Diagnostic sensitivity of ED clinical assessment — Brain Teaser. Do you know the answer? November 26, 2018
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Test your knowledge and see how much you know about treating and managing pediatric bacterial meningitis.
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The correct answer: C.
24-year-old subdued with taser — Brain Teaser. Do you know the answer? November 24, 2018
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Test your knowledge and see how much you know about treating and managing electrical injuries in the ED.
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10 Risk Management Pitfalls in the Management of Pediatric Patients With Bacterial Meningitis November 19, 2018
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The presentation of bacterial meningitis can overlap with viral meningitis and other conditions, and emergency clinicians must remain vigilant to avoid delaying treatment for a child with bacterial meningitis. Here are 10 risk management pitfalls to avoid and 3 time- and cost-effective strategies for when you’re managing pediatric patients with bacterial meningitis.
10 Risk Management Pitfalls in the Management of Pediatric Patients With Bacterial Meningitis
1. “The patient is sleeping. I don’t want to wake her up to perform a neurological examination.”
The neurologic assessment of the young child can be difficult, even under optimal circumstances. If you are performing this evaluation when a child is fearful or when they should be sleeping, it can be even more challenging and requires patience and, frequently, a dedicated period of observation for reassessment. Efforts should also be made to provide distraction to reduce the amount of fear or inhibition caused by the hospital environment to allow the most accurate examination possible. This distraction can be provided by family interaction with the child or by having the child play independently with a toy.
2. “The patient has inflamed tympanic membranes. The fever and irritability are likely due to otitis media. It’s not meningitis.”
Many young children with bacterial meningitis can have concomitant inflammation in other areas on physical examination or diagnostic study. Otitis media and upper respiratory tract infections are common enough conditions that their presence can lead the emergency clinician to “explain away” the child’s more serious symptoms as being due to those pathophysiologic findings. Anchoring on a simpler, less severe diagnosis can result in missing or delaying the correct diagnosis.
3. “The patient likely had a febrile seizure. I can’t get a neurological examination in his postictal state.”
Delay during decision-making can result in harmful diagnostic or therapeutic delay. A high-risk scenario can develop while waiting for a postictal child to awaken from a febrile seizure to perform a thorough neurologic examination and determining the need for a lumbar puncture or empiric antibiotics. The large majority of patients with simple febrile seizure are going to awaken to a baseline neurologic state within 1 to 2 hours after the seizure. Is the patient who is still “sleeping” 2 to 3 hours after a febrile seizure postictal, or is the patient progressing to a state of unresponsiveness? Patients who behave in this manner after a complex febrile seizure can be particularly concerning, and a lower threshold of lumbar puncture should be considered.
4. “This patient’s neck stiffness or meningismus is likely due to pharyngitis or ‘flu-like’ symptoms.”
Pharyngitis and other viral illnesses can also give a clinical presentation of neck stiffness. Meningismus is not specific to meningitis. Emergency clinicians can be inundated with patients presenting with neck stiffness during the winter months, and it is important to be vigilant for any other clues that seem disproportionate to a normal viral illness.
5. “The patient has a normal WBC count, so I don’t need to be worried about meningitis.”
In isolation, the absence of leukocytosis or leukopenia is an inadequate tool by which to make clinical management decisions. The peripheral blood absolute neutrophil count can be used in combination with other elements of the bacterial meningitis score to guide initial decision-making while awaiting results of CSF culture.
6. “The patient likely has viral meningitis, so we don’t need to get a lumbar puncture.”
The notion that emergency clinicians can distinguish the difference between viral and bacterial meningitis based on the history and physical examination is not supported by the available evidence. The clinical overlap of these conditions is substantial, particularly early in the course of illness. Diagnosis should not be made based on the history and physical examination alone.
7. “I did not consider group B Strep in my differential for this perinatal infant.”
GBS infection must be considered in any febrile infant in the first 2 months of life, even after maternal treatment of colonization.
8. “We need to wait for a CT scan and lumbar puncture before we can give antibiotics, as they can cause sterilization of CSF.”
When caring for a patient with a presumptive diagnosis of bacterial meningitis, do not delay administration of appropriate antibiotics for the completion of a CT scan or lumbar puncture or for the results of these studies. Although antibiotics may obscure the ultimate bacteriologic diagnosis, this is a small clinical price to pay to prevent further bacterial proliferation and inflammation within the CNS.
9. “We don’t need to consider tuberculosis or fungal meningitis.”
Meningitis due to atypical pathogens such as Mycobacterium tuberculosis can be notoriously insidious and indolent in presentation. Consider these pathogens, particularly in patients with immunodeficiency, patients traveling from high-risk parts of the world, or, in the case of tuberculosis, those with prolonged contact with an infected individual.
10. “My patient has a positive urinalysis. This is clearly just a UTI. I don’t need to consider any other diagnoses.”
While concomitant UTIs are rare, they do occur. In a recent study involving 1737 infants aged 29 to 60 days, concomitant UTI with bacterial meningitis occurred 0.2% of the time, and was more prevalent in infants aged 0 to 28 days.90
3 Time- And Cost-Effective Strategies For Pediatric Patients With Bacterial Meningitis
- Once there is suspicion for bacterial meningitis, aggressive and early management is important. After initial resuscitation, a child with suspected bacterial meningitis requires inpatient care.
- For children who present with severe symptoms, an intensive care unit setting will allow more frequent monitoring as well fluid balance.
- While treatment for each patient should be individualized, electronic health record 1-click order sets for suspected bacterial meningitis can standardize the diagnostic evaluation and treatment for children with meningitis.
90. Thomson J, Cruz AT, Nigrovic LE, et al. Concomitant bacterial meningitis in infants with urinary tract infection. Pediatr Infect Dis J. 2017;36(9):908-910. (Retrospective study; 1737 infants)
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Human tissues have varying resistance characteristics and susceptibility to damage, so injuries may be thermal, electrical, and/or mechanical, potentially causing burns, thrombosis, tetany, falls, and blast injury. Here are 10 risk management pitfalls to avoid and 4 time- and cost-effective strategies for when you’re managing eletrical Injuries.
10 Risk Management Pitfalls for Electrical Injuries in the Emergency Department
1. “I sent the patient with a low-voltage minor electrical burn home and told her she was fine (she was!). She came back to the ED 2 weeks later and is angry because she developed dizziness and paresthesia in her fingers.”
Electrical injuries have a high incidence of delayed neurological sequelae,41 with studies noting between 25% and 80% of patients reporting neurological complaints after electric shock.39,40 It is important to give specific, detailed discharge instructions, including return precautions for numbness, dizziness, weakness, and mental status changes.
2. “I admitted an electrician with upper extremity and facial burns and airway management who was injured working on a high-voltage line. The orthopedic surgeon called and is angry because he has an open foot fracture. The ED was busy; I can’t take every single patient’s boots off.”
High-voltage injuries have a high incidence of orthopedic injuries, and electrical current at entrance and exit sites can be sufficient to cause open injuries. Remember to completely undress patients so you do not miss injuries on your primary and secondary survey.
3. “The man was found lying in the grass, unconscious. His CT scan and labs were normal. He seemed confused on re-evaluation, so I admitted him for altered mental status, which I thought was probably drug-related. The next day I got a call from the hospitalist; apparently the ENT said he has extensive inner and middle ear damage and is now deaf.”
Patients found unconscious for no apparent reason in an open area should have lightning strike in the differential. (Lightning can strike even when it is not raining, during an event called a “dry” thunderstorm.) The concussive force of the strike can be sufficient to rupture tympanic membranes and cause inner ear damage.47 A thorough ENT examination is necessary.
4. “A patient was brought in by the police last night. He was ‘minding his own business’ and somehow ended up Tasered. He said it hurt to lift his arm. I x-rayed his humerus and elbow, both negative, with normal pulses and sensation, so I discharged him into police custody. Unfortunately, they brought him back 2 days later… he ended up being diagnosed with a scapular fracture.”
Taser (or other electroshock weapon) injuries are on the rise in the United States, and 1 out of 9 police-related injuries presenting to United States EDs are caused by these devices.76,77 The majority of injuries are minor abrasions, lacerations, and contusions. Forceful muscle contraction can cause fractures, including spinous process fractures and scapular injuries. Cardiac electrical capture with subsequent ventricular fibrillation and asystole is a rare complication.78
5. “I work at the regional burn center. EMS brought in a 45-year-old lineman who touched a high-voltage line. The shock entered his left arm and exited his right leg. I admitted him to burn ICU, gave IV fluids for his open injuries, but I didn’t have time to recheck him. He needed multiple doses of pain medicine. While he was holding in the ED his arm became tight, shiny, and pale…he had a delay in his emergent fasciotomy.”
Burn patients with significant orthopedic injuries are at high risk for compartment syndrome, and electrical burns are at even higher risk because of the full-thickness nature of many of these injuries. Frequent neurovascular checks are a must, especially in the first 12 hours. Your ED should have a protocol for neurovascular checks for these patients, and progressive or uncontrolled pain should prompt further investigation.
6. “The 2-year-old had a small burn on his face after playing with an electrical cord. There was no airway involvement, and I sent him home to follow up with a burn specialist. Then 24 hours later, he came back bleeding profusely from the mouth…that airway was touch-and-go.”
Oral burns in children who chewed on an electrical cord have up to 24% incidence of bleeding from the labial artery. Proper initial management is controversial, but ENT consultation should be obtained, and if the patient goes home, you must give strict discharge instructions and set patient/family expectations for the possibility of bleeding.48,49
7. “This patient was transferred to our burn center for evaluation of his high-voltage burns after he was cleared by the trauma center. We admitted him to the burn floor, where he had a seizure and then became obtunded. It turned out he had a basilar skull fracture. The surgeon asked me if I had looked behind his ears.’”
Initial traumatic injuries may not be apparent in high-voltage exposures, and you should do a thorough traumatic evaluation in these patients. In this case, early recognition of a skull fracture (which may reveal the Battle sign, with bruising behind the ears) could have prompted seizure prophylaxis, neurosurgical consultation, intracranial pressure monitoring, etc.
8. “My patient had a high-voltage burn that had entry at his head and exit from the right arm. He had some minor facial burns and an arm fracture. We admitted him to the floor, but he boarded in the ED for a while. I’m glad he did, because he became progressively more dyspneic and needed emergent intubation. He had a lot of edema; I barely got the tube passed.”
Remember that the extent of burn seen on the skin in high-voltage burns may not give an accurate picture of underlying burn injury. You cannot use traditional burn metrics of soot in the mouth or nares, facial hair singeing, or burns to the lips as risk factors for intubation. Maintain a high index of suspicion for airway involvement and consider fiberoptic laryngoscopy or early intubation in electrical burns involving the face or neck.
9. “We saw a patient who grabbed a low-voltage line with both hands. She said that her left arm hurt, but there was no sign of trauma, x-ray was negative, and her ECG was completely normal. That night she returned, and her arm was cold and pale.”
There is a risk of acute arterial and venous thrombosis in patients injured by electric current. This is hypothesized to be due to both thermal damage and electrical damage to the intima of the vessel. In a patient with unexplained pain in a limb after electrical injury, you must document neurovascular status and serial examinations. If pain persists, further workup is necessary, which may include ultrasound, CT angiography, or formal angiography.
10. “This high-voltage injury patient came to the ED with 10% total body surface area burns. I followed the Parkland formula for fluids, but she stayed hypotensive and, during her hospital course, developed acute renal failure. I thought that formula was solid for taking care of a burn patient.”
Electrical burns on the skin do not necessarily give a clear picture as to how much tissue was actually damaged by thermal and electrical energy. Isotonic IV fluids sufficient to maintain urine output at 1.0 to 1.5 cc/kg/ hr must be given to these patients. Continue fluid resuscitation until you reach that urine output and urine myoglobin has cleared. Fluid requirements may be much higher than specified by the Parkland formula. CK levels and myoglobinuria should be monitored.
4 Time- and Cost-Effective Strategies
- Cardiac monitoring in patients with no arrhythmia, syncope, or ECG changes is unnecessary.
- Do not delay transfer to a burn center; once you have determined that transfer is necessary and the patient is stabilized, further diagnostic testing may delay definitive care.
- Many low-voltage exposures may be safely discharged home if there are no or only minor burns, no ECG changes, and no worrisome findings on examination.
- A urinalysis can screen for the presence of myoglobin, leading to a search for rhabdomyolysis.
39. Singerman J, Gomez M, Fish JS. Long-term sequelae of low voltage electrical injury. J Burn Care Res. 2008;29(5):773-777. (Retrospective study; 38 patients)
40.* Bailey B, Gaudreault P, Thivierge RL. Neurologic and neuropsychological symptoms during the first year after an electric shock: results of a prospective multicenter study. Am J Emerg Med. 2008;26(4):413-418. (Prospective cohort study; 86 patients)
41. Tondel M, Blomqvist A, Jakobsson K, et al. [Immediate and delayed outcomes after electrical injury. A guide for clinicians]. Lakartidningen. 2016 Dec 1;113. (Descriptive study and review of Swedish national data; 300 patients)
47. Modayil PC, Lloyd GW, Mallik A, et al. Inner ear damage following electric current and lightning injury: a literature review. Eur Arch Otorhinolaryngol. 2014;271(5):855-861. (Meta-analysis; 35 articles)
48. Canady JW, Thompson SA, Bardach J. Oral commissure burns in children. Plast Reconstr Surg. 1996;97(4):738-744. (Descriptive study; 24 patients)
49. Thomas SS. Electrical burns of the mouth: still searching for an answer. Burns. 1996;22(2):137-140. (Review and case report; 5 patients)
76. Cherington M. Lightning injuries. Ann Emerg Med. 25(4):516-519. (Practice guidelines)
77. Pfortmueller CA, Yikun Y, Haberkern M, et al. Injuries, sequelae, and treatment of lightning-induced injuries: 10 years of experience at a Swiss trauma center. Emerg Med Internat. 2012;2012:167698. (Retrospective study; 9 patients)
78. Gluncic I, Roje Z, Gluncic V, et al. Ear injuries caused by lightning: report of 18 cases. J Laryngol Otol. 2001;115(1):4-8. (Case series; 18 patients)