Dr. Satyanarayana
Dr. Satyanarayana
Dr. Paul Atkinson
Edited by Dr David Lewis
A 70yr old male presents with a typical zoster rash in the left L1 dermatome. He has a past medical history of chronic renal insufficiency. He is started on Valacyclovir 1000mg TID. He represents 3 days later with hallucinations including a feeling that he was occupying a dead body. What is the differential diagnosis?
VZV and antiviral toxicity can present with similar symptoms
Two main risk factors increase the risk for VZV
The main risk factor for antiviral toxicity is renal insufficiency
Differentiation
Cotard’s Syndrome
“le délire des négations”
(delirium of negation)
https://en.wikipedia.org/wiki/Cotard_delusion
Further Reading
Varicella Zoster Encephalitis case report and outline
Valacyclovir Toxicity case report and outline
Drug Dosing in Chronic Kidney Disease
A 28yr old female presents pain, redness and swelling over the right thigh. She has a past medical history of type 2 diabetes. She is managed as an outpatient with intravenous ceftriaxone q24hrs. Her symptoms failed to respond on follow up. What is the concern now? Are there any red flags? What condition needs to be considered in patients with soft tissue infections that fail to respond to antibiotics?
NSTI first described by Hippocrates 5th century BC
“[m]any were attacked by the erysipelas all over the body when the exciting cause was a trivial accident…flesh, sinews, and bones fell away in large quantities…there were many deaths.”
Necrotizing fasciitis is characterized by rapid destruction of tissue, systemic toxicity, and, if not treated aggressively, gross morbidity and mortality. Early diagnosis and aggressive surgical treatment reduces risk; however, it is often difficult to diagnose NF, and sometimes patients are treated for simple cellulitis until they rapidly deteriorate.
Infection typically spreads along the muscle fascia due to its relatively poor blood supply; muscle tissue is initially spared because of its generous blood supply.
Infection requires inoculation of the pathogen into the subcutaneous tissue or via hematogenous spread.
Classification
Early signs and symptoms of NSTI are often identical to those seen with cellulitis or abscesses potentially making the correct diagnosis difficult
‘Classic’ Signs / Symptoms
(1) the presence of bullae
(2) skin ecchymosis that precedes skin necrosis
(3) crepitus
(4) cutaneous anesthesia
(5) pain out of proportion to examination
(6) edema that extends beyond the skin erythema
(7) systemic toxicity
(8) progression of infection despite antibiotic therapy or rapid progression
First 4 are “hard” signs
Streaking lymphangitis favours the diagnosis of cellulitis over necrotizing fasciitis
Diagnosis
PoCUS
Diagnosis of Necrotizing Faciitis with Bedside Ultrasound: the STAFF Exam
Findings – “STAFF”
ST – subcutaneous thickening
A – air
FF – fascial fluid
Ultrasound video demonstrating Subcutaneous Thickening, Air, and Fascial Fluid (STAFF).
Soft tissue ultrasound findings are significantly different when compared to normal soft tissue ultrasound
Bottom Line: Limited data, but basically PoCUS is not sufficient to rule-in or rule out, but might be helpful in raising suspicion level for necrotising fasciitis for physicians who routinely scan all soft tissue infections.
LRINF Score
Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) Score. 2004, retrospective – score >6 negative predictive value of 96.0% and a positive predictive value of 92%.
A validation study looking only at patients with pathology-confirmed necrotizing fasciitis showed that a LRINEC score cutoff of 6 points for necrotizing fasciitis only had a sensitivity of 59.2% and a specificity of 83.8%, yielding a PPV of 37.9% and NPV of 92.5%. However, the study did show that severe cellulitis had a LRINEC Sscore ≥ 6 points only 16.2% of the time. Therefore, the available evidence suggests that the LRINEC score should not be used to rule-out NSTI.
Bottom Line: Doesn’t rule-out…… or rule-in
Suggested Algorithm – UpToDate
EM Cases Review
Further Reading
Necrotizing fasciitis – Can Fam Physician. 2009 Oct; 55(10): 981–987.
A 40yr old female presents with left leg weakness. She has a complex recent past medical history including recently diagnosed pneumonia, previous renal colic and type 2 diabetes. Could this be a stroke? What are the other causes of leg weakness? How does the examination differentiate UMN from LMN lesions? When considering a diagnosis of epidural abscess what investigation is required? How soon should it be performed?
Only 4% of Strokes present with isolated or predominant leg weakness. (Brain. 1994 Apr;117 ( Pt 2):347-54.
doi: 10.1093/brain/117.2.347)
Common mechanisms of weakness:
Full review on Muscle Weakness from the Merck Manual here
Weakness that becomes severe within minutes or less is usually caused by severe trauma or stroke; in stroke, weakness is usually unilateral and can be mild or severe. Sudden weakness, numbness, and severe pain localized to a limb are more likely caused by local arterial occlusion and limb ischemia, which can be differentiated by vascular assessment (eg, pulse, color, temperature, capillary refill, differences in Doppler-measured limb BPs). Spinal cord compression can also cause paralysis that evolves over minutes (but usually over hours or days) and is readily distinguished by incontinence and clinical findings of a discrete cord sensory and motor level.
Unilateral upper motor neuron signs (spasticity, hyperreflexia, extensor plantar response) and weakness involving an arm and a leg on the same side of the body: A contralateral hemispheric lesion, most often a stroke
Upper or lower motor neuron signs (or both) plus loss of sensation below a segmental spinal cord level and loss of bowel or bladder control (or both): A spinal cord lesion
Spinal epidural abscess (SEA) is a severe pyogenic infection of the epidural space that leads to devastating neurological deficits and may be fatal. SEA is usually located in the thoracic and lumbar parts of the vertebral column and injures the spine by direct compression or local ischemia. Spinal injury may be prevented if surgical and medical interventions are implemented early. The diagnosis is difficult, because clinical symptoms are not specific and can mimic many benign conditions. The classical triad of symptoms includes back pain, fever and neurological deterioration.
Spinal Epidural Abscess: Common Symptoms of an Emergency Condition – A Case Report
Further Reading
Edited by Dr David Lewis
A patient presents with recurrent seizures. They have a past medical history of schizophrenia and mental health delay. Following appropriate ED management with complete resolution of seizures and full recovery of the patient – what is the recommended disposition?
Seizure disorder is a common presentation to the Emergency Department. This EM Cases post provides an excellent summary for the ED approach to resolved seizures:
ED approach to resolved seizures – Summary pdf
In this study – Ethanol withdrawal or low antiepileptic drug levels were implicated as contributing factors in 177 (49%) of patients. New‐onset seizures were thought to be present in 94 (26%) patients. Status epilepticus occurred in only 21 (6%) patients.
73% of patients were discharged.
Most authors recommend admission for patients presenting with FIRST Seizure Episode. Patients with a past medical history of recurrent seizure disorder are more likely to be discharged than admitted.
However – this EBMedicine article cites an incidence of 19% seizure recurrence rate within 24 hours of presentation, which decreased to 9% if patients with alcohol related events or focal lesions on CT were excluded. They suggest, that at present, there is insufficient evidence to guide the decision to admit. They recommend this decision be tailored to the patient, taking into consideration the patient’s access to follow-up care and social risk factors (eg, alcoholism or lack of health insurance). Patients with comorbidities, including age > 60 years, known cardiovascular disease, history of cancer, or history of immunocompromise, should be considered for admission to the hospital.
Considerations For Safety On Discharge
Patients and their families should be counseled and instructed on basic safety measures to prevent complications (such as trauma) during seizures. For example, patients should be advised to avoid swimming or cycling following a seizure, at least until they have been reassessed by their neurologist and their antiepileptic therapy optimized, if needed. A particularly important point for seizure patients is education against driving. Although evidence remains controversial on this issue, there is general agreement that uncontrolled epileptic patients who drive are at risk for a motor vehicle crash, with potential injury or death to themselves and others. For this reason, most states do not allow these patients to drive unless they have been seizure-free on medications for 1 year. According to population survey data, 0.01% to 0.1% of all motor vehicle crashes are attributable to seizures
A young female patient with a history of polysubstance drug abuse presents with a psychotic episode. She refuses treatment. What are the competency and capacity implications? She is also pregnant. Does this change the the competency and capacity implications?
This LitFL post provides and excellent outline for Competency and Capacity in the ED:
This article published by the RCPSC provides a useful outline from a Canadian perspective – with the following objectives.
Recommendations from the American College of Obstetricians and Gynecologists
On the basis of the principles outlined in this Committee Opinion, the American College of Obstetricians and Gynecologists (the College) makes the following recommendations:
Further Reading:
How Do I Determine if My Patient has Decision-Making Capacity?
A 12 year old boy presents with scrotal discomfort in the early hours of the morning. The department is very busy and the waiting time to be seen is 4 hours. What triage category is this presenting complaint? If a diagnosis of torsion is considered, how quickly should definitive management be initiated?
Ramachandra et al. demonstrated through multivariate analysis of the factors associated with testicular salvage, that duration of symptoms of less than 6 h was a significant predictor of testicular salvage. They found that the median duration of pain was significantly longer in patients who underwent orchiectomy versus orchidopexy. Similar findings were seen with respect to time to operating room from initial presentation. They concluded that time to presentation is in fact the most important factor in determining salvageability of the testicle in testicular torsion. If surgical exploration is delayed, testicular atrophy will occur by 6 to 8 h, with necrosis ensuing within 8 to 10 h of initial presentation. Salvage rates of over 90% are seen when surgical exploration is performed within 6 h of the onset of symptoms, decreasing to 50% when symptoms last beyond 12 h. The chance of testicular salvage is less than 10%, when symptoms have been present for over 24 h
Factors influencing rate of testicular salvage in acute testicular torsion at a tertiary pediatric center.
Ramachandra P, Palazzi KL, Holmes NM, Marietti S
[PubMed]
This study (Howe et al). confirmed the relationship between duration of torsion and testicle viability and also found a relationship between the degree of torsion
AAFP Review of Testicular Torsion: Diagnosis, Evaluation, and Management
Reviewed and Edited by Dr. David Lewis
All case histories are illustrative and not based on any individual
A 48-year-old female was brought to the emergency department by EMS after developing dystonia that morning, a couple hours earlier, following a restless night. The dystonia had begun affecting her arms, torso and buccal region, but eventually moved to also involve her legs. She had a history of recurrent tardive dyskinesia for the past 20 years since taking stelazine and developing tardive dystonia. She was switched to olanzopine after developing dystonia and stayed on it until two months ago. Her citalopram and clozapam dosing had been increased two weeks ago, and she had also started Gingko biloba extract two weeks ago. She had started Nuplazid 3 days ago.
Upon exam she was diaphoretic with no other abnormal findings other than dystonia affecting the entire body.
Drug | Starting Dose Recommendations | Dose Range |
1st Line | ||
Tetrabenazine | 12.5-25 mg UID | 25-200 mg UID |
Other options | ||
Dextromethorphan | Under 1 mg/kg | Not exceeding 42 mg UID |
Valbenazine | 40 mg UID | Increase to 80 mg after 1 week |
Amantadine | 100 mg UID | 100-300 mg UID |
Clonazepam | 0.5 mg | 0.5-4.0 mg UID |
Diphenhydramine | 25 mg IV | 25-50 mg IV |
Botulinum toxin injection | local injection to treat specific painful dystonia resistant to systemic therapy |
The patient was given 2mg of Benztropine IV with no effect. Twenty minutes later he was then given 1mg of Ativan SL with no effect. Thirty minutes later the patient was given 150 mg Benadryl IV, and some improvement was then witnessed, the patient was allowed to sleep and was discharged approximately 5 hours after his arrival with no symptoms.