Benzos, Bleeding, Burns. Case Conference Review, November 8, 2017


Welcome back to another edition of Case Conference Review here at Academic Medicine Pearls at THE Ohio State University! Old Man Adams starts us off with a 38-year-old male with known history of alcohol abuse presenting via EMS for suspected EtOH withdrawal. On walking into the room, Dr. Adams is greeted with choice expletives and the subsequently refuses any vitals or to participate in the examination. The patient then promptly starts to seize, sending Dr. Adams down his alcoholic withdrawal seizure pathway.

To treat the alcoholic withdrawal seizure, he recommends the following simple piece of advise: “Benzos, benzos, benzos.”

His initial treatment of choice is Ativan 4mg. If that doesn’t work, repeat it. Keep in mind that Ativan (and oxazepam) are also safe benzo choices for cirrhotic patients. Should the seizures be refractory to initial measures and status epilepticus is achieved, intubation may be necessary. RSI should be done using versed or propofol for their GABAnergic effects and your choice of paralytic. Dr. Aziz adds that you may require higher doses of versed than the standard 0.3mg/kg dosing given chronic alcohol abuse.

Other options for seizure control? Propofol and phenobarbital are both good options if benzos fail, with ketamine as a consideration as well. “What about phosphenytoin?” one resident asks. While this is a common secondary agent in any seizure algorithm, it will not be effective in the alcohol seizure. The reason for this lies in the neurotransmitters affected by chronic alcohol use. Withdrawal seizures are caused by reduced GABAnergic and increased glutaminergic activity, on which phenytoin will have no effect, but benzos and barbituates will.

Further workup for this patient should include a head CT and also an EEG if paralyzed. Dr. Rublee reminds us that if suspicious for Wernicke’s, the treatment dose of thiamine is 500mg TID for three days, which Dr. Aziz reminds us should be given IV if possible due to an absorption of only 50% orally.

Dr. Nagaraj then takes us to into procedure land with her patient presenting with headache, fever and maculopapular rash (Figure 1) suspicious for meningococcal meningitis. She asks the question, “When is a lumbar puncture safe in the anticoagulated patient?”

Unfortunately, clear guidelines are not available, though there does exist some information to help us make informed decisions.

When it comes to Coumadin, An INR > 1.4 is considered a relative contraindication. It is recommended to hold Coumadin for five days prior to performing an LP. What if you don’t have five days? Should we give PCC? Dr. Nagaraj comments on a retrospective study that addresses this. PCC can be safely used to reduce INR <1.5 within roughly two hours, creating a safe environment for LP from a bleeding standpoint. In this study, however, thromboembolic events occurred in 6% of patients who received PCC (PCC has 2% established acceptable thromboembolic event rate). While its use in hemorrhaging patients has long been established to be beneficial, its usage in nonemergent scenarios remains unclear.

Information on LPs in patients with NOACs is similarly unclear, with no guidelines in existence. LPs are commonly performed within 24h of a patient’s last dose of a NOAC. Anticoagulation is considered fully resolved after five half-lives have passed for a given drug

Half-lives for NOACs

  • Pradaxa – 3 days
  • Xarelto – 1.5 days
  • Eliquis – 2.25 days

What about low platelet counts? In one study of cancer patients, 199 LPs were performed on patients with platelet counts of 20,000/μL or less, and 742 LPs were performed with platelet counts between 21,000/μL and 50,00/μL, without any cases of major bleeding.

Bottom line: Consistent guidelines do not exist for LPs in patients at risk for bleeding. Use risks and benefit analysis to determine necessity of LP in these patients. Keep in mind that to date, there are only 35 case reports of iatrogenic spinal hematoma in the past 40 years.

Dr. Krystin Miller is up next, with a 33 year-old male who presents with burns to face and upper extremities after a can of PAM explodes after being set next to a hot grill. She started with IV, O2, monitor and ABCs, though had to use a lower extremity for her blood pressure cuff due to burns. She then walks us through standard management.

She reminds us that the first step is stabilization. She offers us the following tips:

  • Remember to check to oropharynx for any singed tissue or swelling. Also listen carefully for stridor, wheezing or any other signs of airway compromise. Intubation should be done early so as to decrease chance of a difficult airway due to swelling.
  • Don’t forget adequate pain control
  • For extremities, it is important to get a good neurovascular exam, especially in cases of circumferential burns that can lead to swelling and neurovascular compromise requiring
  • Cover the burns. Use saline moistened gauze (or dry with adaptic). Sterile drapes may be used for large burns
  • Update tetanus
  • Nutrition is important due to high protein losses with burns and large amount of tissue rebuilding that will take place.

Once stabilization has been completed, appropriate fluid administration must be initiated. The first step is calculating the total body surface area (TBSA) that sustained 2nd or 3rd degree burns. This is done using the “Rule of 9’s,” as seen in Figure 1.

Classification of burns goes according to the following scheme:

First degree: Superfiical, epidermis only. Think sunburns.

Second degree: Epidermis and part of the dermis. Blisters may be present and the wound is very painful.

Third degree: Entire epidermis and dermis are involved. Wound may appear charred, leathery and pale. This should be painless and nerve fibers in dermis have been destroyed.

Once you have the TBSA calculated, you can then use the Parkland Formula to determine fluid administration volumes.

Total fluid to be given within first 24 hours = TBSA x weight (kg) x 4mL

Recommendations are to give one half of this total within the first 8 hours and the rest during the subsequent 16 hours. Due to the large volume being administered, we recommend using lactated ringer’s instead of normal saline to prevent the development of hyperchloremic metabolic acidosis.