CITW 15: The Red Ear

Welcome back to another Clinical Image of the Week from the case files of the Brown EM Residency!

HPI/ROS: 5 year old female with a history of recurrent otitis media who presents to the ED with right ear pain. Per the parents, she developed acute onset right ear pain and “redness” one week ago that was associated with fevers (Tm 103.2). She saw her pediatrician who started a course of Augmentin for otitis media, however, after three days of no improvement, she received IM antibiotics (unknown type) with only minimal improvement in symptoms. On the day of ED presentation, her ear redness had worsened and she had developed limited range of motion of the head and neck. Associated symptoms included headache, hearing loss, and sore throat. No congestion, runny nose, conjunctivitis, visual changes, numbness, weakness, discoordination, cough, dyspnea, wheezing, abdominal pain, vomiting, diarrhea, or rash. No sick contacts or recent travel. Shots are up to date.

Vital Signs: T 102.3, HR 156, RR 22, BP 118/72, SpO2 99% on RA

Pertinent physical exam: Patient found sitting on her mother’s lap, not playful or interactive. Right TM is erythematous and bulging. There is edema and erythema noted behind the right auricle with tenderness to palpation. Shotty cervical chain adenopathy appreciated. No ear discharge. Left TM is clear. Oropharynx is clear with moist mucous membranes. No focal or gross neurological deficits. No meningismus. Neck is supple. Heart is tachycardic. Abdomen soft, non-tender. Lungs clear to auscultation. No rashes. No other pertinent exam findings.

CT imaging was obtained:

Mastoiditis 1
Image 1: CT brain, axial cuts in bone window.
Mastoiditis 2
Image 2: CT brain, coronal cuts in bone window.

What’s the diagnosis?

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Should We Reconsider Antipyretics For Fever?

What is Fever?

Although often used interchangeably, the terms fever and hyperthermia refer to different processes, and the distinction is key. In fever the thermoregulatory set-point is elevated, and the body actively raises its temperature with chills and rigors to reach the new set-point. In hyperthermia the body’s temperature exceeds the set-point, due to increased heat production (eg hypermetabolic state) or decreased dissipation (eg high humidity or ambient temperature).1

Fever is generally defined as temperature ≥38°C (100.4°F) and results from a complex mechanism. The body produces pyrogens (specific cytokines) that act on the thermoregulatory center in the hypothalamus to increase the set-point. This is thought to occur by increased prostaglandin synthesis, and antipyretic drugs lower the set-point likely by inhibiting prostaglandin synthesis.2 There are also numerous endogenous antipyretics (cryogens).

Increased temperatures enhance immune function in many ways, including improved neutrophil migration and secretion of antibacterial substances, increased interferon, and increased T cell proliferation.1

2

Fever Anxiety

A 1980 study titled “Fever phobia: misconceptions of parents about fever” surveyed parents, and found 94% thought fever may have harmful effects, 18% thought brain damage or serious harm could result from fever <38.9°C (102°F), and 16% thought fever could rise up to 48.9°C (120°F) if untreated.3 A 2001 study re-examined similar questions, and found 76% believed serious harm could occur at ≤40°C (104°F).3

This phobia also exists among healthcare workers. A 1992 survey by the American Academy of Pediatrics in Massachusetts showed 65% of pediatricians thought fever alone is potentially dangerous, 72% “always or often” prescribed antipyretics for fever, and 89% recommended antipyretics for fever of 101-102°F.4 A 2000 study of pediatric emergency department nurses, with a median experience of 8 years, found 11% were unsure what temperature constituted fever, 29% thought permanent brain injury or death could occur from high fever, and 18% believed it is dangerous for children to be discharged from the emergency department if still febrile.5

Is Fever Harmful?

Some providers have concerns that the increased temperature or metabolic demand from fever will harm patients. Humans generally tolerate temperatures below 41°C (105.8F) without harm. In contrast to hyperthermia, it is extremely rare for fever as a host defense against infection to reach dangerous temperatures in neurologically normal patients, since the body is actively adjusting both the set-point and actual temperature.3 A 2011 American Academy of Pediatrics policy paper states “There is no evidence that fever itself worsens the course of an illness or that it causes long-term neurologic complications.” 6 Continue reading

POCUS FOCUS: Lung Ultrasound for Pneumonia

BY: MAX RUBINSTEIN, MD

The Case: A 5 year old previously healthy boy presents to the ED with three days of fever and progressive shortness of breath. His exam is notable for course rhonchi and decreased aeration in the right anterior lung. There was no personal or family history of asthma, eczema, or food allergies. He received an albuterol nebulizer with no effect.

The Diagnostic Intervention: Lung Ultrasound

Point of Care Lung Ultrasound:

Point of care lung ultrasound is highly useful in detecting pulmonary pathology commonly encountered in the emergency department, most notably pneumothorax, pulmonary edema, and pneumonia.  The basic technique of lung ultrasound in children is the same no matter what underlying process is suspected. The linear probe is used and oriented perpendicular to the rib in the longitudinal axis. This allows detailed visualization of the pleural line. This is perhaps the most important aspect of lung ultrasonography as 90% of respiratory dysfunction attributable to the lungs affects the pleura.1 Differences in the appearance of the pleural line help the clinician distinguish between causes of respiratory distress. There are several techniques described to adequately assess the lungs by ultrasound, the simplest of which is to image at three interspaces in the midclavicular, mid-axillary, and posterior lung fields.1,2

Figure 1.  Normal Lung Anatomy on Ultrasound

Screen Shot 2016-01-17 at 5.42.35 PM

Pneumonia on Ultrasound:

Pneumonia on lung ultrasound has a characteristic appearance. One can see “hepatization” of the lung as this normally echogenic and artifact filled tissue (see Figure 1) becomes echo-poor and increasingly tissue-like, resembling the liver on ultrasound (see Figure 2).  This is accompanied by “dynamic air bronchograms,” a branching lesion that courses through affected lung and moves with breathing. 3 This mobility helps distinguish pneumonia from atelectasis. A recent study found that dynamic air bronchograms have a 97% positive predictive value for pneumonia.4

How good is lung ultrasound for detecting pneumonia?

  • Sensitivity & Specificity in children > 90%5
  • When performed by emergency medicine physicians who have received a 1 hour training session, sensitivity drops to 86% but specificity is 97%.6
  • Ultrasound may also be better at detecting small pneumonias than standard chest x-ray.6 However, the clinical significance of this finding has yet to be determined.

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Coming Down the Pike: Zika Virus

8x11-ZikaENG
From the Pan American Health Organization Zika virus website: http://www.paho.org/zikavirus

What is Zika Virus?
A single-stranded RNA virus of the Flavivirdae family, genus Flavivirus. The virus was first identified in 1947 in a rhesus monkey in the Zika Forest, Uganda.

What are the signs and symptoms?
Only about 1 in 4 people infected with Zika develop signs or symptoms, which include fever, maculopapular rash, arthralgias and conjunctivitis. Additionally, Zika causes headaches, myalgias, retro-orbital pain and vomiting.

How is it transmitted?
Zika Virus is primarily transmitted through the Aedes mosquito, which also transmits Dengue and Chikungunya. Transmission is also believed to take place vertically between mother and child, and through sexual contact.

Where has it been found?
As of the January 9, 2016, the following Pan American countries have seen confirmed cases of Zika virus: Brazil, Chile, Colombia, El Salvador, French Guiana, Guatemala, Honduras, Martinique, Mexico, Panama, Puerto Rico, Paraguay, Suriname, and Venezuela. 

Countries with confirmed Zika virus outside of the Americas include: Central African Republic, Egypt, French Polynesia, Gabon, India, Indonesia, Malaysia, Nigeria, The Philippines, Sierra Leone, Tanzania, Thailand, Uganda, and Vietnam

Why is it in the news?
Zika virus made national headlines in the United States in late December 2015 when Brazillian health officials advised would-be parents to delay pregnancy over concerns that Zika virus is contributing to a spike in microcephaly. The Brazil Ministry of Health reports a twenty-fold increase in the incidence of microcephaly over the past year in areas that have had confirmed Zika virus transmission (2,782 cases in 2015 versus 147 cases in 2014). The connection was made in November 2015 when Brazilian health officials found traces of Zika virus in a deceased newborn born with microcephaly.
zika_microcephaly
From the Pan American Health Organization Zika virus website, Epidemiological Alert, December 1, 2015

Additionally, Brazil has reported an increase in neurological syndromes in patients infected with Zika virus, most notably Guillain-Barré syndrome.

What is the treatment?
Supportive care: rest, fluids, antipyretics, and analgesics. Hold aspirin or NSAIDs until Dengue has been ruled out to reduce the risk of hemorrhage.

Sources:
Pan American Health Organization Zika virus website: http://www.paho.org/zikavirus

Brazil warns against pregnancy due to spreading virus, CNN, December 23, 2015
http://www.cnn.com/2015/12/23/health/brazil-zika-pregnancy-warning/

Foy BD, Kobylinski KC, Foy JLC, Blitvich BJ, Travassos da Rosa A, Haddow AD, et al. Probable non–vector-borne transmission of Zika virus, Colorado, USA. Emerg Infect Dis. 2011 May; http://www.ncbi.nlm.nih.gov/pubmed/21529401

Pan American Health Organization Epidemiological Alert: Neurological syndrome, congenital malformations, and Zika virus infection. Implications for public health in the Americas; December 1, 2015. PDF Direct Link

A new mosquito-borne threat to pregnancy women in Brazil, The Lancet, published online December 23, 2015. http://www.thelancet.com/journals/laninf/article/PIIS1473-3099(15)00548-4/abstract

Overly Traumatic: A Teenager Elbowed in the Stomach

Link

Overly Traumatic: A Teenager Elbowed in the Stomach

Case: 

A 17 yo healthy M presents with abdominal pain and a syncopal episode several hours after getting elbowed in the stomach at a soccer game.

PMH: Intermittent asthma

ROS: Sore throat, cough and fatigue x 1 week.

Physical Exam:

VS: T 98.3 °F | HR 90 | BP 129/60 | RR 16 | SpO2 100%

Pale but comfortable and alert. Abdomen diffusely tender, guarding in the upper quadrants. Exam otherwise unremarkable.

FAST exam: 

RUQ: Free fluid in Morrison’s pouch & at the tip of the liver

LUQ: Free fluid in splenorenal recess & bowel floating in free fluid

Transverse Bladder: Large amount of fluid & clotted blood anterior to the bladder

Click ahead to reveal diagnosis

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The Neonate in Shock: When to think CARDIAC

Clinical Case:

2-week-old male with history of “funny breathing” since birth presents to ED with 1 day of decreased feeding, now with 30 second apneic and cyanotic episode at home tonight.

Sternal_retractions-3** Neonates in shock MAY show obvious signs/sx of end-organ dysfunction (similar to adults), but their presentation may be subtle and progress rapidly!**

 Signs/Symptoms of Shock in Neonate:

  • History
    • Poor feeding
    • Respiratory distress (tachypnea, cyanotic/apneic episode)
    • Altered mental status (irritability, difficulty awakening)
  • Physical Exam
    • Tachycardia
    • Tachypnea
    • Hypotension
    • Poor Perfusion: Decreased capillary refill, mottled skin

Differential Diagnosis:

Think of “THE MISFITS” to recall critical diagnoses in the neonate in shock:

T –       Trauma (accidental and non-accidental)
H –       Heart disease and Hypovolemia
E –       Endocrine (congenital adrenal hyperplasia, hypothyroid, etc)
M –      Metabolic
I –        Inborn errors of metabolism
S –       Sepsis
F –      Feeding problems, Formula mishaps (under- or over-dilution)
I –        Intestinal catastrophes (NEC, volvulus, etc)
T –       Toxins
S –       Seizures

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US articles: PTX in trauma, FAST for Thoracotomy, Pedi Hip Effusions

brownsound 2

Brown Ultrasound Tape Review:  10/15/15

Article 1: FAST Exam to Predict Survivors of ED Thoracotomy

Inabi, et al. FAST Ultrasound Examination as a Predictor of Outcomes After Resuscitative Thoracotomy. Annals of Surgery 262(3):512-518, 2015.

Fresh off the trauma surgical press last month, this study examined the utility of FAST exam (specifically parasternal and subxiphoid cardiac views) to predict positive outcomes (survival to discharge or organ donation) of ED resuscitative thoracotomy (RT).

This was a prospective cohort study at LA County/USC Medical Center. In 3.5 years, 187 patients arrived in traumatic arrest and underwent FAST and RT (that’s 4-5 thoracotomies a month – WOW!). They documented +/- pericardial fluid and +/-  cardiac motion. PGY2-4 EM residents performed the FAST exams after some formal training, and they were supervised by “faculty” – not clear if those were surgeons or EM attendings.

About ½ patients lost vitals at the scene and another ¼ both en route and in the ED. Overall survival – 6 patients (3.2%). Overall organ donation – 3 patients (1.6%). Cardiac motion on FAST was 100% sensitive for the identification of survivors and organ donors (and 73.7% specific).  While the tables and discussion include a lot on the presence or absence of pericardial fluid, this did not impact the sensitivity or specificity of FAST. If cardiac motion was absent, the likelihood of survival was 0.

Bottom line: Given that RT is such a high risk, low survival procedure, cardiac FAST can be used (with excellent sensitivity) to identify traumatic arrest patients with better odds of survival or organ donation from ED thoracotomy. No cardiac motion means pretty much no chance of survival or organ donation.


 

Article 2: Handheld E-FAST for Pneumothorax

Kirkpatrick, et al. Hand-Held Thoracic Sonography for Detecting Post-Traumatic Pneumothoraces: The Extended Focused Assessment With Sonography for Trauma (EFAST). Journal of Trauma 57:288-295, 2004.

This was another trauma surgery study out of Vancouver Hospital and Health Sciences Centre interested in the test characteristics of hand-held US to look for PTX in trauma patients. They compared EFAST examinations for PTX to:

(1) CXR results

(2) a “composite standard” of clinical information, which included some combination of CXR, CT if it happened, clinical course, and need for chest tubes/needle decompression

(3) CT alone (the gold standard for patients who had a CT).

This was a retrospective chart review on trauma patients (note – those who were in “physiologic extremis” with suspected PTX were excluded). All EFASTs were done by the attending trauma surgeon using a linear transducer. They looked for lung sliding or comet tail artifacts or color power Doppler evidence of pleural sliding in at least 3 rib spaces. PTX was diagnosed if neither sliding nor comet tail artifacts were seen.

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Peds EM Follow Up 2015: Pediatric Osteomyelitis

2 Articles of Interest & An Excruciating, Detailed and Lengthy Guide to Diagnosis and Management

 

Dartnell J, Ramachandran M, Katchburian M. Haematogenous Acute and Subacute Paediatric Osteomyelitis: A Systematic Review of the Literature. J Bone Joint Surg Br. 2012 May;94(5):584-95.

  • A meta-analysis of 1854 papers, 132 of which were examined in detail
  • 40% of patients were afebrile
  • Tibia and femur were most common sites
  • Exam, labs, and imaging must be used in combination
  • S. aureus > Kingella > other
  • Typical treatment: start empiric IV abx, switch to PO when possible

Harris JC, et al. How Useful are Laboratory Investigations in the Emergency Department Evaluation of Possible Osteomyelitis? Emerg Med Australias. 2011 Jun;23(3):317-30. Epub 2011 Apr 4

  • A meta-analysis of 36 studies of adults and children
  • Recommended algorithm:
    • Adults and kids w/ low pretest probability: nL ESR and CRP<5 → done
    • Med/high pretest probability and puncture wounds: nL ESR and CRP<5 → LOW NPV
    • ESR >30 and/or CRP>10-30 → further investigation (imaging) required
    • WBC count is not especially helpful!

Osteo locations

 

PEDIATRIC OSTEOMYELITIS:

  • Definition: bacteria infecting bone
  • Usually hematogenous spread, but can be direct inoculation (surgery, open trauma, puncture, etc) or contiguous spread (skin, sinus, dental infections)

CLINICAL PRESENTATION

  • Constitutional symptoms, irritability, decreased PO
  • +/- fever
  • Localized pain, bony tenderness
  • Functional limitations, i.e. unwilling to crawl or walk
  • Time course: usually several days to >1 week
  • Risk factors: bacteremia, sepsis, immunocompromised, indwelling catheters/hardware, prematurity, skin infection, complicated delivery, GU abnormalities

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Emergent Umbilical Venous Catheter (UVC) Placement

In a sick neonate where peripheral venous access is not possible, placement of an umbilical venous catheter (UVC) may be lifesaving!
The umbilical vein may remain patent for up to 10 days after birth.

Screen Shot 2015-09-11 at 9.50.49 PM

http://www.uichildrens.org/insertion-of-umbilical-vessel-catheters/

Indication:

  • Emergency resuscitation and stabilization of neonates (to give volume or medications, such as epinephrine

Contraindications:

  • Abdomen doesn’t look normal (omphalocele, gastroschisis, omphalitis, peritonitis, necrotizing enterocolitis)
  • Vascular compromise of the lower limbs

 

Umbilical Vessel Anatomy:

Neonatal Anatomy

From Robert and Hedge’s Clinical Procedures in Emergency Medicine

  • Umbilical cord has 2 arteries and 1 vein
    • Vein is thin-walled, usually at 12 o’clock
    • Arteries are smaller and thick-walled
  • Neonatal blood flow:
    • Umbilical vein –> ductus venosus –> IVC –> RA –> PA –> ductus arteriosus –> aortic arch
    • Umbilical arteries –> internal iliac arteries

 

Finding your Materials:

  • In Hasbro ED:
    • Locate UVC Tray and UVC lines in Hasbro Trauma Bay
    • Other materials not in kit:
      • 3-0 silk suture on a curved needle
      • Infusion solution (usually NS or D10W)
      • Three-way stopcock
      • Tegaderm and tape

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