Pearls and Pitfalls in Emergency Medicine

Transcription

1 Pearls and Pitfalls in Emergency Medicine Medicine Evolves and So Do We Objectives Review updates in emergency medicine pertinent to the Primary Care practitioner Low Back Pain Syncope Disclosure No Financial Relationships to Disclose No significant investments or savings Unlimited Expenses Minor Head Injury on Anticoagulants/ Antiplatelet Agents 1

2 35 y.o. morbidly obese F presents with LBP Can t get out of the car because of severe pain - you send her to the ED She is treated with IV narcotics and muscle relaxants and discharged home with follow up by you the next day Today, she is feeling better than yesterday but still uncomfortable and moved from the car to your office in a wheelchair. She has had a low threshold for pain in the past, but no history similar to this. Hx: Endometriosis on OCPs, ½ PPD smoker PEx Neck supple Lungs clear Heart RR without murmur Abdomen soft, nontender Back no clear spinal tenderness Extremities no edema Neuro A+O x 3, moves all extremities, sensation grossly intact to light touch 2

3 Should this patient receive imaging? 60-90% have LBP in their lifetime 90-95% resolves in 2 mos., even with sciatica, regardless of treatment Therefore, it is not that important to distinguish sciatic from non sciatic back pain Most back pain occurs at L4, L5, S1 due to the curvature of the spine This is where most discs herniate Most uncomfortable in sitting position Causes of Functional LBP don t impact course or initial management Protruding Disc Muscle Spasm Facet Syndrome Vertebral Misalignment But I still want the MRI. 3

4 Pts < 60 yrs old Bulging disc: 33% Herniated disc: 20% Pts > 60 yrs old Degenerative changes: 100% Bulging disk: 80% Herniated disk: 33% Spinal stenosis: 20% Rapidly progressive neuro deficits Persistent Back pain in spite of 6 months duration and a trial of physical therapy In non-specific back pain, the purpose of MRI is to direct surgery or epidural injections Most helpful in trauma May pick up some tumors Indications: Trauma Age > 65 (50?) or <18 Duration > 6 weeks Indications: Suspected Epidural Abscess Suspected Cauda Equina syndrome Suspected Spinal Stenosis Intractable pain Rapidly progressive neuro deficit Pain for > 6 mos despite therapy 4

5 35 y.o. morbidly obese F with severe LBP Pt had a complete foot drop that was not recognized for several days Results of outpt MRI returned 5 days later - severe compression of L4-L5 foramen due to disc herniation Neurosurgery took patient emergently to surgery - several post op complications Assess for red flags Cancer Spinal Infection Cauda Equina Trauma osteoporosis, significant bony tenderness Non-spine causes Severe and progressive nerve root compression Assess duration of symptoms and previous imaging History of Cancer The posttest probability of cancer in patients presenting with back pain increases from approximately 0.7% to 9% in patients with a history of cancer Unexplained weight loss (PLR = 2.7) Failure to improve after 1 month (PLR = 3.0) Age older than 50 years ( PLR = 2.7) Fever Injection Drug Use Diabetes Immunosuppression Patients will not have spinal tenderness with epidural abscess! Deyo, JGIM,

6 Sensory/Motor deficits Bowel and Bladder Incontinence Saddle anesthesia Osteoporosis Spare the narcotics with inhaled Salmon Calcitonin Remember to check a rectal exam Aortic dissection Abdominal Aortic Aneurysm Pyelonephritis Pancreatitis Duodenal Ulcer Document the peripheral exam for the 3 commonly involved nerve roots 6

7 Major Risk Factors for or Signs/Symptoms of Cancer Spinal Infection Cauda Equina Severe or Progressive Neuro Deficits ACP Guidelines Chou, Ann IM,

8 Minor Risk Factors for Cancer Inflammatory Back Disease Vertebral Compression Fracture Radiculopathy Spinal Stenosis ACP Guidelines Chou, Ann IM, 2007 Case #2 - Syncope Your first patient of the day is a 66 y.o. M brought by his wife to your office with a 1st episode of syncope 6 hours ago when he got up to pee at 3am. Minimal if any head trauma. ROS is negative. PMHx: Htn, DM, and Afib on coumadin PEx Looks great. No trauma except forehead abrasion. Neuro exam is normal. Syncope Do you need to obtain any further evaluation? Labs ECG CXR Head CT 8

9 Syncope Do you need to obtain any further evaluation? Labs probably reasonable to check INR ECG obtained and normal CXR probably not necessary without symptoms Head CT -? Syncope 2011 Guideline for Transient LOC Ann Intern Med, Sept 19, 2011 Online - National Institute for Health & Clinical Excellence Syncope - Recommendations ECG without further eval for uncomplicated faint, situational syncope, or orthostatic hypotension. Neuro eval for epilepsy. However, brief seizure activity is common during syncope - should not be regarded as epilepsy. Minor Head Trauma & Anticoagulants/Antiplatelet Agents NICE, July 2011 Reviewed whether patients on anticoagulant or anti-platelet Rx without amnesia or loss of consciousness after head injury should receive a head CT or MRI. Cardiology eval for suspected cardiac cause or if unexplained. 9

10 Minor Head Trauma & Anticoagulants/Antiplatelet Agents NICE, July 2011 Conflicting evidence in 15 potentially relevant studies. However, the harmful outcomes of intracranial hemorrhage are significant (i.e. death), and the risk of this subgroup of patients needs to be addressed in a guideline update. Minor Head Trauma - Coumadin Menditto, Ann EM, 2012 Structured protocol: Obs x 24 hrs with repeat Head CT for all patients on warfarin with minor head injury and initial normal Head CT. 5/87 had a new hemorrhage on repeat CT with 3 subsequently hospitalized and 1 receiving craniotomy! Minor Head Trauma - Clopidogrel Nishijima, Ann EM, warfarin pts and 296 clopidogrel pts with minor head trauma More pts on clopidogrel (12% vs 5%) had IC hemorrhage Delayed IC hemorrhage was rare (0.6%) and occurred only in pts receiving warfarin Case #2 Syncope Outcome 66 y.o. M on warfarin with possible micturition syncope Pt was sent to ED. INR = 3.5 Increasing INR (> 2.0) is increasing risk for IC hemorrhage Head CT was obtained and normal Discharged with careful follow up instructions 10

11 Case #3 - Syncope 26 y.o. M presents to your office with episode of syncope yesterday. Witnessed by girlfriend who made him come in. Had been drinking, but not that much. PEx unremarkable except chin bruise Syncope - Recommendations ECG without further eval for uncomplicated faint, situational syncope, or orthostatic hypotension. Neuro eval for epilepsy. However, brief seizure activity is common during syncope - should not be regarded as epilepsy. Cardiology eval for suspected cardiac cause or if unexplained. Case #3: 26 y.o M Syncope yesterday Brugada Long QT IHSS WPW 11

12 RBBB Pattern in leads V1-V3 ST elevation in leads V1-V3 AICD s decrease mortality by 50% Q-T Q-T R-R R-R 12

13 Normal QT = about ½ RR QT increases as rate slows - QTc doesn t change with rate change Abnl > 0.46 Remember to counsel family members for screening Watch for meds that prolong QT Causes Genetic QT duration and history of sudden death is most predictive Treat with Beta Blockers 30 y.o. M with syncope at soccer game 30 y.o. M with syncope at soccer game Kept in ED for 6 hours with serial troponins and ECGs Sent home and followed up with his PMD 3 months later with sudden death during pick up basketball game. 13

14 Hypertrophic Cardiomyopathy (HCM) HOCM (Hypertrophic obstructive cardiomyopathy) IHSS (Idiopathic hypertrophic subaortic stenosis) LVOT (Left ventricular outflow tract obstruction) Thickened myocardium without ventricular dilation without other causes such as hypertension or AS. Hypertrophy is usually asymmetric cardiomegaly not present on CXR Hypertrophic Cardiomyopathy ECG Findings High Voltage Deep narrow Q waves in the inferior or lateral leads Left Atrial Enlargement Other findings include Tall R wave in lead V1 Hypertrophic Cardiomyopathy 30 y.o. M with syncope at soccer game Diagnosis Echo Prognosis 1-3% mortality/year Treatment Beta blockers or Calcium channel blockers for symptoms AICD if high risk of sudden death 14

15 33 30 y.o. M w palps that go away when I cough 30 y.o. M w palpitations that go away when I cough WPW Short PR interval with Delta Wave Meatloaf and Marilyn Manson Prognosis Low Back Pain EP Lab Sudden death risk = 0.6% Treatment Summary - EM Pearls and Pitfalls Ablation vs Meds Avoid imaging Screen for cancer, infection, cauda equina, fracture, non-spine causes, rapidly progressive neuro deficits Syncope (Minor Head Trauma) Avoid neuro imaging Low threshold for neuro-imaging on AC/AP agents 15

16 Summary - EM Pearls and Pitfalls Syncope in the young apparently healthy person Brugada Long QT IHSS WPW 16