A digest of Dr. Herbert’s monthly audio CME series, edited by Chris Feier, MD
As emergency physicians we want to stratify patients into risk categories based on their short-term probability of death or adverse event. This is in contrast to the internist who wants a more global assessment of a patient’s health to determine long-term preventive medications, such as statins. There are many tools we can use for this, but one of the most powerful is the resting EKG.
1.ACS risk stratification: What it is and how to do it.
As emergency physicians we want to stratify patients into risk categories based on their short-term probability of death or adverse event. This is in contrast to the internist who wants a more global assessment of a patient’s health to determine long-term preventive medications, such as statins. There are many tools we can use for this, but one of the most powerful is the resting EKG. Dr. Stuart Swadron points out that an abnormal EKG gives a patient a 17-20x higher risk of dying than a normal EKG. Another tool that can be used in the ED for risk stratification is echocardiography. Unlike other modalities, it can be used to evaluate for other life threatening conditions such as valve rupture or dissection. For risk stratification, we can observe indirect signs of ischemia such as wall motion abnormalities and compensatory hyperkinesis. A future use of echo is contrast enhanced echocardiography. This technique uses gas bubbles that are injected intravenously to enhance the coronary microcirculation. Other risk stratification modalities that are discussed are the stress exercise EKG, nuclear studies, and CT angiogram.
2.Is CT Angiography ready for Prime-time?
CT angiography appears to be an ideal study for an emergency physician to use. The ability to rule-out three life-threatening diseases (ACS, PE and aortic dissection) within a few seconds would be an invaluable tool. However, as call-in guests Drs. Steve Colucciello and Jeff Kline discuss, there are many problems associated with its use. First, even when done under ideal conditions, the image quality is only comparable to an angiogram less than 20% of the time. Also, unlike PE protocol CTs, the CT angiogram may give an equivocal result because multiple filling defects are usually seen. Lastly, we are aware of radiation risks and the potential for future malignancy. A recent New England Journal of Medicine study estimates that one case of fatal malignancy occurs for every 1000 CT scans, and a CT angiogram is equivalent to two CTs. Therefore, they conclude that more studies are needed before we can start incorporating CT angiographies into our daily routines.
3.Stridor, stiff neck, and drooling in the pediatric population all point to retropharyngeal abscess
These symptoms were at one time synonymous with epiglottitis, but thanks to childhood vaccinations, this disease is now very rare. The most common presentation of a retropharyngeal abscess is a neck mass, occurring in over 90% of patients across multiple studies. It is also common to see torticollis and limitation of neck extension, occurring in almost one half of cases. Surprisingly, respiratory distress and stridor occur very rarely, in only 5% of cases. Retropharyngeal abscesses may also present similarly to meningitis, especially in infants and younger children. Therefore, if a child with suspected meningitis has a negative or non-specific spinal fluid result, retropharyngeal abscess should then be considered.
4.Young children who fall with objects in their mouths may suffer from internal carotid and subsequent neurologic injury
Dr. Mel Herbert reviews the algorithm for palatal laceration from Otolaryngology–Head and Neck Surgery 2006 and discusses which child can be appropriately discharged home and who will need further testing and admission. Surgical repair of a palatal wound should be undertaken for large or gaping lacerations, although most heal regardless of intervention. Empiric antibiotic coverage of oral flora can be given for wounds greater than 1-2 cm or if grossly contaminated. Most debate in this area relates to the need for hospitalization and should be considered in any child with evidence of neurovascular injury or an unreliable home situation. Any child discharged home must be monitored closely. Although very rare, delayed carotid thrombosis can occur up to 60 hours after the initial injury and can have devastating consequences.
5.Hemostatic Resuscitation has shown improved survival and decreased complications in the massive trauma patient
Derangements in coagulation occur rapidly after trauma and about 1/3 of patients have a coagulopathy at the time of ED arrival. Coagulopathy is associated with poor outcomes in trauma as demonstrated by a linear relationship between post-trauma INR and mortality. Hemostatic resuscitation focuses on restoring normal coagulation and treating the lethal triad of trauma immediately upon admission. Traditional trauma resuscitation progresses in a stepwise serial manner by administering lactated ringers and blood first and then progressing to plasma and platelets. In hemostatic resuscitation, blood and plasma are given early and in parallel with the entire resuscitative efforts. Early plasma in trauma has been shown to improve mortality significantly as well as decrease medical complications and the use of blood products. As Col Brian Eastridge MD points out the status of hemostatic resuscitation in trauma, there are ongoing retrospective studies for hemostatic resuscitation at multiple civilian trauma centers after which prospective studies can be performed.
6. Lance Brown, MD, reviews pediatric resuscitation pearls
Dr Brown uses a philosophical approach to pediatrics rather than a traditional one. The traditional approach to cardiac arrest is algorithmic and standardized, which is better than chaos. He describes how we want to be at the optimal state of arousal and not let fear break down our cognitive processes. We should also be aware that television shows give the general public unrealistic expectations, such as a high rate of neurologic recovery after CPR (0.3-3% reality vs 63% for general public). Dr Brown also gives a traditional PALS update and reviews pediatric drug dosing, a necessity for every emergency physician. He gives a simplified approach to glucose administration for pediatric resuscitations. Adolescents, like adults can be simply given an ampule of D50. Babies and kids are given 2-4 ml/kg of a D25 solution while neonates are given 5-10ml/kg of a D10 solution. Most emergency departments do not supply the pre-mixed glucose solutions so they might need to be constituted at the bedside. D50 can be diluted in half to prepare a D25 mixture for babies and kids. This can further be diluted in half to produce D12.5 mixture (close enough) that can safely be administered to neonates. This is important because higher glucose concentrations can be very sclerotic to tissue and vasculature, especially in younger children and neonates.
For full summaries and audio downloads, as well as other CME opportunities, visit www.EMRAP.us.