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Section on Emergency Medicine. (Abstracts of Scientific Posters).

EM1-B. ACUTE PRESENTATION OF BARTTER SYNDROME. Ronald M. Roan, MD, Ocean Springs, MS.

A case of Bartter's syndrome in a seemingly healthy 20-year-old Air Force communications student that presented to the Emergency Department (ED) with complaints of diffuse lower body muscle soreness one day after a basketball game is discussed. Evaluation of the patient revealed profound hypokalemia, myositis, weakness, hyperrefiexia, metabolic alkalosis, and hypomagnesemia. Although the patient initially denied any medical history, he later admitted to a known history of Bartter's syndrome since he was a young child. After emergent evaluation and treatment, the patient was discharged and directed to close follow up. Bartter's syndrome is a rare autosomal recessive disorder resulting in an impairment of sodium reabsorption in the loop of Henle. This results in a characteristic set of metabolic abnormalities, including: hypokalemia, metabolic alkalosis, hyperreninemia, hyperaldosteronism hyperplasia of the juxtaglomerular apparatus, and, in some patients, hypomagnesemia. Although the disease is largely control lable with potassium and magnesium supplementation; angiotensin converting enzyme inhibitors; nonsteroidal anti-inflammatory medication; and/or potassium sparing diuretics, the ability to continue military service should be evaluated.

EM2-B. LATE POSTPARTUM ECLAMPSIA. Loretha King, DO, and Lisa Dewitt, DO. Miami Beach, FL.

Eclampsia is a hypertensive disorder characterized by sudden onset of hypertension, proteinuria, and seizures. Approximately 25% of eclamptic episodes occur within the postpartum period. This complication can be seen anywhere from 48 hours to 4 weeks after delivery. We present a case of a patient with late postpartum eclampsia who arrrived in our emergency department complaining of a simple headache and progressed in a matter of hours, and was confirmed by radiologic findings.

EM3-B. JAUNDICE AND ABDOMINAL PAIN: AN UNUSUAL CAUSE--HEMOLYTIC ANEMIA. Antonio E. Muniz, MD. Department of Emergency Medicine and Pediatrics, Medical College of Virginia of VCU, Richmond, VA.

Hyperbilirubinemia with abdominal pain usually reflects an abnormality in the liver or biliary tree. When anemia is present, immune hemolytic anemia must be included in the differential. A 7 year-old girl presented to ED with a 3-day history of fever, nausea, vomiting, upper abdominal pain, and headache. She was seen by her doctor and had an unremarkable head CT. She was sent to our ED because of a hemoglobin value of 5.0 g/dL. Her birth and medical history were normal. She took no medications and had no allergies. She had a temperature of 38.4[degrees]C, initial BP was 88/48 mm Hg, heart rate was 145 beats/min, and respiratory rate set at 22 breaths/min. Examination showed marked paleness. She had a 2/6 systolic ejection murmur. The remainder of the examination was unremarkable. Her WBC count was 5,600/mm3 with 85 % neutrophils. Hemoglobin value was 4.7 g/dL and platelet count was 231,000/mm3. Reticulocyte count was 1.1%. Her Coombs antiglobulin test was positive for IgG. Electrolyte levels were normal. She was diagnosed with autoimmune hemolytic anemia. Prednisone therapy was initiated and she was given blood transfusions. She was discharged in stable condition. Immune hemolytic anemia can be either isoimmune or autoimmune. Autoimmune hemolytic anemias consist of a group of disorders whose common characteristics are the presence of an antibody, which in turn causes short red blood cell life. Antibodies of the IgG class are most commonly responsible for hemolytic anemia in children. Rh erythrocyte antigen is involved in > 70% of cases. Since its maximal activity occurs at 37[degrees]C, it is a warm antibody-induced hemolytic anemia. Clinical features are sudden onset of pallor, jaundice, and red-brown urine (hemogbobinuria). In its severe form, it can be rapidly fatal unless aggressively treated. The cornerstone in the diagnosis is a positive Coomb's antigloblin test. Treatment may include blood transfusion, corticosteroids, immunotherapy, IV gammaglobulin, plasmapheresis, and splenectomy, and varies with the se verity of presentation.

EM4-B. FEVER, EPISTAXIS, ANEMIA, AND THROMBOCYTOPENIA: AN UNUSUAL PRESENTATION OF NEUROBLASTOMA. Antonio E. Muniz, MD. Department of Emergency Medicine and Pediatrics, Medical College of Virginia of VCU, Richmond, VA.

Epistaxis and fever are common complaints in a pediatric ED. It must be emphasized that occasionally these complaints may be a secondary manifestations of a more serious illness. A thorough physical examination should identify most of these abnormal cases. This is a case of a neuroblastoma presenting with epistaxis and fever.

A 21-month-old girl presented to the ED with a 3-week history of fever, malaise, epistaxis, and intermittent abdominal pain. Her birth history and past medical history were unremarkable. She took no medications. Her physical examination was remarkable for being pale. She had dried blood in her left nares and mild gingival bleeding. She had generalized adenopathy. Abdominal examination showed hepatosplenomegaly and a mass in the LUQ. Her skin showed scattered areas of ecchymosis. She had a temperature of 38.1[degrees]C; heart rate, 150 beats/min; respiratory rate, 20 breaths/min; and weight, 11.3 kg. WBC count was 7,800/mm3 with 52 % neutrophils and 6 % bands. Hemoglobin value was 6.2 g/dL and platelet count was 7,000/mm3. Reticulocyte count was 3.9%. Electrolyte levels were normal. Alkaline phosphatase level was 148 U/L; AST level, 315 U/L; and ALT level, 22 U/L. PT was 10.6 sec, INR 1.1, and aPTT 29 sec. Chest radiograph was normal. The patient was given blood and platelet transfusions. The abdominal CT reve aled a large left renal mass. Biopsy confirmed a neuroblastoma. CSF studies were normal. Bone marrow showed abnormal cells, giving her a diagnosis of Stage IV neuroblastoma. She was enrolled on chemotherapy protocol COG # A3973 with cyclophosphamide, doxorubicin, vincristine, and given supportive therapy with MESNA and G-CSF. Prophylactic antibiotic therapy included nafcillin, tobramycin and bactrim. Her hospital course was complicated by staphylococcal coagulase-negative sepsis and Candida fungemia and hypertension requiring treatment with labetalol and enalapril. She required TPN for nutritional support. Two months later she was discharged in good condition. Neuroblastoma is the most common extracranial solid tumor in childhood and usually presents with an abdominal mass. Other symptoms include pyrexia, anorexia, and weight loss. Hematologic manifestations of neuroblastoma are numerous. Bone marrow invasion by tumor cells may cause leukoerythroblastic changes or depression of one or more cell lines in the p eripheral blood. On occasion, extensive bone marrow involvement may cause tumor to be released into the peripheral blood and lead to the erroneous diagnosis of leukemia. Anemia may be seen in 1/3 to 1/2 of children, and usually reflects more severe disease, such as those with stage III or IV disease. Anemia may not only result from bone marrow involvement, but also from bleeding into a tumor mass or from the hemolysis accompanying a consumption coagulopathy. Recognition of these protean hematobogic manifestations may aid in the diagnosis in children with atypical presentations of this highly malignant tumor.

EM5-B. ELEVATED CARDIAC TROPONiN I IN A 9-WEEK-OLD INFANT. Antonio E. Muniz, MD. Department of Emergency Medicine and Pediatrics, Medical College of Virginia of VCU, Richmond, VA.

Elevated cardiac troponin level is a specific marker for myocardial damage for adults and children. It is extremely uncommon in children, especially in infants. It has been reported to be elevated in cases of perinatal asphyxia, severe respiratory distress syndrome, postoperative infants undergoing surgical correction for congenital heart defects, and neonates exposed to magnesium sulfate tocolytic therapy. This is a case of an infant with a complex congenital heart defect with an elevated cardiac enzymes. A 9-week-old female was referred to our pediatric center for congestive heart failure. She had a one-day history of dyspnea, subjective fevers, and decreased oral intake and urination. Her medical history was significant for hetorotaxia syndrome with a single left ventricle, double-outlet right ventricle, AV-valve regurgitation, small bicuspid pulmonary valve with stenosis, asplenia, and GERD. Her medications included ranitidine and metoclopramide. She had a temperature of 37.7[degrees]C; blood pressure, 11 4/76 mm Hg; heart rate, 150 beats/min; and respiratory rate, 62 breaths/min. Her physical examination was remarkable for moderate respiratory distress, retractions, and decreased breath sounds. Heart examination revealed a 3/6 systolic murmur. There was hepatomegaly. Her CBC count, electrolyte levels, and urinalysis were normal. Laboratory values were: creatinine kinase, 436 U/L; CK-MB, 19.3 mg/L; and troponin, 0.4 mg/L. Chest radiograph revealed cardiomegaly with interstitial edema. 12-lead ECG showed sinus tachycardia with left axis deviation and atrial enlargement, but no ischemia. She developed respiratory decompensated requiring intubation. She developed SVT, which responded to treatment with adenosine, and digoxin therapy was started. Over the next few days, she was extubated and discharged in stable condition. Elevated cardiac troponin is a regulatory contractile protein whose detection in the serum has been shown to be associated with acute coronary syndromes primarily in adults and is a specific and sensitive marker for acute myocardial cell injury. These markers have not been routinely used in infants and children, yet, certain infants, such as those with congestive heart failure, may be at risk of myocardial ischemia. This case report emphazises that infants at risk for myocardial damage should have evaluation of cardiac markers. When cardiac troponin level is elevated, the incidence of complications, such as dysrhythmias or worsening cardiac function, has been shown to be increased, which may warrant closer observations and therapy in these infants.

EM6-B. FOSPHENYTOIN INFUSION MAY CAUSE ATRIAL ASYSTOLE. Bruce D. Adams, MD, and Neil Buckley, MD. Department of Emergency Medicine, Medical College of Georgia, Augusta, GA.

Conventional phenytoin (PTN) therapy can cause cardiovascular collapse when given intravenously by inducing hypotension and cardiac dysrhythmias. The more soluble prodrug, fosphenytoin, was recently introduced to avoid PTN's side effects, and has since become first-line therapy for status epilepticus in the emergency department. Fosphenytoin is generally considered safe from cardiac toxicity, and there are no accounts of dysrhythmias in the medical literature. However, we now report two cases of acute atrial asystole contemporaneously associated with iv infusion of fosphenytoin. An 83-year-old woman with a history of epilepsy and renal failure presented to the emergency department after a brief tonic-clonic seizure. We ordered treatment with fosphenytoin iv. After receiving approximately 800 PTN equivalents (FE), she developed hypotension, respiratory failure, and atrial asystole with the ventricular escape rate of 35 b/min. We intubated her and placed a transvenous pacemaker. Her rhythm normalized to sinus a fter 18 hours. An 87-year-old white man presented in hypertensive emergency. One hour later he developed generalized, and then focal, seizure activity A loading dose of fosphenytoin at 150 PE/minute iv was ordered. During the infusion, he suffered a precipitous fall in pulse rate and blood pressure, and was intubated. The fosphenytoin was discontinued. EKG showed atrial asystole with a junctional escape rate of 50 b/min that resolved after 90 minutes. In these cases fosphenytoin apparently induced hemodynamically unstable atrial asystole and bradycardia. We theorize possible mechanisms for this phenomenon. Fosphenytoin offers several therapeutic advantages and has largely replaced PTN in the management of status epilepticus because of its reputation for safety. However, our series suggests that it may produce more cardiac toxicity than previously thought Fosphenytoin should always be administered in a monitored setting at the recommended infusion rate. We encourage clinicians to monitor for and report further cases of cardiac arrhythmias associated with fosphenytoin.

EM7-B. THE UTILITY OF LABORATORY INVESTIGATIONS AND IMAGING STUDIES IN THE EVALUATION OF SYNCOPE IN THE EMERGENCY ROOM. Pierre Giglio, MD. Millard Fillmore Hospital, Kaleida Hospital system, State University of New York at Buffalo, Buffalo, NY.

The purpose of our study was to determine the frequency and importance of laboratory tests and imaging studies in patients presenting with syncope to the emergency department. The charts of patients who had presented to the emergency department of a local private hospital with an episode of syncope were identified retrospectively. A six-month period was chosen, and 128 charts of patients with this diagnosis were identified by searching the hospital computer database. The following information was extracted: demographic data, pertinent information in history and physical findings, outcome (admission vs. discharge), relevant medical history, results of hematology, blood chemistry, electrocardiograms and head computed tomography (CT) scans. Patient characteristics: there were 85 female and 43 male patients. The mean age was 63.5 years. A definitive diagnosis for the cause of syncope based on history and physical evaluation alone was possible in 31 patients (24.2%). 84 patients (65.6%) were admitted to the hospit al for observation and/or further evaluation. The most common conditions noted on medical history were hypertension (65%) and cardiac disease (51%). Other relevant illnesses were neurologic (40%), endocrine (31%), psychiatric (23%), and pulmonary (18%). All patients had complete blood counts, and mild anemia was noted in 13 patients. In none of these patients was the hemoglobin level felt to have contributed significantly to the syncope. One patient had serum sodium level of 111mEq/L, and this was felt to have contributed to the loss of consciousness by inducing an unwitnessed seizure. Hypoglycemia was documented in only one patient , but a diagnosis of hypoglycemia was made in one additional patient based on history. Routine electrocardiograms in the emergency department were helpful in making a diagnosis of syncope from arrhythmia in 7 patients (5.5%). 42 patients (32.8%) had a head CT scan in the emergency department. 20 of theses studies were normal. In 19 patients, the scans showed findings that were fel t to be chronic and probably not related to the syncope. In 3 patients, the head CT scans revealed changes that were acute and/or probably related to the syncope. All of these patients had findings on history or physical examination indicative of possible central nervous system pathology. In two patients, there were changes consistent with early brain ischemia/infarction. One patient had diminished visual acuity and a bitemporal visual field deficit and was found to have a pituitary mass on imaging. A diagnosis after complete evaluation was possible in 73 patients (57%). The breakdown for the final diagnosis in the emergency department was as follows: vasovagal (20); cardiac (20); orthostasis (8); neurologic (7); drug-induced (2); hysterical (1); others, including syncope during pregnancy, alcohol-related (15); unknown cause (55). Our retrospective review of 128 patients with syncope reaffirms that clinical evaluation alone can result in a diagnosis in a significant number of patients. Laboratory tests and im aging studies can help confirm clinical diagnosis and guide further management, but these test requests must be guided by clinical information. Electrocardiograms are still the most useful test in this regard. Head CT scans (2.4%) had a higher than expected yield, considering that seizure patients were excluded. As with other tests, however, clinical information guided the CT scan request in the positive cases. The study once again confirms the need for a large prospective trial utilizing a comprehensive clinical evaluation as its backbone and including long-term follow-up of patients presenting with syncope. Such data could help increase efficiency and efficacy and decrease cost in evaluating this common symptom.

EM8-B. CONSTIPATION AND WEIGHT LOSS IN A TEENAGE MALE. Join Y Luh, MD, and Bernard Karnath, MD. Department of Surgery, Division of Emergency Medicine, and the Department of Internal Medicine, University of Texas Medical Branch at Galveston, TX.

A 19-year-old Hispanic man with no medical history presented to the ED with a 2- month history of constipation, 17-pound weight loss, and fatigue. He attributed his weight loss to his poor appetite due to early satiety and frequent nausea, vomiting, and abdominal cramping after meals. During this time, his stools were small and hard, with occasional streaks of mucus and blood. Family history revealed a mother with diabetes, a father with arthritis, and 9 healthy siblings. He was employed as a waiter, smoked about a pack a week, and drank an average of 24 beers on weekends. Physical examination revealed a well-developed, well-nourished, 6-foot-2-in, Hispanic male weighing 200 pounds, with normal vital signs. Basilar crackles were auscultated on lung examination; abdomen was soft and nontender, with mild distension but no palpable masses; and a firm right inguinal mass was noted. Both testicles were descended, nontender, and without masses. An acute abdomen series revealed clear lungs nad multiple small-bowel l oops, suggesting early small-bowel obstruction. Initially, a plan to discharge the patient with increased fluid intake and stool softeners was discussed. However, when a rectal examination was performed to characterize any possible impaction, a large, tender soft tissue mass was palpated posteriorly. A retroperitoneal CT revealed ascites with extensive nodularity on the peritoneal surface of the diaphragm and peritoneal walls; a 15 x 12 x 14-cm heterogeneous mass occupying the pelvis, surrounding and compressing the rectosigmoid colon; a 10 x 7 x 7cm mass in the root of the mesentery with lymphadenopathy; and no organomegaly. The differential diagnosis at that point included lymphoma, sarcoma, or germ cell tumor. Beta-HCG and alpha-fetoprotein levels were within normal limits. Biopsy of his right inguinal mass revealed an intraabdominal desmoplastic small round cell tumor. He underwent surgical debulking, chemotherapy, and radiotherapy, with significant reduction in tumor burden. Nine months after diagnosis, he is doing well and continues to receive chemotherapy. Desmoplastic small round cell tumor (DSRCT) is a rare malignancy that occurs most commonly in young males, making early diagnosis difficult. The aggressive nature of this tumor, relative resistance to chemotherapy, and difficulty of complete surgical resection, make the prognosis dismal. Overall survival has been reported in one case series to be 29% at three years from diagnosis. Improved overall survival has been reported with intense alkylator induction chemotherapy, followed by aggressive surgical debulking and external beam radiotherapy. In this case, findings on a rectal examination performed in the ED proved to be essential in propelling the work-up that followed. Clinicians should seriously question why a young patient would present with constipation. A high index of suspicion for pathology, as well as a complete physical examination, can put a patient with a potentially fatal diagnosis on the road to appropriate treatment.

EM9-B. PROPOFOL FOR DEEP PROCEDURAL SEDATION IN THE EMERGENCY DEPARTMENT. John Coyner, MSII, Paul Lageman, RN, and Mitch Charles, MD. Department of Emergency Medicine, Joan C. Edwards School of Medicine, Marshall University, Huntington, WV.

Numerous painful procedures, such as orthopedic reduction, lumbar puncture, chest tube insertion and abscess incision and drainage are performed in the Emergency Department. Prior methods of sedation either resulted in inadequate sedation or sedation to the point of failure by the patient to maintain adequate oxygenation. Propofol treatment has the theoretical advantage of rapid onset of action and short half-life. The objective of this study was to assess the safety and efficacy of propofol for the use of deep procedural sedation by physicians in a community emergency department, thus determining if the theoretical advantage was applicable to the clinical setting. A retrospective chart review of 53 consecutive patients that had undergone deep procedural sedation with propofol in an urban emergency department over a 1-year period was completed. Patients were given propofol in a titrated dose at the discretion of the emergency department physician until the desired level of sedation was obtained. Vital signs a nd pulse oximetry were recorded during the procedure and until recovery. The nurses recorded complications in the nursing notes. Case data and complications were extracted by chart review. Hypotension of SBP < 90 mm Hg, hypoxemia of pulse ox < 90%, respiratory depression requiring assisted ventilation or intubation, aspiration, airway obstruction, or anesthesia consultation were considered complications. Over 12 months, 53 patients received propofol for orthopedic reduction (58%), lumbar puncture (36%), and other indications (6%). Mean total dose of propofol was 151 mg (range, 30 to 400 mg). Transient hypotension (SBP < 90 mm Hg) occurred in 2 patients (3.8%; 95% CI, 0% to 8.8%), transient hypoxia (SpO2 ox < 90%) in 1 patient (1.9%, 95% CI, 1.8% to 2%), assisted ventilation in 1 patient (1.9%, 95% CI, 1.8% to 2%), no patients required intubation, aspirated, had airway obstruction, or required anesthesia consultation. The transient hypotension responded quickly to normal saline bolus and resolved in less than 1 minute. The single patient with hypoxia responded to minimal assistance and regained the ability to maintain adequate oxygenation without assistance in less than 2 minutes. Our study is the first to date investigating propofol use by emergency department physicians without stringent protocols concerning dosage. Prior to this study, propofol had been considered an "anesthesia only" drug. Propofol is a safe drug when used for deep procedural sedation by emergency department physicians in actual clinical situations. After an extensive MEDLINE search, only two studies could be found that assessed propofol for deep procedural sedation in the Emergency Department. These studies had rigid protocols as to the amount of propofol administered. Our study reviewed the safety of propofol when given at the physicians' discretion, thus making it the first to look at propofol use in actual clinical practice. It is well known that medications used in a study yield better results with fewer complications than are found later when these drugs are used in widespread clinical practice. By performing a retrospective chart review of propofol use at the physicians' discretion, our findings give a better picture of clinical practice. The most dreaded complication, hypoxia, was noted in only one patient, who required assisted ventilation for less than two minutes. Even in this study of 53 patients, the 95% confidence interval of 1.8% to 2.0% is so narrow that the results would be reproducible and are thus applicable to the population in general. The complication of transient hypotension occurred in only two patients and responded quickly to saline bolus; however, the 95% confidence interval was 0% to 8.8%. This suggests that a larger study is needed to adequately assess this complication. The physicians in our study used propofol without regard to time of last meal. In fact, one patient undergoing orthopedic reduction had eaten a large meal 20 minutes prior to performance of the procedure. Aspiration did not occur in any patients, possi bly due to propofol's inherent anti-emetic properties. Finally, the safety of propofol is proven in clinical practice and is known to produce adequate sedation for painful procedures. Given propofol's rapid onset of action (minutes), the short half-life of the drug, with documentation of all patients awake for discharge in 5 to 15 minutes in our study (very desirable in busy, overcrowded emergency departments), and now proven safety when used by emergency deparment physicians, this medication should become the standard for painful procedures in emergency departments throughout the world.
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Publication:Southern Medical Journal
Article Type:Bibliography
Geographic Code:1USA
Date:Dec 1, 2002
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