Questions of the Week for 1/23/2024
Author: Christian Gerhart
Q: A 55 yo male with a past medical history of alcohol use disorder presents with acute alcohol intoxication. You initially obtain an ethanol on arrival and observe him until his ethanol clears. However, after being observed to when you expect him to be sober, he appears confused but is able to confidently tell you that his cellphone is a magical wand that was given to him by Harry Potter. What diagnosis and treatment should be considered?
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This patient’s history and exam are concerning for confabulation should prompt consideration of Wernicke’s encephalopathy. This should be treated with high dose thiamine, which is generally dosed at 500 mg IV every 8 hours.
Q: A young male presents with bilateral foot frostbite that reaches to the metatarsal heads after falling asleep outside. His extremities are being actively warmed. What treatment should be considered?
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Systemic thrombolysis. Patients with frostbite have vascular thrombosis of the affected tissue and tPA has been proposed as a possible treatment, assuming the patient has no contraindications for systemic thrombolysis. The American Burn Association recommends the use of IV tPA for patients in whom treatment can be initiated within 48 hours of exposure, and who have evidence of ischemia proximal to the distal phalanx. Intra-arterial (IA) tPA has been proposed but there does not seem to be a firm consensus regarding IA vs IV tPA. Interventional radiology can be consulted for IA tPA. Thrombolysis is generally followed by systemic anticoagulation.
A proposed dosing strategy from Hennepin is below:5
Alteplase bolus of 0.15 mg/kg over 15 minutes followed by alteplase infusion at 0.15 mg/kg/hr for six hours. Once alteplase infusion is complete, initiate enoxaparin 1 mg/kg BID or unfractionated heparin with goal of aPTT of 2x normal value.
Q: You are caring for a 67-year-old female who presents with bloody stools. Her hemoglobin is 4.5 g/dL and she has a heart rate of 115 and BP of 97/60. She adamantly refuses blood transfusion administration as she is a Jehovah’s Witness. What treatments can be considered for this patient?
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IV iron and erythropoiesis stimulating agents (ESAs) are treatments that can improve formation of red blood cells and should be considered in these patients. In addition to these therapies, correction of coagulopathy, limitation of blood draws (consider using pediatric/neonatal tubes for any essential blood draws) and avoidance of excessive dilution by crystalloid administration is important. Most protocols also recommend repletion of B12 and Folate. 9 IV iron historically was associated with anaphylaxis, but this complication is now thought to be much lower (around 1%) than previously thought.7 Common IV iron formulations are Iron sucrose 100 mg IV (no test dose required) or Iron Dextran 1000 mg IV (test dose required). Some ESA formulations have albumin in them, which is usually not an accepted formulation among patients who are Jehovah’s Witnesses. As with any GI bleed, consider how source control can be achieved by either GI or interventional radiology. Consider consulting hematology for these cases as these cases are complex and many of these treatments are less commonly used in the ED.
Q: You are caring for a young male patient with no prior medical history who presented with hypothermia secondary to environmental exposure after he was intoxicated and fell asleep outside. On arrival his temperature was 33 C. He is now rewarmed to 37 C but his blood pressure has dropped to 90/60 from his initial blood pressure of 130/90. What could be the cause of this?
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In an otherwise healthy individual with hypothermia secondary to cold exposure, the most likely cause of hypotension after rewarming is hypovolemia. Patients with hypothermia experience a “cold diuresis” from renal fluid wasting and decreased ADH secretion.10 The relative vasodilation from rewarming can also result in a drop in blood pressure. A patient such as this one would probably benefit from relatively aggressive fluid resuscitation with warmed fluids at a temperature of 38-42 C. If a fluid warmer is not available, the Belmont/Level One transfuser can be used to warm them as they are administered. As always, investigate for other causes of hypotension such as infection as indicated, especially if the patient does not improve with resuscitation.
Q: A 22-year-old male presents after he saw a small brown spider bite him two days. He has a small area of red/purplish discoloration on his right forearm. He is reporting nausea, myalgias and dark urine. What workup should be obtained?
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This patient’s history and symptoms are concerning for a brown recluse spider bite with resultant systemic loxoscelism. Brown recluse bites can lead to hemolytic anemia, DIC, rhabdomyolysis and renal failure. A CBC, CMP, PT/PTT, CK and UA can be obtained as the initial workup. If a hemolytic anemia is suspected a type and screen, haptoglobin, LDH, reticulocyte count, peripheral smear and fibrinogen can be obtained.
Q: You have a 25 yo male patient who presents with left hand pain. He is intoxicated and says that he got upset during an argument and punched a brick wall. He has a 0.5 cm laceration overlying the dorsal surface of the 4th MCP joint. How should this patient be managed?
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This patient’s injury is highly concerning for a “fight bite” or a clenched first injury from a punch to the mouth. A significant portion of patients will not be forthcoming with the history and may not admit to punching someone. These injuries are extremely high risk for infection given the avascular nature of the tendons and thin overlying skin with minimal protection of the underlying structures. These should be thoroughly examined through the full range of motion to identify the extent of the injury. Patients will often present days after the initial injury with a frankly purulent wound. These cases need hand consultation and operative washout. There is some controversy for how these patients should be managed when presenting early after then injury. Some authors recommend early operative exploration and washout whereas others recommend less aggressive treatment with bedside irrigation and antibiotics.11,12 Fight bites generally require specialist evaluation for consideration of early operative management.
References:
1) Hickey S, Whitson A, Jones L, et al. Guidelines for Thrombolytic Therapy for Frostbite. J Burn Care Res. 2020;41(1):176-183. doi:10.1093/jbcr/irz148
2) Lindford A, Valtonen J, Hult M, et al. The evolution of the Helsinki frostbite management protocol. Burns. 2017;43(7):1455-1463. doi:10.1016/j.burns.2017.04.016
3) Lee J, Higgins MCSS. What Interventional Radiologists Need to Know About Managing Severe Frostbite: A Meta-Analysis of Thrombolytic Therapy. AJR Am J Roentgenol. 2020;214(4):930-937. doi:10.2214/AJR.19.21592
4) Nygaard RM, Lacey AM, Lemere A, et al. Time Matters in Severe Frostbite: Assessment of Limb/Digit Salvage on the Individual Patient Level. J Burn Care Res. 2017;38(1):53-59. doi:10.1097/BCR.0000000000000426
5) Lacey AM, Rogers C, Endorf FW, et al. An Institutional Protocol for the Treatment of Severe Frostbite Injury-A 6-Year Retrospective Analysis. J Burn Care Res. 2021;42(4):817-820. doi:10.1093/jbcr/irab008
6) Posluszny JA Jr, Napolitano LM. How do we treat life-threatening anemia in a Jehovah's Witness patient?. Transfusion. 2014;54(12):3026-3034. doi:10.1111/trf.12888
7) Beverina I, Razionale G, Ranzini M, Aloni A, Finazzi S, Brando B. Early intravenous iron administration in the Emergency Department reduces red blood cell unit transfusion, hospitalisation, re-transfusion, length of stay and costs. Blood Transfus. 2020;18(2):106-116. doi:10.2450/2019.0248-19
8) DeLoughery TG. Transfusion replacement strategies in Jehovah's Witnesses and others who decline blood products. Clin Adv Hematol Oncol. 2020;18(12):826-836.
9) Shander A, Goodnough LT. Management of anemia in patients who decline blood transfusion. Am J Hematol. 2018;93(9):1183-1191. doi:10.1002/ajh.25167
10) Brown, D. J. , Brugger, H. , Boyd, J. & Paal, P. (2012). The New England Journal of Medicine, 367 (20), 1930-1938. doi: 10.1056/NEJMra1114208.
11) Perron A., Miller M. And W. Brady. Orthopedic pitfalls in the ED: Fight Bite. AJEM. March 2002. Vol. 2.2.114-117
12) Harper CM, Dowlatshahi AS, Rozental TD. Challenging Dogma: Optimal Treatment of the "Fight Bite". Hand (N Y). 2020;15(5):647-650. doi:10.1177/1558944719831238