Episode 22a: Whistler Update in Emergency Medicine Conference 2012

In this bonus episode, our second installment of the highlights from Whistler Update in Emergency Medicine Conference 2012, we have Dr. Eric Letovsky talking about complications of MI and the importance of listening for cardiac murmurs. Next, I moderate an expert panel on the current trends on imaging patients who present with renal colic and query appendicitis with Dr. Connie Leblanc, Dr. Joel Yaphe, Dr. David MacKinnon & Dr. Eric Letovsky. We then hear from Dr. Adam Cheng, Dr. Dennis Scolnick & Dr. Anna Jarvis in a pediatric expert panel about the newest on minor head injury, otitis media, mastoiditis and bronchiolitis. Dr. David Carr reviews one of the most important articles in 2011 regarding subarachnoid hemorrhage, and Dr. David MacKinnon gives us tonnes of clinical pearls when it comes to everyone’s favourite subject, anorectal disorders.

 

MECHANICAL COMPLICATIONS OF ACUTE MYOCARDIAL INFARCTION

Eric Letovsky

  • Free wall rupture – patients usually come in VSA
  • Interventricular wall rupture – patients present in profound shock, with distended neck veins and a palpable thrill felt over precordium
  • Acute papillary muscle rupture leading to severe mitral regurgitation – patients present in acute pulmonary edema, and have a loud, holosystolic murmur loudest at the apex, usually from inferior MI that can be a small MI

 

ANORECTAL DISORDERS

David MacKinnon

  • WASHtherapy for most diseases: Warm Water, Analgesia, Stool softeners/Laxatives (not Colace as it is not effective), High fiber diet
  • No good evidence for sitz baths
  • Thrombosed external hemorrhoid management: thrombectomy (excision leads to fewer recurrences than incision alone), most effective topical treatment is lidocaine gel with nifedipine gel (96% resolution in 2wks in one small study)
  • Thrombectomy method: use local anesthetic directly in the hemorrhoid itself, do elliptical incision with scalpel to allow evcuation of clot, then excise the skin tag, clean and put gauzes between the buttock cheeks with the underwear over it
  • Peri-anal abscesses (consider procedural sedation, X-shaped incision & only 1 time packing) that may extend further (eg, ischiorectal, intersphincteric and supralevator) may present with few signs of abscess, but pain out of proportion to findings, tenesmus on rectal exam, may result in permanent anal sphincter dysfunction and should be managed in the O.R. and followed by surgery
  • Rectal foreign body: Be careful about attempting to remove large rectal foreign bodies that have been in situ for prolonged periods of time, as they might be higher than expected and the rectal wall may be thin and fragile due to pressure and ischemia, and therefore at risk for perforation
  • Consider using vaginal speculum, a Foley catheter that is passed beyond and then inflated, suprapubic pressure, and always be careful of sharp objects (x-ray all of them!)

 

PEDIATRIC EXPERT PANEL: Anna Jarvis, Dennis Scolnik, Adam Cheng

Clinical Decision Rules for Pediatric Appendicitis

Alvarado score for appenditicis

  • 1 point for migration of pain to RLQ, anorexia, nausea or vomiting, elevated temperature (>37.3°C), rebound tenderness and leukocyte left shift, and 2 points for RLQ tenderness or leukocytosis >10,000
  • Score >6 has sensitivity of only 72%

Samuel pediatric appendicitis score

  • 1 point for migration of pain, anorexia, pyrexia, nausea or vomiting, leukocytosis >10,000 and left shift of leukocytes, and 2 points for cough/percussion/hopping tenderness and tenderness over the right iliac fossa
  • Score >5 has sensitivity of 82%

 

Scoring systems for Pediatric Minor Head Injury

PECARN – Kuppermannet al.: Identification of children at very low risk of clinically- important braininjuries after head trauma: a prospective cohort study. Lancet 2009;374(9696):1160-70

  • Children younger than 2yo: normal mental status, no scalp hematoma except frontal, no or 3ft , or head struck high-impact object), no palpable skull fracture, and acting normally according to the parents
  • Children >2yo: normal mental status, no loss of consciousness, no vomiting, non- severe injury mechanism (same as above except fall >5ft if >2yo), no signs of basilar skull fracture, and no severe headache
  • No CT head required (<0.05% risk of clinically important traumatic brain injury)

CATCH  Study –   Osmond  et  al.  Canadian  Assessment  of  Tomography  for  Childhood  Injury. CMAJ   2010;182(4):341-8

  • High-risk criteria: GCS
  • Medium-risk criteria: Dangerous mechanism (MVA, fall >3ft or 5 stairs, bicycle accident without helmet), large boggy hematoma, or signs of basal skull fracture – 98% sensitive to predict brain injury on CT scan

 

Expert Panel Pearls for Pediatric Minor Head Trauma

  • Always consider abuse in pediatric patients with large scalp hematoma
  • Consider bleeding disorder in pediatric patients with large scalp hematoma
  • Consider skull X-ray as initial screening test in Age
  • Parietal and temporal hematomas have a higher incidence of intracranial hemorrhage compared to frontal hematomas

 

Bronchiolitis

  • Some experts recommend nebulized epinephrine (3ml in 1:1000 solution) + high dose dexamethasone 1mg/kg in ED then 0.6mg/kg for 5 days where as others recommend a trial of nebulized ventolin in the ED and if no response then no specific treatment required.
  • REFERENCE: Plint, A. Epinephrine and Dexamethasone in Children with Bronchiolitis. N Engl J Med 2009; 360:2079-2089

 

Canadian Pediatric Society Guidelines on Acute Otitis Media

  • Criteria for ‘watchful waiting’ (no antibiotics unless no improvement in 48-72hrs) : child >6mo old, and no immunodeficiency, or Down syndrome, chronic cardiac or pulmonary disease, anatomical abnormality of head or neck, and no history of complicated AOM, and illness not severe (mild otalgia and T° <39°C without antipyretics), parents capable of noticing worsening disease and can readily access care
  • If no improvement and diagnosis still most likely AOM, then use antibiotics for 5d (or 10d if <2y/o, recurrent frequent OM, antibiotic failure, suppurative complications)
  • Antibiotics (in decreasing order of preference):
    • High-dose amoxicillin (75-90mg/kg/d 2 doses), cefprozil 30mg/kg/d, cefuroxime 30mg/kg/d, ceftriaxone 50mg/kg IM or IV one dose, azithromycin 10mg/kg/d x1 dose then 5mg/kg/d for 4d, clarithromycin 15mg/kg/d
    • For children with antibiotic treatment failure use clavulin (75-90mg/kg/d 2 doses)
    • Exclusions to ‘watchful waiting’ approach according to Dr. Jarvis: Canadian aboriginal children, Sickle Cell Disease, Leukemia, immunosuppressed patients, skull defect
    • Reference:Management of Acute Otitis Media. Canadian Pediatric Society. Paediatric Child Health 2009;14(7):457-60.

     

CT ONLY FOR SUBARACHNOID HEMORRHAGE?

  • Perry et al. Sensitivity of computed tomography performed within six hours of onset of headache for diagnosis of subarachnoid haemorrhage: prospective cohort study. BMJ 2011;343:d4277.
  • Inclusion criteria: headache peak intensity within 1hr, time to CT within 6hrs of symptom onset, CT read by experienced radiologist, GCS 15 with no focal neurological deficit
  • Conclusion – CT within 6hrs of onset of symptoms has 100% sensitivity to rule out SAH
  • Bottom line – treat “sudden thunderclap headache” as a “code SAH” and expedite imaging within 6hrs, and if patients fulfill all the inclusion criteria and the patient has a low pre-test probability of SAH, then consider excluding LP

 

IMAGING CONSIDERATIONS FOR APPENDICITIS & RENAL COLIC

Renal Colic

  • In a young patient with classic story and prior similar nephrolithiasis, who does not have red flags (abdominal tenderness, fever, Marphanoid features – AAA, signs of infected stone and signs of testicular torsion), consider simply treating symptomatically without imaging
  • In older patients, regardless of prior history, imaging is often recommended to rule out other more sinister diagnoses (eg: AAA)
  • Ultrasound is often an adequate first-‐line study, even though low-‐lying and small stones might not be visualized, because those will often pass on their own and rarely lead to significant complications

Appendicitis

  • Consider developing care pathways in conjunction with the surgeons in order to refer young male patients with classic clinical picture without any imaging
  • Ultrasound should always be considered as the first-‐line imaging option

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About the Author:

Dr. Anton Helman is an Emergency Physician at North York General in Toronto. He is an Assistant Professor at the University of Toronto, Division of Emergency Medicine and the Education Innovation Lead at the Schwartz-Reisman Emergency Medicine Instititute. He is the founder, editor-in-chief and host of Emergency Medicine Cases.

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