Case 12

22 year old female brought in semi-conscious by boyfriend.

BP 90/60, HR 150/min.
Hypocount : 5.2 mmol

10 minutes later she developed a generalized tonic-clonic seizure.

What does the ECG show?
What is the likely underlying cause?


Answer : Tricyclic Antidepressant (TCA) Overdose

The ECG shows a broad-complex tachycardia which raises the suspicion of a VT (ventricular tachycardia). This is unusual in a young female patient, as VT usually occurs in the setting of more elderly patients with underlying cardiac disease.

Involvement of the cardiovascular and neurological systems in a young patient who presents with in this manner (brought in by boyfriend) should alert us to the possibility of a drug-overdose, especially that of tricyclic antidepressants (TCA) such as amitriptyline.

Presenting features of TCA toxicity may include:

Cardiovascular : Palpitation, Chest pain,  Hypotension

CNS : Convulsion, Decrease mental status, Respiratory depression, Drowsiness, Coma

Peripheral autonomic system : Dry mouth, Dry skin, Urinary retention, Blurred vision

Treatment

·        ICU management

·        Support airway and vital signs

·        Activated charcoal for GI decontamination

·        IV Sodium Bicarbonate esp. in prolonged QRS

·        Benzodiazepines for seizures

·        Consider hemodialysis

Case 11

30 year old male

The 10th case of fever and sorethroat you've seen tonight. Why can't they come during the office hours ?!?!

Answer : Acute Epiglottitis

• taught in medical school under paediatrics, but is actually 2-3 times more common in adults
• common pathogen : Haemophilus influenzae, B-hemolytic strep
• classical presentation of drooling child with tripod stance may not be seen in adults, who commonly present with sorethroat, odynophagia, muffled voice
• unlike in children, emergent airway mx usually not an issue in adults due to larger diameter of airway; however be careful if there is stridor
• Xray - classical 'thumb sign'; FBC - white cell count > 10,000 in 80% of cases
• Management key : (1) Admit for close airway monitoring KIV intubation, (2) IV antibiotics (Ceftriaxone, Cefotaxime, Ampicillin/ Sulbactam). Steroids are commonly used but no randomised trials.
  

Case 10

20 year old Indian male construction foreign-talent brought into the A&E in semi-conscious state.

His worried colleagues claim that he has been lethargic for a few weeks, with episodes of abdominal pain and seems to have lost weight. They initially blamed it on him losing money at RWS.

BP 100/60, Temp 37.6
Groaning away
abdo : diffusely tender

UC9 : negative for WBC, blood, glucose or protein
Na 128, K 6.5, Urea 14, Bicarb 12.8 (all in mmol/l)

What is your diagnosis?

Answer : Addisonian crisis

• acute and life-threatening condition due to adrenal (cortisol and aldosterone) deficiency.
• most common cause : adrenal suppression due to long-term corticosteroid use with subsequent abrupt withdrawal or sudden exposure to increased stress (e.g. illness, injury, surgery etc).
• other causes : autoimmune adrenalitis (in developed countries), infections e.g. TB (developing countries), metastasis, heparin therapy

Clinical features (usually non-specific)

• Weakness, nausea, vomiting
• abdominal pain
• weight loss, loss of appetite
• increased pigmentation of skin and mucous membrane
• Inx : hyponatremia, hyperkalemia, metabolic acidosis, hypoglycemia, pre-renal azotemia
• Definitive tests such as the short and long Synacthen tests are usually not done at the level of the ED
  

Management

• High index of suspicion
• fluid resuscitation (dextrose saline preferable)
• IV Hydrocortisone 100 mg bolus (Hydrocort messes up the synacthen test so may consider using IV Dexamethasone 4 mg IV instead)
• Search for precipitating cause (e.g. sepsis, trauma, acute coronary syndrome etc)
• Admit to HD/ ICU under Endocrinologist for close monitoring and management
  

Case 9

30 year old female
Punched in the left eye after quarrel with boyfriend.
What is the diagnosis?
How would you manage this condition?

(P.S : ignore the radio-opaque artifact in the right orbit)

Answer : Blow-out Fracture


As shown above, a blow-out fracture results from a direct compressional force to the orbit, which results in increased intraorbiral pressure. The weakest part of the orbit is its inferomedial floor (lamina papyracea). The fracture may lead to the herniation of the orbital contents into the maxillary antrum.

Approach

1. As for all trauma cases, ensure ABCs are secure, esp. with respect to head injuries or cervical spine injuries that may require earlier attention than the orbital fracture.
2. Examine the affected eye to rule out urgent ocular injuries e.g. penetrating globe injury/ compressive orbital emphysema/ retrobulbar hemorrhage --> refer to Eye stat!
   
3. Test eye-movements to look for impingement on upward gaze (demonstrated in the clinical photograph above), which may suggest herniation and entrapment of extraocular muscle.
   
4. Test for infraorbital anesthesia - tap incisors on both sides to see if there's any difference in sensation.
   
5. Plain facial (OM view) X-rays to look for 'tear-drop' sign (suggestive of herniation into maxillary antrum and seen in X-ray above) and fluid-level/ opacification in affected maxillary antrum (likely to be bleeding in trauma setting).
6. Disposition - Refer to Plastics/ Eye. Consider antibiotics if there is evidence of blood in maxillary antrum.
7. Offer referral to counselling/ PSY in the setting of abuse. Document all findings carefully because this is a potential legal case and you may be asked to appear in court later.
   

Breaking Bad News at the A&E

A recent resuscitation case at the department prompted me to write this post.

Attending to collapse and resuscitation cases is something we are prepared to do as emergency doctors and nurses, but sometimes we may be too caught up with the medical situation (What is the cause of the collapse/ what drugs should I give/ Should I defibrillate etc) that we do not give enough thought to the anxious family members waiting outside the resus room. Managing them can be as difficult, if not more difficult, than managing the collapsed patient himself.

Throughout my career in emergency medicine I have had my fair share of resus cases. In some cases we manage to restore a rhythm and BP, but the majority of cases do not make it despite our best efforts. Below are some practical points that might be helpful for the doctor who is about to break the bad news to the anxious and expectant family members.

(1) Always prime and prepare the family members. The resuscitation period may be prolonged, and during this time, someone should update the family members regularly. If the outcome does not look good, the family members should be prepared mentally to be ready for the worst, so that when the eventual bad news is broken, the impact would (hopefully) be less devastating.

(2) When it's time to break the bad news,

• location - choose an empty consultation room where all the family members can be gathered around. Some departments have specific grieving rooms for this purpose. Do not break the news in the common areas (e.g. at the counter/ waiting area) if possible. This is to allow the family members privacy and dignity while they grieve, and also to minimize emotional disturbance to the other patients in the department.
• Have another staff on hand to assist you while you break the bad news. You never know how people may react.
• If possible, have enough chairs around the room so people can be seated. The last thing you want is a vasovagal syncope and head injury after you break the bad news.
• Speak in a slow and clear manner. Be factual. Explain the sequence of events that has taken place during the resuscitation but avoid excessive jargon or details. Maintain good eye contact all the time.
• Be direct and non-ambiguous. Say something like, 'Despite our efforts, we were unable to revive so-and-so. He has died/ passed away.' Do not use vague terms such as 'he has gone to a better place' or 'he is no longer with us' - you may find it easier speaking this way, but the family members may end up confused.
• Do not talk too much ! After breaking the news, it is useful to pause and allow the information to sink in. Keep a respectful and sympathetic silence, but do not rush out of the door straight away (even though you have another 10 patients waiting). Allow the family to grieve, but be on-hand to answer any questions or render assistance they need.
• Avoid saying things like 'I understand how you feel' or 'Don't worry the pain will ease with time'. You do NOT understand how they feel - you will go home to your loved ones after your shift, but their loved one will never come back. The pain may indeed ease with time, but this is neither the time nor place to say it.

(3) Viewing the body

• once the nurses have tidied up the resus area, the family members should be allowed to view the body and say their goodbyes.
• Before they enter the room, prepare them for what they are going to see, e.g. endotracheal tubes/ IV lines/ chest tubes etc, so they are not shocked when they see it.
• If there are any other patients in the same room/ area, transfer them elsewhere so the family has privacy, and the other patients are not emotionally traumatized.
• This is the most emotionally-charged part of the process - expect an outpour of raw emotions, predominantly grief. It is hard as a human being not to be affected by such scenes, hence one must remember to take a step back - remember our job is to be in the background respectfully, giving them the space and time to grieve but be ready to assist them at any time they need us.

(4) Coroner's Case

• Most deaths at the A&E end up being Coroner's cases, because of their sudden and unexpected nature. It can also be a difficult subject to broach with the relatives, sometimes even more difficult than the news that their loved one has died.
• Personally I usually do so at a later time (after they have come to terms with the demise of the patient) rather than give them 2 blows at the same time. Another method I find useful is to speak to someone who seems to be in an authoritative position and who seems less emotionally affected (e.g. the eldest son).
• Again, be firm and factual. Explain that you are obliged under the laws to make the case a Coroner's case rather than sign it up. Explain the process it entails (notifying police, transferring body to SGH Forensic Path dept etc) and reassure them that your staff will assist them in this.
• Most of the time the family will ask whether an autopsy will be conducted. I always tell them it is up to the discretion of the Coroner, who is assisted by the forensic pathologist. Show that you understand their concerns. Sometimes the family members may request you to include in your notes that they hope an autopsy can be avoided. Personally I will include that information in my notes, but I always tell them that the ultimate decision still lies with the Coroner.

Whatever emotional trauma the medical staff may encounter during a resuscitation, remember that the family members experience it a hundred times worse. You have lost a patient, but they have lost a father/ spouse/ child. Respect and acknowledge their grief, do not trivialize nor magnify it. Be empathetic and professional.

Case 8

78 year old female

Brought in by SCDF ambulance. Acutely unwell.
BP 85/50, Temp 37.8. Drowsy and unresponsive.
No family members around to give more history.

What is the diagnosis?
Which drug would you give first in her management?

Answer : Hyperkalemia

On first look, the ECG looks bizarre and not like something which we can fit a pattern to. This in itself should already remind you to think of hyperkalemia. On closer inspection we can see that the QRS complexes are widened and there is also suggestion of tall T waves.

Management

• Immediate management in P1 area. Full monitoring.
• Supplemental oxygen
• IV access; take blood form FBC/ UE/ ABG/ cardiac enzymes & Troponin/ blood cultures; consider IV fluids but need to exclude fluid overload first
• Drugs

1. IV Calcium gluconate/ chloride (10 mls stat) - first drug to be given in treatment of hyperkalemia; to stabilise the myocardium
2. IV Insulin 10 units with IV Dextrose 50% 40 mls - shifts ECF potassium into ICF
3. IV Sodium Bicarbonate (1 meq/kg BW ) IV bolus over 5 mins - also to shift ECF potassium into ICF. Limited use if patient is non-acidotic, and carries risk of fluid overload/ cerebral oedema.

Other drugs which can be considered include Salbutamol nebulisation (be careful in patients with IHD because of resultant tachycardia), as well as Resornium (K-binding resin) but it's not much use in A&E because of relatively longer onset of action (about 1-2 hrs).

This lady has a history of chronic renal impairment on dialysis. Her acute presentation is probably exacerbated by a concomitant infection (chest/ urine).

Remember :

• Consider non-cardiac pathologies when intepreting ECG
• When confronted with bizarre-looking ECG, consider severe hyperkalemia

Case 7

56 year old male, known hypertensive

Found collapsed at home by relatives.
On arrival, GCS 7. BP 170/90

What is the diagnosis?
How would you manage this patient?

Answer : Subarachnoid hemorrhage (SAH)

The CT scan shows presence of blood (the whitish stuff) within the subarachnoid space in the brain, sometimes referred to as the 'Mercedes sign' because it resembles the automaker's logo.

Causes

• Berry aneurysms (70%) - 30% of which in anterior communicating artery and 20% in posterior communicating artery
• Arteriovenous malformation (10%)
• No cause found (10-15%)

Typical presentation

• sudden onset of severe headache ('worst ever' headache)
• nausea and/ or vomiting
• neck pain
• photophobia
• loss of or altered consciousness

First test for patient with suspected SAH - plain CT head

• 93% sensitivity; but sensitivity diminishes with time
• if high suspicion of SAH but CT normal/ non-diagnostic, proceed with lumbar puncture (if no evidence of raised intra-cranial pressure), looking for xanthochromia and elevated RBC count (which does not diminish with successive collections)

A&E management

• Secure airway - in this patient whose GCS is only 7, endotracheal intubation following rapid sequence induction (RSI) to control airway and reduce risk of aspiration
• Supplemental oxygen, IV access and take blood for FBC/ UE/ Coagulation/ GXM
• Close monitoring of vital signs, keep systolic BP between 90-140 mmHg
  
• Contact neurosurgeon immediately with view to timely intervention (angiography/ coiling/ clipping etc)

I remember reading somewhere that an average doctor should expect to come across 3 cases of SAH in his/her career. Well, I have already seen two cases in my (relatively) short career - perhaps a doctor working in the ER will definitely see more of them.

I still remember the first case - a 30 year old lady with hx of migraine, who came in at 4 am with a headache which she claims is similar to her migraine attack. She was perfectly lucid and comfortable, and the only tiny red-flags I had were (1) I seldom see migraines at 4 am, and (2) there was very mild neck stiffness on examination. Being newly-employed in a private hospital where your license is much more on-the-line, I suggested a CT scan. She was reluctant but her husband persuaded her, and it turned out she had a SAH. She was admitted and underwent endovascular coiling immediately, and I hope she is doing well today.

So the lesson - the next tension-headache that walks in may not be a tension-headache. Keep your eyes open.