Indications of Steroids in Emergency Department

Steroids 

Steroids are a commonly used group of medications in the Emergency Departments. There are plenty of indications to use them, some remain controversial while others are widely accepted. Most side effects result from long-term usage but its worth having a discussion with the patient when prescribing steroids to take away. 

Mechanism of Action

• Steroids work by reducing the production of leukotrienes and prostaglandins 
• Inhibits phospholipase A2 and expression of COX-2
• Stimulate the bone marrow to produce neutrophils resulting in leukocytosis\
• Halting inflammatory cascade

https://step1.medbullets.com/endocrine/109043/glucocorticoids

Potential Side Effects of Steroids 

• Impair immunity
• Hyperglycemia
• Hypertension
• GI Ulcers
• Delay Wound Healing
• Increase Risk for Cardiovascular diseases 
• Weight gain
• Osteoporosis
• Myopathy
• Avascular Necrosis
• Depression/Mood changes

Tapering is not generally needed for short courses (up to 2 weeks)

Indications (Not an exhaustive list)

• Intracranial SOL
• Strep Pnemo Meningitis
• Pharyngitis (steroids did decrease the duration of symptoms by about 24-48 hours.)
• Asthma/COPD
• Allergic Reactions
• Connective Tissue Flare 
• Bells Palsy 
• Gout
• ?Headache (Steroids prevent recurrence)
• Septic Shock
• Temporal Arteritis 
• Addisons Crisis (Hypoadrenal Shock)
• ?Pnemonia 
• ?Back Pain in selected patients 

Take Home

• Discuss pros and cons of prescribing steroids
• Short courses from ED do not require tapering 

Posted by:

              

     Lakshay Chanana

     

     ST4 Trainee

     Royal Infirmary of Edinburgh

     Department of Emergency Medicine

     Edinburgh

     Scotland

     @EMDidactic

Diplopia - ED evaluation

Primary eye disorders or systemic diseases presenting as ophthalmologic complaints may present to the Emergency Department especially when symptoms are acute in onset. Diplopia is one such complaint which we might come across in ED. 

Key Questions when evaluating diplopia:
1. Is it Monocular or Binocular Diplopia?

• Monocular Diplopia - Eye Problem (cataract irregularities, lens displacement, or primary problems with the corneal curvature such as keratoconus.)
• Binocular Diplopia (Common) - Likely Neuro Problem (3,4,6 Nerve lesions, Grave's eye Disease, Myasthenia gravis, Orbital Myositis)

2.  Does the degree of diplopia change with direction of gaze and/or head position?  (Determines whether deficit related to cranial nerve innervation)

3. Is the diplopia horizontal or vertical?  

(Horizontal diplopia suggests cranial nerve III or VI deficit (i.e. lateral gaze function); vertical diplopia suggests cranial nerve IV deficit (i.e. elevator/depressor gaze function).

4. Associated pain? (Suggests possible foreign body or extraocular muscle entrapment).

5. Associated trauma? (Blow-out fractures can be associated with diplopia).

6. Associated weakness, headache, confusion, or dizziness?  (Imaging usually indicated to rule out intracranial processes such as stroke or increased intracranial pressure).

3rd Nerve palsy

• Supplies most of the EOM
• Lesion results in Down and out deviation of eyeball, Ptosis due to levator palpebrae paralysis and Ptosis due to damage to parasympathetic pupil-constrictor fibers from the Edinger-Westphal nucleus

Most third nerve palsies are caused by ischemic events due to hypertension or diabetes. 

Pupillary involvement is a crucial diagnostic sign -- compressive lesions tend to involve the pupil, while vascular lesions might actually spare it! This is due to the fact that the parasympathetic nerves course along the surface of the oculomotor nerve making them susceptible to compressive lesions from the outside whereas ischemic lesions occur deeper within the oculomotor nerve and thus spare the superficial parasympathetic fibers.


4th Nerve Palsy

• Difficult to diagnose
• Innervates Superior Oblique muscle
• These patients have an upward deviation of the affected eye with a tilt their head away from the lesion
• Possible Causes include Trauma, ischemia, congenital lesions, malignancy

6th Nerve Palsy

• Supplies the lateral rectus muscle
• Loss of function renders the eye unable to abduct (turn out). 
• Patients go cross-eyed, so to compensate they may turn their head to avoid double vision.
• Susceptible to high intracranial pressures.e.g. pseudotumor cerebri 

Table from Rosen's EM Textbook - Causes of Diplopia

Take Home

• Differentiate betweekn monocular and binocular diplopia is the key
• Think compressive causes e.g. P Comm Aneurysm with a dilated pupil (3N palsy)

Posted by:

              

     Lakshay Chanana

     

     ST4 Trainee

     Royal Infirmary of Edinburgh

     Department of Emergency Medicine

     Edinburgh

     Scotland

     @EMDidactic

Can we rule out appendicitis with a low ALVARADO score?

Abdominal pain is a common ED presentation and one of the top differential for RLQ pain is Acute Appendicitis. Early in the course, examination findings are often subtle and bloods may not show a raised WCC or CRP. One way to further risk stratify patients is by using 
the Alvarado score or the Modified Alvarado Score.

The original Alvarado score was on a 10 point scale. It has been modified to exclude criteria of a left shift. The sensitivity of the Alvarado score is about 72% and the specificity is 54% and like any other decision rule, this is not flawless. Relying solely on the score may miss about a third of patients with Appendicitis. Since multiple organ systems are represented in the abdomen, it is hard to create a clinical decision rule which can precisely identify the diagnosis. 

Additionally, using this score in females can be tricky due to possible OBGYN pathologies. 

Bottomline

• Use your clinical acumen and utilize Alvarado score only as an adjunct.
• Use Alvarado Score as more of a "rule-in' test, not "rule-out" test. 
• It is worth doing and documenting serial abdomen exams in non-specific abdo pains. d/w Surgical in-patient teams for possible admission for observation rather than directly jumping to imaging. 
• If discharging, give strong worsening statements and explain uncertainty about the diagnosis and need for review if symptoms change. 

References

1. Meltzer AC, Baumann BM, Chen EH, Shofer FS, Mills AM. Poor sensitivity of a modified Alvarado score in adults with suspected appendicitis. Annals of emergency medicine. 2013 Aug 1;62(2):126-31.
2. Ohle R, O'Reilly F, O'Brien KK, Fahey T, Dimitrov BD. The Alvarado score for predicting acute appendicitis: a systematic review. BMC medicine. 2011 Dec;9(1):139.

Posted by:

              

     Lakshay Chanana

     

     ST4 Trainee

     Royal Infirmary of Edinburgh

     Department of Emergency Medicine

     Edinburgh

     Scotland

     @EMDidactic

Utility of CRP in Emergency Departments

C-reactive protein (CRP) is an acute phase protein synthesized in the liver. It is commonly used in Emergency Departments, especially in febrile and possibly infectious patients. It is also used as a measure of tissue inflammation, a biomarker of disease activity and a prognostic tool of many acute and chronic diseases. CRP functions as a bacterial opsonin, promoting phagocytosis, accelerating chemotaxis, and activating platelets. Normal levels increase with aging. Other possible reasons for higher levels could be:

• Pregnancy
• Coronary Artery Disease
• Viral Infections (10–40 mg/L)
• Bacterial infection (>40mg/dL)
• Malignancy, Obstructive Sleep Apnea, Connective Tissue Disorders

Serial CRP measurements may be helpful to monitor a patient’s response to medical intervention. Although CRP rises with tissue injury or ischemia, in septic patients with fulminant hepatic failure, it is more to be a marker of severe liver dysfunction rather than be used as a marker of infection.

Utility of CRP

1. ACS and Aortic Dissection - For ACS and Dissection, the higher CRP levels, the worse prognosis. It is not used to diagnose ACS/Dissection. Increased CRP levels were independently associated with mortality. 

2. Meningitis - For meningitis, CRP plays a role of distinguishing bacteria from non-bacteria etiology infection.

3. CRP in Acute Abdomen pain
CRP cannot play a suitable role in the diagnosis of cholecystitis but can be a factor indicating the severity of cholecystitis and response to therapy. A normal CRP along with a normal WBC count and a normal neutrophil count is unlikely to be a case of appendicitis. Although early in the course of appendicitis, the white blood cell (WBC) count has shown the best diagnostic sensitivity among laboratory tests, there are 21% of appendicitis is normal levels of WBC count before appendectomy. 

An elevated serum CRP concentration is not accurate in localizing the site of a urinary tract infection in girls who do not have clinical signs of acute pyelonephritis. 

There is no substitute for serial and prudent clinical examinations during an observation period for abdominal pain, especially the initial epigastric pain or peri-umbilical pain.

4. Pnemonia

For pneumonia, CRP plays the roles of prognosis prediction and therapy reflector rather than making diagnosis. CRP is an independent biomarker of severity in community-acquired pneumonia. 

5. Sepsis
Sepsis is a clinical diagnosis and CRP should never used be rule out infection. Procalcitonin has emerged as the most studied and promising sepsis biomarker. For diagnostic and prognostic purposes in critical care, PCT is superior to CRP and other traditional markers of sepsis.


Take Home

In the ED, CRP should not be used to make a diagnosis but to assist evaluation and support your clinical suspicion. In clinically unwell patients, a normal CRP level should never delay antibiotic coverage in ED.  Like other biomarkers, it does not stand alone. In admitted patinets or those on thepary for chronic inflammatory states, CRP can be used for treatment monitoring and severity. 

References

1. Su YJ. The value of C-reactive protein in emergency medicine. Journal of Acute Disease. 2014 Jan 1;3(1):1-5.
2. Rossi E. C-reactive protein and progressive atherosclerosis.Lancet 2002; 360(9344): 1436-1437.
3. Schillinger M, Domanovits H, Bayegan K, Hölzenbein T, Grabenwöger M, Thoenissen J, et al. C-reactive protein and mortality in patients with acute aortic disease. Intensive Care Med2002; 28(6): 740-745.

Posted by:

              

     Lakshay Chanana

     

     ST4 Trainee

     Royal Infirmary of Edinburgh

     Department of Emergency Medicine

     Edinburgh

     Scotland

     @EMDidactic

Wrist Block (Landmark Technique)

While a majority of injuries on hand can be managed by local infiltration of anesthetics, wrist nerve blocks may be required in instances such as diffuse lesions, deep lacerations, deep contaminated abrasions, hydrofluoric acid and thermal burns. Wrist blocks are also particularly useful when the injured extremity is swollen and local infiltration may lead to severe pain.  

Nerves at the level of the wrist are more easily accessible anatomically and can be blocked more reliably. All three nerves (Median, Radial, Ulnar) lie in the volar aspect of the wrist near easily palpated tendons. However, a full wrist block may have a slow and unreliable onset and can require more time to take effect. 

Right wricrossectionalonal view

1. Median Nerve

Location - Just below the palmaris longus (PL) tendon OR slightly radial to it between the PL and flexor carpi radialis (FCR) tendons. The nerve lies relatively superficially (1cm or less from skin) but deep to the fascia of the flexor retinaculum. 

PL tendon is located by having the patient make a fist with the wrist flexed against resistance. Use a 25-gauge needle and go perpendicular to the skin on the radial border of the palmaris longus tendon just proximal to the proximal wrist crease. Advance the needle slowly until a slight “pop” is felt as the needle penetrates the retinaculum. Inject 3 to 5 mL of anesthetic in the proximity of the nerve at a depth of 1 cm under the tendon.  

https://www.researchgate.net/figure/Peripheral-nerve-blocks-at-the-wrist-A-Median-nerve-block-B-Ulnar-nerve-block-C_fig2_320883196

Caveats - PL may be absent in up to 20% of patients, in which case you inject at about 1 cm in the ulnar direction from the FCR tendon. The superficial position of the median nerve at the wrist is a major cause of failure of this block as the anesthetic is often instilled too deep.

2. Radial Nerve

Nerve block of radial nerve requires an injection in close proximity to the artery and a field block that extends around the dorsal aspect of the wrist. Radial nerve follows the radial artery into the wrist but gives off sensory nerve branches proximal to the wrist. These branches wrap around the wrist and fan out to supply the dorsal and radial aspect of the hand.

Insert a 25-gauge needle and inject 2-5ml of LA immediately lateral to the palpable artery at the level of the proximal palmar crease. Inject another 5 to 6 mL of anesthetic subcutaneously from the initial point of injection to the dorsal midline. Withdraw the needle and reposition it to complete the block.

3. Ulnar NerveThe ulnar nerve follows the ulnar artery into the wrist, where they both lie deep to the flexor carpi ulnaris (FCU) tendon (The nerve lies between the tendon and the artery). The FCU tendon is palpated just proximal to the prominent pisiform bone by having the patient flex the wrist against resistance. 

Use a lateral approach to ulnar nerve block rather than volar approach due to risk of ulnar arterial puncture. Use a 25-gauge needle and inject on the ulnar aspect of the wrist at the proximal palmar crease and deposit a wheal of anesthetic horizontally under the flexor carpi ulnaris tendon. Then direct the needle toward the ulnar bone at a point deep to the flexor carpi ulnaris tendon and inject 3 to 5 mL of anesthetic solution as the needle is withdrawn. Block the dorsal cutaneous branches by subcutaneously injecting 5 to 6 mL of anesthetic from the lateral border of the flexor carpi ulnaris tendon to the dorsal midline. 

Images from:

Roberts and Hedges’ Clinical Procedures in Emergency Medicine

Posted by:

              

     Lakshay Chanana

     

     ST4 Trainee

     Royal Infirmary of Edinburgh

     Department of Emergency Medicine

     Edinburgh

     Scotland

     @EMDidactic