Case Conference Summary, October 11, 2017

Some rapid fire review of cases presented by our residents this week:

Leslie Adrian presented a pediatric case with a young male complaining of abdominal pain after sustaining a handle bar injury to the abdomen after falling off his bike.  Initial vital signs showed tachycardia and age adjusted hypotension.  He had RUQ abdominal pain on examination and a FAST was positive.  He was stable enough for CT scan which showed a large liver laceration and ultimately taken to the OR for definitive management.  She did an excellent job of reviewing the literature on management of blunt pediatric abdominal trauma.  In particular, management has changed dramatically recently, with hemodynamic and clinical status guiding management of solid organ injury versus grade of injury.  In particular, for blunt liver trauma the following algorithm applies:

  • Hemodynamically unstable patient or with signs of peritonitis = OR
  • Hemodynamically stable patient = abdominal CT versus labs and serial exams
    • Stable + “blush” = consider angiography
    • Stable without blush and no peritoneal signs = non-operative management, serial exams and labs
      • Non-operative management should only be provided in an environment that provides appropriate monitoring and an OR

Grace Rodriguez discussed management of suspected upper GI bleeding.  In particular, in patient’s with cirrhosis with or without known varices considering broadening management with the following:

  • Close hemodynamic monitoring
  • Resuscitate:
    • Hb goal >7
    • Platelet goal >50,000
    • Correct coagulopathies
      • Coumadin, DOAC – consider vitamin K (especially in cirrhotics), PCC or FFP
      • Remember that the INR in cirrhosis does not correlate with underlying coagulopathy
        • Consider TEG to guide management
        • Check a fibrinogen
          • Consider cryoprecipitate to maintain fibrinogen level >150-200
          • Consider tranexamic acid if hyperfibrinolysis is suspected
    • Ovoid over resuscitation, especially with crystalloids to prevent worsening bleeding
  • Administer a PPI
    • No mortality benefit but may prevent rebleeding
    • Bolus dosing non-inferior to bolus and an infusion
  • Give a third-generation cephalosporin (i.e ceftriaxone) if they have cirrhosis
    • Mortality benefit
    • Treats underlying precipitant (i.e. SBP) of variceal bleeding
  • Consider octreotide
    • No mortality benefit
    • Decreases transfusion requirement
  • Consult GI
  • Intubate for airway protection if massive bleeding

Other considerations we can utilize in our hospital’s clinical guidelines include the modified Glasgow-Blatchford Score to discharge low-risk risk patients with a score of zero (no GI bleeding mortality at 6 month follow-up).

Lalitha Kunduru presented the management of superficial venous thrombosis, which most commonly occurs in the long saphenous vein (50-60%), short saphenous vein (11-15%) and tributaries of both (30-40%).  Risks for complication include being male, a history of VTE, cancer, recent surgery, involvement above the knee, SVT in non-varicose veins, thrombosis >5 cm and thrombosis involving the saphenofemoral junction.  Importantly, the rate of concomitant DVT is 25% and PE is 5%, which must remain on the differential.   The CALISTO Study Group and other sources recommend consideration for anticoagulation, especially for thrombosis >5 cm or within 5 cm of the saphenofemoral or saphenopopliteal junction.  Recommended medications include fondaparinux at 2.5 mg SQ daily, lovenox at 40 mg SQ daily, or a DOAC.  Otherwise, patients should be followed closely as an outpatient for progression and managed with NSAIDs and compression stockings (20-30 mmHg).

Finally, a case of angioedema was presented which reviewed some of the current literature in how to manage.  If anaphylaxis is suspected or considered, IM epinephrine, H1/H2 blockade, and steroids might be considered.  However, these treatments are unlikely to be successful in hereditary or ACE inhibitor induced angioedema.  While hope was given to icatibant as a potential treatment option, studies have not shown great benefit, and it’s pretty pricey.  Less expensive options include consideration for FFP, which may show benefit but is poorly studied.  Factor replacement with C1 esterase inhibitor is first line in patients with hereditary angioedema.  If the airway looks eminent or worsening, intubate early!  If stable, observation for 4-6 hours is appropriate and if swelling is isolated or improving consider discharge.  ED work-up is often limited, but consider checking a C4 level to screen for hereditary angioedema if suspected and if you have the resources.  If low, send off a C1INH protein level for outpatient follow-up.

Lastly, we reviewed a recent EM:Rap topic on the reasons we intubate which we really liked and is easy to remember – ABCDEF!

  • Airway – obstruction (i.e. FB, angioedema, etc.)
  • Breathing – not oxygenating (type 1 respiratory failure), not ventilating (type 2 respiratory failure)
  • Circulation – shock with impending respiratory failure (type 4 respiratory failure)
  • Disability – altered mental status (i.e. airway protection)
  • Expected course – anticipated worsening of ABC or D
  • Feral – when your patient is that altered and combative either from intoxication or trauma that you can’t get the studies you need to do to rule out life threatening illness.