as trisomy 21 or osteogenesis imperfecta
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.