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Case Studies in Emergency Medicine

John Beuerle, M.D.

Department of Emergency Medicine

Regional Medical Center of San Jose

El Camino Hospital – Mountain View

32 y.o. Male with Eye Pain

• Sent from Urgent Care

• Reports left eye pain x 1 day

• Mildly blurred vision

• Usually wears contact lenses. Had difficulty getting contact out of his left eye the night before.

“I think I might need a specialist.”

Work‐up for Eye Pain

• Topical Pain Relief

• Visual Acuity

• Inspection of the eye and lids

• Pupillary response

• EOMs

• Fundoscopy

• IOP

• Fluorescein staining

• Ultrasound

Ultrasound to r/o Retinal Detachment

Corneal Abrasions

• Corneal abrasions are very uncomfortable.

• Patients come to the ED because they are in pain and want it to stop.

• Oral analgesia does a poor job of controlling ocular pain.

• The effects of tetracaine and properacaine last about 10 – 15 minutes.

• Outpatient use of topical anesthetics is discouraged due to poor wound healing of the corneal epithelium.

Where does the evidence for no outpatient topical anesthetic use on corneal abrasions come from?

Topical Anesthetics for Corneal Abrasions

• Case reports, case series, and animal studies.

• In all but one of the cases, patients were abusing topical anesthetics at high concentrations for weeks to months.

Author Year of Study

Number of Patients

Topical Anesthetic

Used

Type of Study

Results

Epstein DL, et.al.

1968 5 patients 5% tetracaine Case series Keratitis

Willis WE,et. al.

1970 9 patients 0.5% proparacaine

Case series Cornealulcerations

Duffin RM, et. al.

1984 1 patient 0.5% tetracaine

Case report Severe Ocular Complications

Churn KC, et. al.


0.5%tetracaine

Case series Superinfectionwith Candida may occur

Wasserman, et. al.

2002 1 patient 0.5% proparacaine

Case report Abuse can lead to corneal ulcers

What trials have evaluated the outpatient use of topical anesthetics on corneal abrasions?

Author Year of Study

Number of Patients

Comparison Results

Verma S, et. al.

1995 44 patients 1% tetracainevs.

placebo

Better pain control with tetracaine. No difference in healing at 72 hours.

Verma S,et. al.


0.75%bupivacaine


Ting JY,et. al.

2009 47 patients 0.4% tetracainevs.

normal saline


Ball IM,et. al.


vs.placebo

Better pain control with proparacaine. No difference in healing at 72 hours.

Waldman N,et. al.


normal saline

No difference in pain control, but higher patient satisfaction with tetracaine. No difference in healing at 48 hours.

How To Make a 1:10 Dilution (0.05%) From 0.5% Proparacaine

How To Make a 1:10 Dilution (0.05%) From 0.5% Proparacaine

• Label the bottle with the following instructions:

Proparacaine 0.05% Ophthalmic1 – 2 drops in affected eye q30 min prn painDisp: 3 mL

**Do not use for longer than 2 days.**

10 y.o. Male with Abdominal Pain

10 y.o. Male with Abdominal Pain

• No appetite x 2 days

• Pain began this morning in the periumbilical area

• Pain is now most prominent in the RLQ

• No fever or chills

Physical Exam

• Abdomen soft with RLQ tenderness

10.315.7

47.1211

Labs

AST 8, ALT 12, bili(T) 0.4, ALK 211, lipase 105

137

4.2

100

29

10

0.0691

What’s next?

Ultrasound of the Appendix

• Thickening of the appendix, concerning for acute appendicitis.

Now what?

Consult the Surgeon

• Surgeon says:

“Admit to medicine for IV antibiotics.”

Nonoperative Approach to Pediatric Appendicitis

Surgical vs. Nonoperative Management for Pediatric Appendicitis

Minneci PC et al. JAMA Surg 2015 Dec 16.



• Prospective study

• Pediatric emergency department

• Children aged 7 to 17 years who presented with nonperforated acute appendicitis and ≤48 hours of abdominal pain

• Laparoscopic appendectomy vs. nonoperativemedical management based on patient and family choice



• Patients in the surgery group received IV antibiotics and underwent appendectomy within 12 hours.

• Those undergoing nonoperative management received IV antibiotics for at least 24 hours followed by a 10‐day course of oral antibiotics.

• Patients with worsening or nonchanging symptoms after 24 hours underwent appendectomy.



• Of 102 children enrolled, 37 chose nonoperativemanagement and 65 chose surgery.

• The success rate of nonoperative management (i.e., no appendectomy) at 1 year was 76%.

• In the surgery group, the negative appendectomy rate was 6% and the 1‐year postoperative complication rate was 8%.



• At 1 year, the rate of perforated appendicitis was similar between the nonoperative and surgery groups (3% and 12%).

• The nonoperative group had fewer disability days (8 vs. 21) and lower appendicitis‐related healthcare costs ($4219 vs. $5029).

• The two groups had similar quality of life scores.


Efficacy and Safety of Nonoperative Treatment for Acute Appendicitis: A Meta‐analysis

Roxani G, et al. Pediatrics. February 2017.

• Efficacy and Safety of Nonoperative Treatment for Acute Appendicitis: A Meta‐analysis

(Roxani G, et al. Pediatrics. February 2017.)

• Ten studies reporting 413 children receiving NOT

• Six studies, including 1 RCT, compared NOT with appendectomy.

• The remaining 4 studies reported outcomes of children receiving NOT without a comparison group.

• Efficacy and Safety of Nonoperative Treatment for Acute Appendicitis: A Meta‐analysis

(Roxani G, et al. Pediatrics. February 2017.)

• NOT was effective as the initial treatment in 97% of children.

• At final reported follow‐up (range 8 weeks to 4 years), NOT remained effective (no appendectomy performed) in 79% of children.

• Recurrent appendicitis occurred in 14%.

• Complications and total length of hospital stay during follow‐up were similar for both groups.

• No serious adverse events related to NOT were reported.


• NOT is still experimental and not yet standard of care.

• Requires a conversation with the patient and parents (informed consent).

• These studies do not support sending appendicitis patients home from the ER.

88 y.o. Female with a Fever

88 y.o. Female with a Fever

• Arrived via EMS from a Nursing Home

• Fever and altered mental status that began today

Physical Exam

• Vitals: HR 128, RR 30, BP 82/60, Temp 103.6 F, 92% on room air

• Awake, moans, confused at baseline• Dry mucous membranes• Bilateral rhonchi • Abdomen soft • G-tube and indwelling Foley catheter• Contractures to the bilateral UEs and Les• Sacral decubitus ulcer

This patient probably has: (a) Acute appendicitis(b) Fibromyalgia(c) Benign positional vertigo(d) Septic shock(e) Takotsubo cardiomyopathy(f) Mental telepathy(g) Bullous Pemphigoid(h) Paronychia

How do we treat it?

Early Goal‐Directed Therapy in the Treatment of Severe Sepsis and Septic ShockEmanuel Rivers, M.D., M.P.H., Bryant Nguyen, M.D., Suzanne Havstad, M.A., Julie Ressler, B.S., Alexandria Muzzin, B.S., Bernhard Knoblich, M.D., Edward Peterson, Ph.D., and Michael Tomlanovich, M.D., for the Early Goal‐Directed Therapy Collaborative GroupN Engl J Med 2001; 345:1368‐1377November 8, 2001

SEPSIS TREATMENT

So, what happened next?

Subsequent Studies

• ProCESS Investigators, Yealy DM, Kellum JA, et al. A randomized trial of protocol‐based care for early septic shock. N Engl J Med 2014; 370:1683.

No benefit of EGDT over Standard Treatment

• ARISE Investigators, ANZICS Clinical Trials Group, Peake SL, et al. Goal‐directed resuscitation for patients with early septic shock. N Engl J Med 2014; 371:1496.


• ProMISS Investigators, Mouncey PR, Osborn TM, Power GS, et al. Trial of early, goal‐directed resuscitation for septic shock. N Engl J Med 2015; 372:1301.


Time to Treatment and Mortality during Mandated Emergency Care for Sepsis. Seymour CW, Gesten F, Prescott HC, et al.N Engl J Med 2017; 376:2235

Recent Studies

• Database study of nearly 50,000 patients with sepsis and septic shock who were treated with various types of protocolized treatment bundles

• Found that time is of the essence, particularly with antibiotic administration.

• Increased mortality associated with delayed administration of antibiotics.

• Patients who drank Pepsi did far better at fighting off sepsis than those who drank Coke.

• Retrospective analysis of over 17,000 patient with sepsis and septic shock

• Delay in first antibiotic administration was associated with increased in‐hospital mortality with a linear increase in the risk of mortality for each hour delay.

Empiric antibiotic treatment reduces mortality in severe sepsis and septic shock from the first hour: results from a guideline‐based performance improvement program. Feffer R, Martin‐Loeches I, Phillips G, et al.Crit Care Med 2014; 42:1749.

• Reviewed 11 studies (16,178 patients) with severe sepsis or septic shock.

• Found no significant mortality benefit of administering antibiotics within 3 hours of ED triage or within 1 hour of shock recognition in severe sepsis and septic shock.

The Impact of Timing of Antibiotics on Outcomes in Severe Sepsis and Septic Shock: A Systemic Review and Meta‐Analysis. Sterling S, Miller WR, et al.Crit Care Med 2015 Sept; 43(9):1907‐15.

2016 Sepsis Guidelines

• Despite advances in treatment, septic shock still has a mortality rate of about 40%.

• EARLY RECOGNITION is important.

2016 Sepsis Guidelines

• Administration of ANTIBIOTICS, ideally within the first hour.

• IV FLUID BOLUS of 30 mL/kg

• Initial and serial LACTATES to guide resuscitative efforts

• LEVOPHED for persistent hypotension following adequate IV fluids

• REASSESS FREQUENTLY

• Early admission to the ICU

MEDICAL RESEARCHDECADES OF RIGOROUS STUDIES, ONLY TO FIND OUT

THAT YOU WERE DOING THINGS RIGHT THE FIRST TIME

47 y.o. Male in Cardiac Arrest

Patients without ST elevation after return of spontaneous circulation may benefit from emergent percutaneous intervention: A systematic review and meta‐analysis. Millin MG, Comer AC, Nable JV, et al. Resuscitation 2016; 108:54

• Meta‐analysis of 11 retrospective studies involving several thousand patients

• 30% of post‐arrest patients with no ST elevation had acute coronary artery occlusions regardless of their presenting rhythm

• While randomized trials are needed, it is reasonable to perform coronary catheterization in spontaneous cardiac arrest patients without discrete signs of ACS

54 y.o. male w/ a headache

• Arrives by private vehicle

• CC: headache x 1 day

• HPI: occurred suddenly while watching T.V.

• ROS: No recent illness, fevers, vomiting, vision changes, or focal numbness or weakness

• PMHx: HTN

• Rx: HCTZ

• SocHx: smoker, occas. alcohol use, no drug use


• Physical Exam:

– Alert, no apparent distress

– Vitals: 142/90, HR 72, RR 16, Temp 98.4 F

– HEENT: PERRL, EOMI, no nuchal rigidity,

no photophobia

– CVS: RRR, no M/R/G

– Resp: lungs CTA

– Abd: soft and nontender, no hernias

– Extremities: normal

– Neuro: A&O x 3, CN II-XII intact, no motor/sensory deficits


• Differential diagnosis?

• Work-up?

• Treatment?


• Who votes for a CT of the head?

• Who votes for an LP?

• Who votes for reassessing the patient after analgesics?

• Who votes for ending this lecture early and heading out to the golf course?


• What life-threatening conditions are we

ruling-out here?– “It might be a tumor!!!”

– ICH

– Meningitis / encephalitis

– SAH

– Acute narrow angle glaucoma

– Temporal arteritis

– CO toxicity

CT head

Hx & Physical Exam

Hx, Physical Exam, CT, and …

LP

54 y.o. male w/ a headache• When should we do a CT?

– Risk factors• Age, co-morbidities, Family Hx, Social Hx

• Concerning HPI– Sudden onset– Does it need to be the “worst headache of your life”?– Associated symptoms

» Fever, nausea, vomiting, vision/speech changes, dizziness, vertigo, motor/sensory changes

• Abnormal physical exam findings– Motor or sensory deficits, speech changes, cerebellar dysfx.– Altered mental status, photophobia, nuchal rigidity

• If they just don’t look good.

54 y.o. male w/ a headache• Okay, the CT is negative. • When should we do an LP?

– What are we ruling-out now?• Meningitis • SAH

(fever, meningeal signs)


It’s time for a discussion with your patient.

• Tell them why it’s necessary.

• Discuss the risks versus benefits.

• Explain the procedure in such a way that they won’t run screaming out of the ER.

Here’s a technique you might want to try . . .


54 y.o. male w/ a headache• SAH (Perils and Pitfalls)

1) “It wasn’t the worst headache of their life.”

“How bad is your headache?”

“It’s horrible.”

Worst headache of your life??

“Yeah, but howbad?”

“Extremely bad.”


“But not the worst headache of your

life, right?”

“It’s excrutiating.

I feel like I’m gonnapuke.”


“But you’ve had worse.”

“No, I have not.”


“Come on, you must’ve

experienced pain worse than this

before.”

“Absolutely not. This is the worst.”


“Are you drunk?I’ll bet you’re drunk.

You can’t be a reliable historian if you’re drunk,

you know.”

“No, I’m not drunk!

What sort of questions are these,

anyway?!”


“Okay, what if you got attacked by a bear? What if he bit you

right in the head? I betcha that’d give you

a worse headache than this.”

“Maybe.

“If he bit me right in the head.”


“Sure, that’d hurt like a son-of-a-gun!It’d hurt way more

than this.”

“I suppose.”


“So, if you wereattacked by a bear, in the future I mean…

“I guess not.

… then in retrospect, today’s headache would not be the worst headache of your life.”


If I was attacked by a bear.”

“So we’re clear then. You’re telling me that this is not the worst

headache of your life.”


“Right. The bear would be worse.”

“Are you a real doctor?”


“Well, that’s all I needed to know.”


2) “The neuro exam was completely normal.”

• The neuro exam is often completely normal

following a sentinel bleed.


3) “The patient’s headache improved/resolved

following analgesics.”

• Of course. Let’s face it: that’s what analgesics do.


4) “The head CT was negative.”

• Head CT will miss about 15% of SAH’s

• Or will it??!

Sensitivity of computed tomography performed within six hours of onset of headache for diagnosis of subarachnoid hemorrhage: prospective cohort study. Perry, JJ, et al. BMJ 2011 Jul.; 343

– 11 tertiary care EDs across Canada (2000-2009)– Neurologically intact adults w/ non-traumatic HA

peaking within 1 hour, in whom a CT was ordered by the ED physician

– 3,132 enrolled patients -> 240 SAH’s (7.7%)– Overall sensitivity of CT for SAH was 92.9%– Subset analysis:

• HA onset < 6 hours (953 patients scanned)– 121 patients had a SAH (all identified by head CT)

• HA onset > 6 hours (2179 patients scanned)– 119 patients had a SAH (CT missed 17 patients)

Time-Dependent Test Characteristics of Head Computed Tomography in Patients Suspected of NontraumaticSubarachnoid Hemorrhage. Backes D, et al. Stroke 2012; 43(8): 2115-9.

– Single center retrospective study in the Netherlands of 250 patients

– HA onset ≤6 hours (137 patients scanned) • 69 Patients had negative Head CT

• 1/69 had SAH from cervical AVM on LP

– HA onset >6 hours (113 patients scanned) • 76 Patients had negative Head CT

• 5/76 had a SAH

Sensitivity of Early Brain Computed Tomography to Exclude Early Aneurysmal Subarachnoid Hemorrhage: A Systemic Review and Meta-Analysis. Dubosh NM, et al. Stroke 2016; 47(3): 750-5.

• Reviewed original research studies of adults presenting with a history concerning for spontaneous SAH and who had noncontrast brain CT scan using a modern generation multidetector CT scanner within 6 hours of symptom onset

• 5 articles met inclusion criteria (8,907 patients)

• 13 patients (0.14%) had a missed SAH on brain CTs within 6 hours

“I wouldn’t let you touch me with a

ten-foot pole, you quack!”

So … it requires a conversation.

“You ready for that spinal tap now?”

24 y.o. male s/p MVC


• HPI: – Reported LOC

– Patient amnestic to the event

– Mild SOB, chest and abdominal pain

• PMHx: none

• Rx: none

• SocHx: negative

• SurgHx: none


• Physical Exam: – Vitals: 118/52, HR 89, RR 20, 99% on RA

– Neck: no c-spine tenderness

– CVS: RRR

– Resp: diminished bilaterally, but CTA

– Abd: soft with diffuse tenderness

– Neuro: A&O x 3, no motor or sensory deficits


Case 2(24 y.o. male, s/p MVC)

• Diagnostic Work-up: – CXR

– CT studies

– Labs

15.215.8

44.2289

Labs

139

3.6

104

29

27

1.2127

UA: normal

UDS: negative

BAL < 2

3919 0.3

83


• Disposition: (a) Discharge home

(b) Admit for observation

(c) Consult a specialist

(d) Invite patient to dinner

(e) Both a and d are correct

(f) Both b and c are correct

(g) None of the above


• Return ED visit (later that evening):

• cc: “Too many Heinekens.”

• Physical Exam: – Vitals: 92/42, HR 160, RR 14, 99% on RA

– CVS: tachycardic, regular rhythm

– Resp: CTA

– Abd: firm; diffusely tender

– Neuro: somnolent; difficult to awaken


• Plan of action: (a) Ask the patient, “Do you feel safe at home?”

(b) Repeat a CT scan

(c) Repeat the FAST exam

(d) Call the surgeon

(e) Admit to the ICU and let the intensivist figure it out.

(f) Discharge the patient home. He’s a drug seeker if you ever saw one!


• Hospital Course: • Patient taken to the O.R.

• Small bowel perforation repaired

• Admitted to the ICU

• Patient discharged on hospital day # 6


• Discussion: • Patients with a seatbelt sign are at increased risk for

intra-abdominal injuries.

Seatbelt sign following blunt trauma is associated with increased incidence of abdominal injury. Chandler, et al. Am Surg, 1997 Oct; 63(10): 885-8.

– Retrospective review of 117 MVC patients

Seatbelt sign (14 patients)

– 64% had an intra-abdominal injury

– 36% required operative repair

– 21% had a small bowel perforation

No seatbelt sign (103 patients)

– 8.7% had an intra-abdominal injury

– 3.8% required operative repair

– 1.9% had a small bowel perforation

• Discussion: • Patients with a seatbelt sign are at increased risk for

intra-abdominal injuries.

• A negative CT does not rule-out bowel injury.

• Patients with blunt abdominal trauma and persistent abdominal pain warrant admission for further observation.

Performance of CT in detection of bowel injury. Butela, et al. AJR, 2001 Jan; 176(1): 129-35.

– CT sensitivity of 64% in the diagnosis of bowel injury

What did we learn?

What did we learn?

What did we learn?

What did we learn?

What did we learn?

What did we learn?

What did we learn?

August 16, 20177 PM

Books Inc.317 Castro StreetMountain View, CA

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