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F.O.A.M. BLOG

Las Vegas FOAM Blog is dedicated to sharing cutting edge learning with anyone, anywhere, anytime.  We hope to inspire discussion, challenge dogma, and keep readers up to date on the latest in emergency medicine. This site is managed by the residents of Las Vegas’ Emergency Medicine Residency program and we are committed to promoting the FOAMed movement.

Going Live: The First Day of an EMR to EMR Transition

1/22/2018

1 Comment

 
By Emerson Posadas MD MBA PGY-2

This is the first of a series of blog posts about administrative and management aspects of the Emergency Department. The first blog in this series describes the transition from one electronic medical record (EMR) system to a new one in our own Emergency Department and all the challenges we faced.

As part of the American Recovery and Reinvestment Act, all pubic and private healthcare providers were required to adopt electronic medical records in 2014. There have been multiple articles on the transition from paper charting to EMR. However, not much has been discussed regarding the transition from one EMR system to another one. With an ever-increasing amount of electronic platforms available, EMR transitions are a common challenge faced by many hospital systems. At University Medical Center of Southern Nevada (UMC) we recently transitioned from McKesson software to EPIC software as our primary EMR system. With this, there were multiple opportunities to improve our workflow and operations in the emergency department. However, as with all transitions this was not as seamless as envisioned.

This transition period was preceded by months of preparation, as we customized the EMR system to our needs. We attempted to develop efficient pathways in the EMR to improve patient care and bring efficiency benefits. This involved multiple meetings with the EMR representatives, gathering input from all staff including physicians, nurses, and pharmacists. We received several notifications in the preceding months that we were “going live” on December 1st 2017. Staff was informed that there would be multiple EPIC “Superusers” available to us in the emergency department during the first month of transition period. Luckily, I was scheduled to work the night we went live.

I was in the middle of a busy night shift. We had been informed that at 3:00 am our current EMR system would be disabled, and there would be a downtime before the new EMR went live. However, we found that the downtime started to occur much earlier than we expected, and by 1:00 am our original EMR had gone down. Orders were no longer going through the computer system. Radiology reports were not being received. Further, there was no electronic tracking board to display which patients had been placed in a bed, discharged, or admitted. In the already chaotic environment of the Emergency Department, another layer of disarray had been added.

However, what occurred next was actually a marvelous display of problem solving and teamwork that was a testament to the preparedness of our Emergency Department. We dusted off old containers that held old paper order forms. The clerks got in contact with the radiology reading room to fax over any reads, and the nursing staff constantly printed and brought them to the physicians. The charge nurse created a makeshift tracking board on a white board that was constantly updated. We were going old school, and it was working. I credit the staff and administration for converting what could have been a terrible situation into something that was manageable. Further, I was able to peer into a time before computers and electronics dominated the healthcare environment. It was simple, but it worked. Over the next few hours, our new EMR system slowly started to become “live.”

​Over the next few weeks, there were growing pains with incorporating the new system to our workflow, but I believe the transition has been a good thing. It has been an opportunity to address core issues in the emergency department to increase efficiency, processes, and ultimately deliver the best possible patient care.
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Baby It’s Cold Outside- Review of Current Literature and Protocols of Resuscitation of the Accidental Hypothermic Patient

12/19/2017

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By M. Subramanian, MD and J. Haber, MD
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​Image by Alessandro M via flickr
With Punxsutawney Phil predicting another 6 weeks of winter, it’s time for a review of literature on resuscitation of the hypothermic patient. Hypothermia can be a source of anxiety for the emergency physician. The risk of malignant arrest or arrhythmia is very high (and should be expected to occur) in any patient with a core body temperature under 32 degrees Celsius, despite rewarming and resuscitation; this is due to a phenomenon called Rescue Collapse or Afterdrop. Morbidity and mortality are very high in these patients, with less than 50-60% of patients survive neurologically intact after experiencing hypothermic arrest. While there are very few studies on hypothermia resuscitation, there exists some interesting opinions on protocols.
Let’s start at the beginning….
​
Many of the protocols start with recognizing hypothermia, either by measuring core temperature (which is difficult to do in the field) or by feeling a cold trunk.  Hypothermia is defined as a core temperature of less than 35 degrees Celsius. A few studies show that esophageal measurement of core body temperature is equivocal to rectal and bladder temperature, but rectal and bladders temperatures may lag behind core temperatures during the process of rewarming.
The next step should be assessment of vital signs. Hypothermic patients may have cardiac instability or irritability, which places them at a very high risk of developing a malignant arrhythmia. Initiation of CPR in an altered hypothermic patient with a bradycardic pulse may actually cause cardiac arrest. Many of the protocols recommend gentle handling of the altered hypothermic patient, and one even recommends checking for a plus for 60 seconds before initiating CPR. Staging the degree of hypothermia is important to determine management; the standard scale used is the Swiss Hypothermia Scale. 
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Classification depends more on clinical symptoms rather than core temperature. A patient with a core temperature less than 35 degrees Celsius who is alert (Stage 1) can be treated with passive rewarming measures, such as blankets, heat lamp, and active movement. It is important that the patient have a shivering response as this is key to recovery.

For the altered hypothermic patient with a pulse (Stage 2 or 3), many protocols recommend passive and minimally invasive rewarming.  These include blankets/Bair huggers and warm lights. It is generally not recommended to attempt bladder lavage, peritoneal lavage or thoracic lavage in these patients as such practices may aggravate the cardiac membrane and initiate malignant arrhythmia. Warm IV fluids does not substantially contribute to rewarming, but may be used for volume resuscitation as hypothermia may cause cold-diuresis. One protocol recommends normal saline boluses of 500 ml. Other protocols, however, recommend using crystalloids other than normal saline as patients may require massive amounts of fluids and large boluses of normal saline may worsen acidosis. Warmed humidified air has been seen in multiple studies to improve rewarming rates and is recommended by most protocols. Early airway management was also generally recommended as endotracheal intubation had low rates of instigating arrhythmias in hypothermic patients. As providers should expect a fatal arrhythmia to occur, securing the airway, placing of defibrillating pads and adequate IV access is recommended. Different protocols recommended rewarming the patient to 32-34 degrees Celsius, and then following therapeutic hypothermia rewarming protocols over the next 24 hours. Sinus bradycardia is a normal physiological process in the setting of hypothermia. It is not necessary to use atropine or cardiac pacing, as this will resolve with rewarming. Hypotension or ventricular arrhythmias reflect cardiac irritability, and while supportive management is the mainstay, providers must prepare for a probable malignant arrhythmia.

The hypothermic arrest patient provides a challenge to the typical ACLS resuscitation. The physiology of medication metabolism and the cardiac myocyte response to electricity in hypothermia decreases success of current practices. European guidelines recommend trying 3 rounds of epinephrine and cardiac defibrillation before core body temperature is rewarmed to 32 degrees Celsius. Other sources say to only give one round of epinephrine and one defibrillation attempt before core temperature reaches 32 degrees Celsius. Dr. Doug Brown recommends a combination of the two; one dose of epinephrine and one defibrillation attempt (in the setting of a shockable rhythm) at first, then continuous CPR with rewarming. With every 5 degree Celsius increase in core body temperature, he recommends checking for pulse and shockable rhythm, and if pulseless with shockable rhythm, giving another round of epinephrine and defibrillation. If that does not work, continue CPR and rewarming until core body temperature is 32 degrees Celsius, and a last round of epinephrine and defibrillation. If at that point the arrest is not reversed, the patient is presumed dead and CPR may be terminated. As the emergency medicine adage goes- “the patient is not dead, until warm and dead”. This alteration to the typical ACLS process allows for fewer interruptions of CPR and defined end point. Unfortunately, there is no solid evidence defining what is “warm enough”, but consensus appears to settle around 30-32 degree Celsius.

It is in the setting of Stage 3-4 that invasive rewarming techniques is found to be most beneficial. Multiple case reports and series have shown an advantage to patients who received extracorporeal warming. Techniques include continuous venovenous, continuous arteriovenous (which can be done in the ED), hemodialysis and cardiac bypass. Other techniques of invasive rewarming include lavages of the bladder, peritoneum (similar to a DPL) and thoracic cavities. While these latter techniques are recommended by a few protocols, Dr. Weingart of EMCrit discourages against bladder and peritoneal lavage. He states the risk of complications with peritoneal lavage is not worth the benefit of rewarming. Also, bladder lavage rewarming rates are not aggressive enough to justify the intervention. However, given the high mortality of stage 3 and stage 4, it may be reasonable for clinicians to decide to perform these procedures, as a last resort if all else has failed. Almost all protocols agree that extracorporeal warming is the best for rapid rewarming. Mortality rates improve from below 37% survival to 50-60% survival. Unfortunately many community practices do not have facilities to achieve this, and transfer to such facilities may be difficult to ensure. Hemodialysis is more readily available and has rewarming rates of 1.5 degrees Celsius/hour. Dr. Gentilello created a machine that took blood from an arterial line to a level 1 infuser, warming the blood and connecting it to a venous catheter. However it is difficult to find this adapter anymore.

If a patient does not rewarm at the established rates (given the rewarming interventions), providers should consider other causes preventing an increase in core body temperature. Most common causes of failure to rewarm include hypoglycemia, alcohol intoxication, infection/sepsis, Addison’s, malnutrition and myxedema coma. It is important to check a fingerstick glucose as well as labs for CBC, metabolic panel, thyroid function tests and blood cultures.
While there are many case reports of successful return of spontaneous circulation in hypothermic arrest patients, slow or stagnant neurologic recovery is a significant part of morbidity. Stage 1 patients have the best chances of survival with rates up to 100% neurologically intact. Organ failure is common within the first 24 hours of Stage 4 hypothermic patients, with pulmonary edema as the leading cause of death. Resuscitated hypothermic patients have an in-hospital mortality of 40%. However, given the existence of case reports highlighting the rare patient with full neurologic recovery from Stage 3 or 4 hypothermia, it is difficult to counsel family on withdrawing care. One study found that patients with hypothermia that were found indoors had worse outcomes. Other prognostic factors include serum potassium. A significantly elevated serum potassium is indicative of hypoxia and traumatic cell death. One protocol suggested termination if serum potassium was greater than 12 mmol/liter. Another factor is hypothermia from avalanche burial; indications that hypoxia preceded hypothermia (and therefore not likely to respond to CPR) include snow in the airway, asystole and burial time greater than 35 minutes.

While there are multiple protocols addressing the management of the hypothermic patient, there is little evidence to support one protocol versus another. More research is needed to determine the best evidence based approach to hypothermic patients. Therefore, consider contributing your hypothermia cases to the International Hypothermia Registry, and increase available data to help establish a standard of practice.  

​
Resources:
Brown DJ, Brugger H, Boyd J, Paal P. Accidental hypothermia. N Engl J Med. 2012;367(20):1930-8.
Gervais J, Sholl M, Holmes J. Accidental Hypothermia Guideline. Maine Medical Center. Jan 2013. < http://www.mainehealth.org/workfiles/mmc_em/Accidental-hypothermia-v2.pdf>
Mulcahy A, Watts M. Accidental Hypothermia: An Evidence Based Approach. Emergency Medicine Practice. 2009;11(1).
Van der ploeg GJ, Goslings JC, Walpoth BH, Bierens JJ. Accidental hypothermia: rewarming treatments, complications and outcomes from one university medical centre. Resuscitation. 2010;81(11):1550-5.
Boue Y, Lavolaine J, Bouzat P, Matraxia S, Chavanon O, Payen JF. Neurologic recovery from profound accidental hypothermia after 5 hours of cardiopulmonary resuscitation. Crit Care Med. 2014;42(2):e167-70.
Roeggla, M., Holzer, M., Roeggla, G., Frossard, M., Wagner, A. and Laggner, A. N. (2001), Prognosis of Accidental Hypothermia in the Urban Setting. Journal of Intensive Care Medicine, 16: 142–149.
Jones AI, Swann IJ. Prolonged resuscitation in accidental hypothermia: use of mechanical cardio-pulmonary resuscitation and partial cardio-pulmonary bypass. Eur J Emerg Med. 1994;1(1):34-6.
Weingart, Scott. "Podcast 66 – …Until They Are Warm and Dead: Severe Accidental Hypothermia." Review. Audio blog post. EMCrit. Scott Weingart, 7 Feb. 2012. Web. 27 Feb. 2014.
Brown, Doug, and Mel Herbert. "Accidental Hypothermia- Part 2." Review. Audio blog post. EM:RAP. Mel Herbert, Jan. 2014. Web. 27 Feb. 2015.
Petrone P, Asensio JA, Marini CP. Management of accidental hypothermia and cold injury. Curr Probl Surg. 2014;51(10):417-31.
Kosiński S, Darocha T, Gałązkowski R, Drwiła R. Accidental hypothermia in Poland – estimation of prevalence, diagnostic methods and treatment. Scand J Trauma Resusc Emerg Med. 2015;23:13.
Gordon L, Ellerton JA, Paal P, Peek GJ, Barker J. Severe accidental hypothermia. BMJ. 2014;348:g1675.
Paal P, Gordon L, Strapazzon G, et al. Accidental hypothermia-an update : The content of this review is endorsed by the International Commission for Mountain Emergency Medicine (ICAR MEDCOM). Scand J Trauma Resusc Emerg Med. 2016;24(1):111.
Walpoth B, Meyer M. International Hypothermia Registry. University Hospital Geneva, Switzerland. Accessed 12/14/17. <https://www.hypothermia-registry.org/>
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Spinal Cord Metastases

4/16/2017

3 Comments

 
By Schon Roberts MD PGY-3

61yo M with h/o of metastatic adenocarcinoma p/w numbness, tingling, and weakness in B/L UE and LE X 3 weeks. This has worsened in the past 3 days. He is now unable to walk or feed himself. He denies bowel/bladder incontinence, HA, fevers, chills, N/V/D, abdominal pain.  He denies any IVD. He was 3 weeks ago able to work full time as an electrician. He complains also of chronic neck and back pain.
Vital Signs are unremarkable.  Back is normal appearance. Pt has 4/5 strength in B/L UE and LE. He has rigidity of R arm with spasm. Decreased sensation B/L UE and LE R>L.  What is the best treatment option for this pt?

A. Discharge home. This is chronic back pain.
B. Refer patient to both pain management and a spinal surgeon to evaluate for disc herniation
C. Obtain consults from nuclear medicine, spinal surgery, and admit pt. Give steroids
D. Place pt in a TLSO brace and admit to the hospital
E. Start broad spectrum antibiotics: pt has an epidural abscess  

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Case: 14mo F with Rash

4/12/2017

4 Comments

 
By Schon Roberts MD PGY-3

14 mo F, seen 3 days ago in ED with fever and possible UTI p/w new onset rash. She was placed on Omnicef and followed up with her regular doctor today. He sent her for evaluation. Parents state that she has had swelling of her hands and feet. Mother states that she has had a fever for 5 days. Fever was TMax 103 F. She has had adequate PO intake with good urine output and stooling. Parents deny URI Symptoms, N/V/D, or recent travel. Vital Signs show a pulse of 179, RR of 28, Temperature of 102.1 F, and patient has a spO2 of 99% on RA. Physical exam is remarkable for injected sclera, swelling of her hands and the dorsum of her feet. She has an erythematous rash on her trunk and extremities that blanches. It spares the palms and soles. Lungs are CTABL and cardiac exam is unremarkable. What is the best treatment option for this child?
 
A. Broaden antibiotic coverage for meningitis to include listeria coverage, LP, and admit to the hospital
B. Discharge home; Pt has a URI
C. PO Tylenol, wait for defervescence, and D/C if improved
D. Obtain an echocardiogram, start on high dose ASA, IVIG, and admit
E. Start on steroids and admit with nephrology consult

​

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Enter the Trump Health Care Bill

3/22/2017

5 Comments

 
By Zachary Skaggs MD PGY-2

          The U.S. House is debating and scheduled to vote this week on the American Health Care Act, a bill which Speaker Paul Ryan and his allies say will “repeal and replace” the Affordable Care Act (ACA). Yet the infrastructure of the AHCA is in many ways very similar to the ACA. There are some differences, though, and we will examine those differences and what they may mean here. We will also examine the probability that this bill passes.

          Like the ACA, the AHCA has a system of subsidies for Americans facing high premiums for medical insurance. Under the ACA, the Department of Health and Human Services collects income data from patients and the IRS to calculate their eligibility for a premium. HHS then pays the subsidy directly to the insurance companies.
          Under the system envisioned by AHCA, patients would receive “monthly refundable tax credits” from the IRS which individuals would use to pay the full cost of the premium. Either way, Americans receive subsidies from the federal government to pay high health-insurance premiums (and must be fully engaged with the income tax system or risk losing the subsidies). Under the present system, premiums have risen. One potential cause is the “guaranteed issue” provision of ACA that requires insurers to cover people with pre-existing medical conditions. This removes the primary element of risk management from health insurance markets and creates a problem of “adverse selection” whereby the sickest patients requiring the most medical attention are buying into the system. Younger, healthy people have less incentive to buy insurance when they can wait to do so until they are already sick.
        The ACA tries to address this problem by mandating individuals buy health insurance and provide proof to the IRS that they did so. Taxpayers who didn't have insurance would have to pay the IRS either $695 or 2.5 percent of income, whichever is greater. AHCA removes the IRS mandate penalty, but still tries to mitigate the adverse selection problem by allowing insurance companies to directly charge a 30% higher premium to new customers who had let their medical insurance coverage lapse.
          The AHCA has one more provision to try to address this problem of adverse selection. The bill would give insurance companies wider latitude to set premiums based on age. This would be an added incentive for younger -- typically healthier – people to buy into the private insurance system by keeping their premiums somewhat under control.
          But between that provision and a cut in the total amount for federal money appropriated for subsidies (or “tax credits”), the Congressional Budget Office numbers say some lower-income older Americans who aren't yet eligible for Medicare could face out-of-pocket health costs several times as much as they do now. AHCA opponents have seized on the example of a 64-year-old making $26,500 who is paying $1,700 a year now and would pay $14,600 under the AHCA changes.
          Such high prices could drive these individuals out of the private insurance system entirely. And without insurance, critics say, patients are more likely to let health problems accumulate until they have to go to an emergency room to receive more expensive care. Certainly I have seen this in my own practice.
          Another issue raised by the CBO scoring is the number of uninsured Americans. It is predicted by CBO that under the current AHCA proposal the number of uninsured Americans will rise 24 million, from 28 million to 52 million, by 2026.
        But Speaker Ryan and President Trump say the CBO's numbers regarding future uninsured patients can't be trusted. And they say the CBO's financial projections can't be considered definitive because they plan more changes to health insurance with further reforms which will lower prices. “Phase II” of this process is to include as-yet unwritten regulations from HHS Secretary Tom Price. “Phase III” is separate legislation including reforms designed to increase competition among both consumers and insurance companies.
         
Since this AHCA bill is being passed as part of the budget, it only needs a simple majority of 51 votes. However, the Phase III reforms which go beyond taxes and subsidies must be passed separately under regular Senate rules requiring 60 votes. One Phase III idea is allowing people to buy insurance across state lines; with the increased competition theoretically diving down the price. Another idea, which has already passed the House as the Small Business Health Fairness Act, would allow small businesses to pool together so they have the same leverage as large businesses in negotiating insurance plans for their employees. Phase III, should it happen, could also involve letting insurance companies and state insurance regulators offer a wider range of insurance products. The AHCA also wants to give state regulators more power in the area of Medicaid. Currently, Congress gives states matching funds based on how much the state spends on treating Medicaid patients. The ACHA would instead give “per capita block grants” to states based on the number of people enrolled in the program. The ACHA also seeks budgetary cost savings in Medicaid in other ways. The Medicaid expansion passed as part of Obamacare raised the eligibility level for Medicaid enrollees to 138 percent of the federal poverty level. Thirty-two states signed up for this expansion. The Trump / Ryan bill would phase out this expansion starting in the year 2020 – though it would include a generous grandfather clause for persons who had already signed up.
        Speaker Ryan and President Trump face a delicate balance in trying to get the bill through Congress. It is likely no Democrat will vote for a bill repealing Mr. Obama's signature initiative. Centrist Republicans worry about Medicaid enrollees and older Americans facing higher premiums losing coverage. Conservative Republicans, including the Freedom Caucus, say they won't vote for a bill that retains a system of subsidies and guaranteed-issue. Their skepticism is heightened given that the Phase III reforms – some of which have already passed the House – will need 60 votes to pass under Senate rules.
            
President Trump is an accomplished salesman, but no matter how you look at it, he has a hard sell here getting this America Health Care Act through the House and the Senate. Even should he manage to do so, it is not entirely clear that his health care bill will save the federal government money, or that it will help solve American's health care woes.
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​Las Vegas Emergency Medicine Grand Rounds – 01/25/16

1/25/2017

1 Comment

 
By Emerson Posadas MD PGY-1
 
Aaron Heckleman, MD
The Crashing Heart
Heart Failure
  • if nitroglycerine helps, be aggressive with it, but maintain blood pressure MAP >=65
  • start the nitroglycerine drip at 100 mcg/min, go up by 50 q5min
  • critical aortic stenosis is preload dependent
 
Adenosine
  • Safe for everyone except Afib with WPW (Wide, irregular)
  • If giving through central line cut the initial dose in half to 3 mg
 
Ross Berkeley, MD
Advanced Documentation
  • don’t forget to document patient reassessments, interventions performed, discussion with patient/family, chaperone in the room, informed consent, conversations with consultants, review of EMS/nursing notes
  • document due diligence, that you reassessed
 
 
Kelly Morgan, MD
Traumatic Brain Injury
  • Mild Traumatic Brain Injury – GCS 13-15 with no structural change
  • Second Impact Syndrome – rare condition caused by rapid brain swelling/herniation after a second concussion in close succession to a prior MTBI
  • Explain expected course and possibility of post-concussive symptoms to patients
 
 

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Vaginal Bleeding and other Awesome Stuff: A Dr. Zitek Lecture

1/6/2017

4 Comments

 
Dr. Tony Zitek offers his evidence-based approach to pregnant and non-pregnant vaginal bleeding in this lecture. This lecture is a nice evidence-based complement to the most recent EMRAP C3 project on this topic.
4 Comments

Intracranial Hemorrhage Management

12/28/2016

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By Schon Roberts MD PGY-3

A 5 yo Male with PMH of Down’s Syndrome presents with AMS while jumping on his bed. Mother states that he was jumping and suddenly became limp. She denies any trauma, fevers, seizure activity, or any other recent medical complaints or illnesses. The patient is intubated. CT Brain shows ICH of the Left Frontal Lobe with 6 mm of Left to Right Midline shift. Pt is stable with normal BP. Which intervention is the most correct to perform next?

A. Paralyze the patient with vecuronium
B. Immediately hyperventilate the patient to a PaCO2 of 30
C. Place the patient on a propofol drip
D. Administer a Hypertonic Saline bolus with 3-5 ml/kg 3% NaCl.
E. Administer a 0.6 mg/kg decadron bolus


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Update on BRUE: Formally known as ALTE

12/23/2016

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​Certainly, a more in depth review will reveal a more complete understanding of the methodology, however, here are a few takeaways: First, a thorough history and physical is necessary in these cases. If my patient meets the definition of BRUE, they are in the low risk category and I find no worrisome characteristics on physical and history and can have follow up the next day, then I plan to discharge them. I would consider keeping the patient hooked up to a cardiorespiratory and pulse ox monitor during my evaluation and would consider getting an EKG, as there is a 4% incidence of cardiac disease found in ALTE patients in one study. Beyond those things, I would not do any more for my low risk BRUE patients.  With this guideline in place, the hope is more specific research and studies can be done to further guide practitioners in dealing with BRUE patients.
 
References
1.     Tieder JS, Bonkowsky JL, Etzel RA, et al. Brief Resolved Unexplained Events (Formerly Apparent Life-Threatening Events) and Evaluation of Lower-Risk Infants. Pediatrics. 2016 May;137(5).
2.     McGovern MC, Smith MB. Causes of apparent life threatening events in infants: a systematic review. Arch Dis Child. 2004;89(11):1043–1048pmid:15499062
3.     Tieder JS, Altman RL, Bonkowsky JL, et al. Management of apparent life-threatening events in infants: a systematic review. J Pediatr. 2013;163(1):94–99, e91–e96
4.     Brand DA, Altman RL, Purtill K, Edwards KS. Yield of diagnostic testing in infants who have had an apparent life-threatening event. Pediatrics. 2005;115(4):885–893pmid:15805360
5.     Green M. Vulnerable child syndrome and its variants. Pediatr Rev. 1986;8(3):75–80pmid:3332339
6.     Claudius I, Keens T. Do all infants with apparent life-threatening events need to be admitted? Pediatrics. 2007;119(4):679–683pmid:17403838
7.     Bonkowsky JL, Guenther E, Filloux FM, Srivastava R. Death, child abuse, and adverse neurological outcome of infants after an apparent life-threatening event. Pediatrics. 2008;122(1):125–131pmid:18595995
8.     Al-Kindy HA, Gelinas JF, Hatzakis G, Cote A. Risk factors for extreme events in infants hospitalized for apparent life-threatening events. J Pediatr. 2009;154(3):332–337, 337.e1–337.e2
9.     Ramanathan R, Corwin MJ, Hunt CE, et al; Collaborative Home Infant Monitoring Evaluation (CHIME) Study Group. Cardiorespiratory events recorded on home monitors: comparison of healthy infants with those at increased risk for SIDS. JAMA. 2001;285(17):2199–2207pmid:11325321
10.  Mittal MK, Sun G,, Baren JM. A clinical decision rule to identify infants with apparent life-threatening event who can be safely discharged from the emergency department. Pediatr Emerg Care. 2012;28(7):599–605pmid:22743742
11.  Hoki R, onkowsky JL, Minich LL, Srivastava R, Pinto NM. Cardiac testing and outcome in infants after an apparent life-threatening event. Arch Dis Child. 2012;97(12):1034-1038pArchmid:23012307
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​Dystonia: A Classic Case Presentation

12/21/2016

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Travis Marshall MD PGY-1
 
A 14 year-old female walks into your ED with her parents. She has a wobbling gait with chorea-like movement of her extremities and her head, and her jaw protrudes to the left in a fixed position. You enter the room and after introductions, ask the patient what brought her in today. She is lying stiffly on the exam bed with her head still rigidly to left and you are able to discern a mumbled “I can’t move my jaw.” You turn to her parents and ask why they bought her in. They respond, “An hour ago, she became stiff and had difficulty talking so we came here.” When asked what medical problems she has, they report “she was diagnosed with a mood disorder three months ago and has been on these medications.” Mom pulls three medications out of her purse and hands them to you: Sertraline, Buspirone, and Aripiprazole. She notes that she just started the aripiprazole a few days ago. You ask the nurse to place an IV and give 50 mg of Benadryl.
 
While she is doing this, you complete a quick neurologic exam having already assessed her gait as she walked in. She responds appropriately to your questions but it is difficult to understand her. The patient is unable to move her jaw and neck but her cranial nerves are otherwise intact. Her eyes track but revert to the left upper quadrant when relaxed. Her jaw is stuck in a mid-open position. She has full range of motion of her extremities, but they appear stiff and slow in their movement.  Her reflexes are 2/4 bilaterally in the upper and lower extremities. Sensation with 2-point discrimination is intact.
 
At this point, the nurse has placed an IV and given the Benadryl. Over the course of 45 seconds while you watch the clock, you see the patient’s jaw relax and head and eyes turn to midline. When asked how she is feeling, she clearly states “I feel amazing.” She then promptly falls asleep. Well done, doctor. Over the course of four minutes, you’ve correctly identified, diagnosed, and treated this patient’s Dystonic Reaction. After a period of observation, she was discharged with Benadryl 25mg Q6h for 48 hours and told to stop the aripiprazole after speaking to her psychiatrist.
 
Quick Review for Dystonic Reactions:
  • Classically caused by antipsychotics
  • 50% of reactions occur within 48 hours and 90% with 5 days of starting a D-2 antagonist.
  • Beware of laryngeal dysfunction (rarely, can be an airway emergency)
  • Physical Exam Findings May Include:
    • Trismus
    • Eye deviation in all directions
    • Forced jaw opening
    • Torticollis
    • Difficulty speaking
    • Facial grimace
    • Tortipelvic crisis: tensing of hip, pelvis, and abdominal wall muscles that cause difficult ambulation
  • Treat acutely with Benadryl 25-50mg or Benztropine 1-2mg, weight-based for children.
  • Recommend continuing treatment for 48-72 hours to ensure resolution of reaction.
  • Symptoms may recur for up to 72 hours but no long term effects are expected.

 
References:
Barach E, Dublin LM, Tomlonavich LC, Kottamasu S. Dystonia presenting as upper airway obstruction. J Emerg Med. 1989 May-Jun. 7(3):237-40
Hawthorne JM, Caley CF. Extrapyramidal reactions associated with seritonergic antidepressants. Ann Pharmacother.  2015 Oct. 49(10)1136:-52.
Hockberger RS, Richards JR: Thought Disorders; in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 8. St. Louis, Mosby, Inc., 2014, (Ch) 110: p 1460-1466.
Juurlink DN. Antipsychotics. Nelson NS, Lewin NA, Howland MA, Hoffman RS, Goldfrank LR, Flomenbaum NE. Goldfrank’s Toxicologic Emergencies. 9. New York, McGraw-Hill; 2011. 1007-8.
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