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May is Trauma Awareness Month! May 16, 2019

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Clinical Pathway For Management In The Emergency Department Of Pediatric Patients With Suspected Cervical Spinal Cord Injury

Spinal injuries from blunt trauma are uncommon in pediatric patients, representing only about 1.5% of all blunt trauma patients. However, the potentially fatal consequences of spinal injuries make them of great concern to emergency clinicians.

Clinical goals in the emergency department are to identify all injuries using selective imaging and to minimize further harm from spinal cord injury. Achieving these goals requires an understanding of the age-related physiologic differences that affect patterns of injury and radiologic interpretation in children, as well as an appreciation of high-risk clinical clues and mechanisms.

Clinical Pathway For Management In The Emergency Department Of Pediatric Patients With Suspected Cervical Spinal Cord Injury

This clinical pathway will help you improve care in the management of pediatric patients with suspected cervical Spinal cord injury. Click here to download yours today. 

It is Stroke Awareness Month! May 16, 2019

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10 Risk Management Pitfalls For Cervical Artery Dissections

Cervical artery dissections involve the carotid or vertebral arteries. Although the overall incidence is low, they remain a common cause of stroke in children, young adults, and trauma patients. Symptoms such as headache, neck pain, and dizziness are commonly seen in the emergency department, but may not be apparent in the obtunded trauma patient. A missed diagnosis of cervical artery dissection can result in devastating neurological sequelae, so emergency clinicians must act quickly to recognize this event and begin treatment as soon as possible while neurological consultation is obtained.

Use these risk management pitfalls to avoid unwanted outcomes when performing cervical artery dissections. Download now.

1. “This patient has a left temporal headache that radiates into his left ear. His examination is benign, except his pupil is smaller on that side. I did a noncontrast CT head and it’s negative. The headache is probably just due to a hard game of basketball yesterday. I’m going to give him some IV ketorolac and send him out.”

Dissections can occur spontaneously or as a result of minor trauma, even from a basketball game. Failure to consider the diagnosis will result in a missed diagnosis. Headaches in carotid artery dissections can be nonspecific, but are mostly located in the frontal or temporal regions; the radiation to the ear is also characteristic. His examination is also concerning for a partial Horner syndrome. Both of those are suspicious for carotid artery dissection and warrant further vascular imaging.

2. “She has a history of migraines, and she says that this one is different from what she usually feels, but it definitely sounds like a migraine because it is unilateral, pulsatile, and she had a visual aura. I’m going to give her the usual migraine cocktail and see how she does.”

Not suspecting cervical arterial dissection in the beginning of the evaluation results in a significant delay to diagnosis. It can be many hours by the time she has a couple of migraine cocktails before you realize her headache isn’t better and you need to rethink your plan. Due to the risk of early stroke in these patients, a delay in diagnosis could lead to long-term neurological sequelae. Headaches in carotid dissections can be unilateral, pulsatile, and with an aura. Any time a patient with a history of migraines states that the symptoms are not typical, take note.

3. “A 35-year-old woman was attacked by her boyfriend. He hit her on the right side of the neck near her jaw, causing her head to snap around to the left. Her neurological examination is completely normal. She is in a great deal of pain, but it seems to be related to the soft-tissue injury from the hit, because her noncontrast CT head and c-spine are negative. I’m going to treat her pain and see how she feels.”

Pain due to the trauma could mask specific signs or symptoms of dissection. In these patients, relying on the history to identify high-risk factors is important. Due to the location of the blow, it may have caused a hyperextension and rotation of her head in addition to direct trauma, which could have caused a dissection. Patients with risk factors should have advanced vascular imaging (CTA or MRA).

4. “I couldn’t do a neurological examination because she was in too much pain. I’ll treat her headache and then try again later.”

Although it seems kind to give patients a little time to obtain comfort before performing an examination, a prompt neurological examination is absolutely necessary in order to determine any findings that need to be addressed immediately, such as an acute stroke.

5. “A 12-year-old boy fell off of his bike after running into a parked car, and then he had a seizure. The noncontrast CT head and c-spine were normal. He is still in some pain, but I don’t see anything abnormal on his neuro examination, so I’m going to clear his c-spine.”

Pediatric patients with dissection have different symptoms from adults; seizure has been shown to be a presenting symptom in 12.5% of cases. The seizure, along with the mechanism, should prompt vascular imaging to assess for a cervical artery dissection before the cervical collar is removed.

6. “I really thought that patient with the headache, anterolateral neck pain, and partial Horner syndrome had a carotid dissection, but the CTA was read as negative, so I guess I was wrong. I’ll just treat her pain and send her home.”

CTA is an excellent screening tool, but it is not 100% sensitive and can miss small intimal flaps, intramural hematomas, or a slight fusiform dilatation of the vessel. In patients for whom there is a high suspicion of dissection and a negative or equivocal CTA or MRA, further imaging with MRI or digital subtraction angiography is indicated.

7. “The CTA showed a dissection, so I gave him an aspirin and called neurology. However, he now says he doesn’t want to wait and wants to go home. His neuro examination is normal, so I was thinking of sending him out on aspirin.”

Sending the patient home in the acute setting without consultation is not a good idea. Due to high risk of stroke in the first 24 hours and the high incidence of progression of lower-grade dissections, these patients warrant close monitoring and early follow-up imaging to determine the need for escalation of care.

8. “The intubated trauma patient had his noncontrast CT head and c-spine and the radiologist just called and said there is a temporal bone fracture through the carotid canal. I’m going to pass it along and let the trauma service finish the workup after he gets to the intensive care unit.”

This will lead to a significant delay in diagnosis, which could be devastating for the patient. Due to its sensitivity and availability in the ED, a CTA should be performed prior to the patient being transported upstairs, so treatment can be started immediately.

9. “The CTA showed a vertebral artery dissection on that patient from the roller coaster ride, so I consulted the neurology service for admission. Her neuro examination is normal, so I’m going to wait to treat her and see what they recommend.”

An antithrombotic agent for stroke prevention needs to be started on this patient and can be started in the ED to avoid treatment delays. Studies in this population have not shown superiority of one over the other, so the choice of aspirin or heparin depends on patient factors. For uncomplicated dissections, antiplatelet agents are sufficient, and heparin is preferred in patients with an acute thrombus or high risk for thromboembolic events if no contraindications exist.

10. “The patient is a 42-year-old man presenting with an acute onset of right-sided hemiplegia and global aphasia that started 1 hour ago while at the grocery store. His CT head was negative for hemorrhage, but the CTA showed a dissection in his left carotid artery with about 50% vessel occlusion. Unfortunately, that excludes him from treatment with rtPA due to the risk of hemorrhage or intramural hematoma expansion.”

Data have shown rtPA to be as safe in patients with cervical dissections as with patients with strokes due to other causes. Therefore, this patient should be treated with rtPA as soon as possible if there are no contraindications. Endovascular treatment should also be considered if there are contraindications to IV rtPA or if he does not improve after treatment.

Need more information or Stroke CME?
Click here to review the issue and take the CME test, but hurry, CME expires August 1, 2019!

It is Stroke Awareness Month! Can you solve the stroke case below? May 10, 2019

Posted by Andy Jagoda, MD in : What's Your Diagnosis , 1 comment so far

Was it a “mini stroke”? — ED Management of Transient Ischemic Attack

Case Recap:
A 59-year-old obese woman presents to your community hospital ED after experiencing a distinct episode in which her left hand felt “clumsy,” along with a left facial droop and left-sided numbness. She denies experiencing frank weakness and states that the symptoms resolved in less than 10 minutes. She mentions that she experienced a similar episode 2 weeks prior, and is concerned because both her parents and an older sibling experienced disabling ischemic strokes. Her vital signs and point-of-care glucose were normal, and her ECG showed sinus rhythm. Her physical examination, including a detailed neurologic examination, was largely unrevealing, with no facial asymmetry, unilateral weakness, sensory loss, or dysmetria appreciated. A noncontrast cranial CT scan of the brain was remarkable only for nonspecific subcortical and periventricular white matter changes without evidence of acute or old infarction, mass, or hemorrhage. Although she is relieved to learn that she has not had a stroke, she is concerned that this may be a precursor of a more serious event. She does not have a primary care physician and states that she has not seen a physician in several years. She asks whether this was a “mini stroke” and, if yes, what the chances are that she will have a stroke in the future?

Case Conclusion:
The 59-year-old obese patient’s detailed description of abrupt, negative symptoms appropriately raised your concern for a right anterior circulation TIA. You calculated her ABCD2 score as a 2, correctly counting her reported facial droop and unilateral weakness. Knowing recent risk stratification data, you counseled her that her 7-day stroke risk was very low; however, you also remembered that the periventricular white matter hypointensities on CT may be indicative of underlying small-vessel cerebrovascular disease, and her report of multiple recent episodes raised your concern. Since your observation unit was at capacity, you insisted on hospital admission. As an inpatient, she underwent MRI/MRA, revealing extensive small-vessel disease and multiple lacunar infarctions of varying ages. She was seen by a neurologist, started on antiplatelet therapy, and counseled on diet and exercise strategies. She remained stroke-free at a 3-month follow-up appointment.

Did you get it right?

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Clinical Pathway for Emergency Department Management of Subarachnoid Hemorrhage February 17, 2019

Posted by Andy Jagoda, MD in : Feature Update , 1 comment so far

Headache is the fourth most common reason for emergency department encounters, accounting for 3% of all visits in the United States. Though troublesome, 90% are relatively benign primary headaches –migraine, tension, and cluster headaches. The other 10% are secondary headaches, caused by separate underlying processes, with vascular, infectious, or traumatic etiologies, and they are potentially life-threatening.

This clinical pathway will help you improve care in the management of patients with subarachnoid hemorrhage. Download now.


Life-Threatening Headache. What do you do? February 12, 2019

Posted by Andy Jagoda, MD in : What's Your Diagnosis , 2comments

A 55-year-old man with history of nonsmall cell lung cancer who is on cisplatin presents with an acute headache and lethargy for 6 hours. His vital signs are remarkable for a blood pressure of 210/120 mm Hg, heart rate of 70 beats/min, and a temperature of 36.7°C (98°F). His physical exam reveals a lethargic patient with no localizing neurologic signs and no meningismus. You order a noncontrast CT of the head and consider lowering this patient’s blood pressure, though you wonder how much and how fast it should be reduced…

Case Conclusion:
You recognize that this cancer patient’s change in mental status and severely elevated blood pressure was likely the result of PRES. You obtained a CT of the head, which revealed white-matter changes in the posterior cerebral hemispheres. Utilizing IV nicardipine, you lowered the patient’s MAP by 25% over the first hour. In addition, you temporarily discontinued his chemotherapy medication. He subsequently became more alert and responsive.

Would you have done it different? Tell us how you would have handled this case.

Diagnostic sensitivity of ED clinical assessment — Brain Teaser. Do you know the answer? November 26, 2018

Posted by Andy Jagoda, MD in : Brain Tease , add a comment

Test your knowledge and see how much you know about treating and managing pediatric bacterial meningitis.


 

Did you get it right? Click here to find out!

The correct answer: C.

Earn CME for this topic by purchasing this issue. 

 

10 Risk Management Pitfalls in the Management of Pediatric Patients With Bacterial Meningitis November 19, 2018

Posted by Andy Jagoda, MD in : Feature Update , add a comment

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

Reference:

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)

 

Which empiric antibiotics to use? — Pediatric Bacterial Meningitis Conclusion November 14, 2018

Posted by Andy Jagoda, MD in : What's Your Diagnosis , 1 comment so far
Case Recap:
A 4-month-old boy presents with a history of cough, pallor, fever to 38.9°C (102°F), and decreased feeding on the morning of presentation. The infant drank 6 ounces about 4 hours before arrival, but would not feed at presentation. The boy’s parents state he did not vomit or have diarrhea. His past medical history is notable for cesarean delivery at 36 weeks’ gestation. There was prolonged rupture of membranes and he was hospitalized for 3 days after delivery. The boy’s parents report no prior illnesses, and his immunizations are up-to-date. On physical examination, the boy’s vital signs are: temperature, 38.9°C (99.6°F); heart rate, 158 beats/min; respiratory rate, 50 breaths/min; and oxygen saturation, 98% on room air. The boy is arousable but sleepy and does not fix and follow. His fontanel is flat. His HEENT examination is notable for nasal congestion with mucus secretions. The boy’s cardiopulmonary and abdominal examinations are unremarkable. The boy’s capillary refill is < 2 seconds, but his muscle tone is decreased. He is fussy during the examination. 
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Is this merely an upper respiratory infection or should meningitis be considered? What are common clinical features of meningitis in this age group? What further management is indicated? Which empiric antibiotics—if any—are indicated at this time?
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Case Conclusion:
The 4-month-old boy with a history of cough, pallor, fever, and decreased feeding was placed in a warmer on a cardiorespiratory monitor with continuous pulse oximetry. His heart rate and respiratory rate rose and his degree of responsiveness declined. You decided the patient needed a lumbar puncture, knowing that vital sign abnormalities and subtle neurologic changes can be the first signs of bacterial meningitis in this age group. After obtaining consent from the mother, CSF was obtained on the first attempt, and was visibly purulent. The CSF WBC count was 2257 with 85% polys. The CBC showed a peripheral WBC of 9.9, Hb of 9, and platelets of 329,000. A CSF Gram stain revealed gram-positive cocci in pairs and occasional chains. You immediately suspected pneumococcal meningitis and initiated IV dexamethasone 0.15 mg/kg and IV cefotaxime 100 mg/kg and admitted the patient to the PICU. The CSF grew S pneumoniae that was sensitive to cefotaxime. Over the next 24 hours, the patient developed respiratory failure and progressive cerebral edema, the complication that you feared most. Over the next several days, his cerebral edema was unresponsive to therapy and the child died on the seventh day of hospitalization due to this complication.
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Which empiric antibiotics to use? — Pediatric Bacterial Meningitis November 7, 2018

Posted by Andy Jagoda, MD in : What's Your Diagnosis , 8comments
A 4-month-old boy presents with a history of cough, pallor, fever to 38.9°C (102°F), and decreased feeding on the morning of presentation. The infant drank 6 ounces about 4 hours before arrival, but would not feed at presentation. The boy’s parents state he did not vomit or have diarrhea. His past medical history is notable for cesarean delivery at 36 weeks’ gestation. There was prolonged rupture of membranes and he was hospitalized for 3 days after delivery. The boy’s parents report no prior illnesses, and his immunizations are up-to-date. On physical examination, the boy’s vital signs are: temperature, 38.9°C (99.6°F); heart rate, 158 beats/min; respiratory rate, 50 breaths/min; and oxygen saturation, 98% on room air. The boy is arousable but sleepy and does not fix and follow. His fontanel is flat. His HEENT examination is notable for nasal congestion with mucus secretions. The boy’s cardiopulmonary and abdominal examinations are unremarkable. The boy’s capillary refill is < 2 seconds, but his muscle tone is decreased. He is fussy during the examination. 
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Is this merely an upper respiratory infection or should meningitis be considered? What are common clinical features of meningitis in this age group? What further management is indicated? Which empiric antibiotics—if any—are indicated at this time?
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Last Modified: 06-17-2019
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