EM Clerkship

The 3 Worst Causes of Neonatal Conjunctivitis

* Gonorrhea* Causes corneal ulcers and sepsis* Red flags* 1st week of life* Copious purulent drainage* Diagnose with cultures* Treatment* Cefotaxime (3rd generation cephalosporin)* Admit* Chlamydia* Occurs in 1st month of life* Treat with PO erythromycin* HSV* Can disseminate to the brain* Red flags* Mother tested positive (or had active lesions)* Vesicles on baby* Treatment* IV acyclovir* Admit

Other Causes of Conjunctivitis

* Viral/other bacterial* Treat with erythromycin ointment* Chemical conjunctivitis* Caused by eye drops given after birth* Dacryostenosis (closed eye ducts)* Watery eyes from tears not draining

Additional Reading

* Neonatal Conjunctivitis (CDC)

T→ Episode Summary

History

* Sudden and maximal in onset* Compared to previous headaches* Family history of aneurysm* Associated Symptoms* Photophobia* Visual Changes* Neck Stiffness

Exam

* Full neuro examination* Cranial nerves* Visual fields* Speech* Cerebellar (finger-nose)* Motor* Sensation* Gait

Testing Plan

* Non-contrast head CT* Excellent sensitivity <6 hours from onset* Lumbar puncture* >100 RBCs in tube 4* Can be difficult to interpret after a traumatic lumbar puncture* Xanthochromia

Treatment Plan

* Prevent rebleeding* Keep SBP <140* Nicardipine* Reverse any anticoagulants* Vitamin K* Prothrombin complex concentrate* Fresh frozen plasma* Prevent vasospasm* Nimodipine PO* Prevent delayed ischemia* Avoid hyperthermia* Avoid hyper/hypoglycemia* Prevent seizures* Levetiracetam (aka Keppra)

Additional Reading

* Ottawa Subarachnoid Hemorrhage (MDCalc)

The 4 Most Common Causes of Blood in Diaper

* Urinary crystals* Will be guaiac negative* Common in first few weeks of life* Vaginal bleeding* Common in newborn females as they withdraw from maternal estrogen* Maternal blood* Swallowed during birthing process* Breastfeeding with cracked/bleeding nipples* Anal fissures* Common and will improve on its own

Basic Approach

* Step 1: Check if guaiac positive* If negative, it’s not blood* Urinary crystals, food coloring, etc* Step 2: Consider vaginal bleeding* Step 3: Perform apt test* Diagnoses maternal blood* Step 4: Check for anal fissure* Self resolve* Step 5: Expand the differential diagnosis* Necrotizing enterocolitis* Intussusception* Cow’s milk allergy* Colitis* Red Food Dye

Additional Reading

* Neonate With Bloody Stool (Pediatric EM Morsels)

Consider In High Risk Patients

* Alcoholics* GI disorders* Eating disorders* Starvation/poor diet* Extremes of age

Thiamine (B1) deficiency

* Causes damage to neurons and cardiac myocytes* Manifestations* Dry beriberi* Neuropathy* Paresthesias* Wernicke’s encephalopathy* Ophthalmoplegia* Ataxia* Altered mental status* Korsakoff syndrome* Ophthalmoplegia, ataxia, altered mental status* PLUS* Confabulation* Memory loss* Wet beriberi* Heart failure from cardiac damage* Treatment* High dose thiamine

Niacin (B3) Deficiency

* “Pellagra”* Clinical Triad* Diarrhea* Dementia* Dermatitis* Scaly rash* Neck* Dorsum of hands* Treatment* Vitamin B3

Folate (B9) Deficiency

* Megaloblastic anemia* Treatment* Folate

B12 Deficiency

* Classically occurs in vegans (in addition to the previous high risk groups)* Manifestations* Megaloblastic anemia* PLUS* Neurologic complaints* Subacute combined (posterior and lateral column) degeneration of spinal cord* Posterior columns* Impaired vibratory sensation and propioception* Lateral columns* Sensory loss* Motor weakness

Additional Reading

* Thiamine Deficiency: Pearls and Pitfalls (emDOCs)

Mnemonic: DARTH VADER

Death

Arrhythmia

* ACS patients need to be placed on cardiac monitor* Frequently degenerate into non-perfusing rhythms

Rupture of Ventricle

* Occur within a few days of myocardial infarction* Rapid decompensation* Bedside ultrasound will show pericardial effusion and tamponade

Tamponade

* Multiple etiologies* Rupture of ventricle (see above)* Pericarditis* Becks Triad* Jugular vein distension* Muffled heart sounds* Hypotension* Diagnosed with bedside ultrasound* Treatment is pericardiocentesis

Heart Failure

* Occurs in approximately 1/3 post-MI patients* Leads to cardiogenic shock* Treatment* Fluid bolus* Vasopressors (esp. norepinephrine)* Inotropes (milrinone, dobutimine)* Left ventricular assist devices* Intra-aortic balloon pumps

Valve Failure/Rupture

* Rapid decompensation (similar to ventricular wall rupture)* PLUS* New heart murmur* Surgical emergency

Aneurysm

* A classic STEMI mimic* Large Q waves with ST segment elevation (IN ASYMPTOMATIC PATIENT)

Dresslers Syndrome/Pericarditis

* Rule out cardiac tamponade* Treatment* NSAIDS/colchicine

Embolism

* Occur in damaged ventricles and in cardiac aneurysms* Require anticoagulation

Recurrence

* Emphasize lifestyle management

Additional Reading

* Approach to STEMI (EM Clerkship)

t→ Episode Summary

My original source for this episode was the MDCalc tPA contraindication guidelines which are based off older recommendations (2015). Stroke guidelines and tPA contraindications have changed and are rapidly changing. Always follow the most up to date AHA/ASA guidelines or your institutional protocol, as much of this information may be outdated.

Introduction

* tPA is one of the core treatments for acute ischemic stroke* The history of tPA is filled with controversy* Mechanism* Activates plasminogen to plasmin* Plasmin breaks down fibrin

Contraindications to tPA

* Objective contraindications* Hypoglycemia* Blood pressure (>185/110)* Hemorrhagic CVA seen on head CT* Other common contraindications* Mnemonic: ABCDE* A– History of Aneurysm, AVMs (or other intracranial structural problems)* B– Actively Bleeding* C– IntraCranial injuries (trauma, surgery, or strokes) within last 3 months* D– Bleeding Diasthesis (blood thinners, abnormal coagulation panels, clotting disorders)* E– Endocarditis* Relative Contraindications (Discuss with neurology)* Minimal or resolving symptoms* Recent surgery or major trauma* Seizure* Recent lumbar puncture* Pregnancy* Active pericarditis* 3-4.5 Hour Contraindication Addons* A- Age >80* B- Bad Stroke (NIH >25)* C- CT shows multilobar stroke* D- Bleeding diasthesis (even if coagulation studies normal)* E- Ever had old stroke or diabetes

Additional Reading

* tPA Contraindications for Ischemic Stoke (MDCalc)* 2018 Stroke Management Guidelines (AHA/ASA)

I→ Episode Summary

Sepsis guidelines are constantly changing. Refer to your national guidelines or institutional protocol for most up to date treatment information.

Introduction

* Sepsis is bad and needs to be treated aggressively* Confusion around multiple conflicting guidelines and requirements* Surviving Sepsis Campaign recommendations* CMS requirements* Sepsis-3* SOFA/SIRS/qSOFA* Institutional protocols

Sepsis-3 Proposed Recommendations

* Screen for sepsis by applying qSOFA instead of SIRS criteria* qSOFA criteria* Altered mental status* Tachypnea* Hypotension* SIRS criteria* Tachycardia* Tachypnea* Leukocytosis* Hyper/hypothermia* qSOFA criteria miss cases of sepsis (too specific)* SIRS calls everything “sepsis” even if the patient is fine (too sensitive)* Change definition of “Sepsis” (no more SIRS plus source)* New definition* Source of infection* PLUS* Organ disfunction* Determined by SOFA score (different purpose than qSOFA)* Eliminate the term “severe sepsis” completely* Redefine “septic shock”* Persistent hypotension* OR * Lactic acid >4

Current Approach to Sepsis

* Step 1- If the patient has SIRS plus source* Get labs including a lactic acid* Step 2- If the patient has organ dysfunction* Diagnose sepsis* Step 3- If the patient has sepsis* Order broad spectrum antibiotics* Order blood cultures* Needs to be completed in <3 hours* Step 4- If the patient has persistent hypotension or lactate >4* Diagnose septic shock* Step 5- If they have septic shock* Give 30ml/kg crystalloid bolus* Start vasopressers if hypotension doesn’t improve with bolus

Additional Reading

* CMS Sepsis Core Measures (ACEP)* Sepsis-3 Recommendations (EMJ)* Surviving Sepsis Campaign (SCCM)