1/11/2018 1 COLA 2017 (or 14) Omar Francis, DO Jennifer Stevenson, DO, FACEP Henry Ford Health System MCEP Winter Symposium January 26, 2018 Immune Thrombocytopenic Purpura (ITP) • Medscape. Craig M Kessler, MD. Updated December 2, 2016
1/11/2018
1
COLA 2017 (or 14)
Omar Francis, DO
Jennifer Stevenson, DO, FACEP
Henry Ford Health System
MCEP Winter Symposium
January 26, 2018
Immune Thrombocytopenic Purpura (ITP)
• Medscape. Craig M Kessler, MD. Updated December 2, 2016
1/11/2018
2
Pathophysiology
epidemiology
1/11/2018
3
Signs and symptoms
NOT ITP ITP
Diagnosis
• Isolated thrombocytopenia
1/11/2018
4
Management
Morbidity/Mortality
1/11/2018
5
Prognosis
Acute Pericarditis
New England Journal of Medicine : 371;25 - December 2014
1/11/2018
6
Acute Pericarditis – Case
A previously healthy 25-year-old man presents with pleuritic pain in the left side of the chest of 3 hours’ duration, radiating to the left trapezius ridge and relieved by sitting forward. On physical examination, he appears anxious. His pulse is 104 beats per minute and regular, his blood pressure is 125/80 mm Hg without a paradoxical pulse, and his temperature is 37.8°C. A three-component friction rub is auscultated along the left sternal border. An electrocardiogram (ECG) reveals ST-segment elevations in multiple leads, which are consistent with acute pericarditis. How should this case be managed?
Acute Pericarditis - Introduction
• 80 – 90% of cases idiopathic • assumed viral
• 10 – 20% of cases• post-cardiac syndromes
• connective tissue diseases (SLE)
• genetic auto-inflammatory diseases• TRAPS and familial Mediterranean fever
• Incidence : 5% of ED patients with non-ischemic CP
• 2:1 Male to Female ratio
1/11/2018
7
Acute Pericarditis – Introduction
• 1/3 of idiopathic pericarditis is associated with myocarditis
• *Mortality is low and prognosis is excellent
• Left-ventricular dysfunction is uncommon
• Pericardial effusions are present in 2/3 of patients
• *Sequela include Beck’s Triade & cardiac tamponade
• Most patients have one or two recurrences
Acute Pericarditis – Clinical Features
• Pleuritic chest pain
• Viral illness
• Sinus tachycardia and low-grade fever
• Pericardial friction rub
• ECG changes – diffuse ST elevation
• Pericardial effusion
• Diagnosis – 2 of the following :
• chest pain consistent with pericarditis, pericardial friction rub, typical ECG changes, or a pericardial effusion
1/11/2018
8
Acute Pericarditis - Diagnostics
• CBC, CRP, troponin I, Cr, LFTs
• WBC count modestly elevated.
• WBC > 13,000 suggests specific cause
• Anemia suggests underlying disorder
• CRP elevated in 75% of cases
• CXR usually normal
• Echocardiogram routinely indicated
1/11/2018
9
Acute Pericarditis - Treatment
• NSAIDS
• Ibuprofen, indomethacin, aspirin
• Aspirin is the preferred post MI
• Colchicine
• European Society of Cardiology 2004 guidelines
• recommended NSAIDs + colchicine
• ICAP trial 2013
• Glucocorticoids • immune-mediated disorders
• Pericardiocentesis - cardiac tamponade
• consider in patients with large effusions without tamponade
Acute Pericarditis – Treatment
• Disposition• Low-risk patients maybe discharged (Imazzio et al)
• NONE of the following:
• fever, immunosuppression, trauma, myopericarditis, a large pericardial effusion, cardiac tamponade & not on anticoagulant
• Duration
• NSAIDs 1 – 2 weeks
• Poor response – consider work up
• Colchicine 3 months
1/11/2018
10
Acute Pericarditis – Recurrence
• Recurrent pericarditis • Women at higher risk
• Treatment with steroids
• Reinstitute NSAIDs and add colchicine
• Serious late complications (constrictive pericarditis) is rare
Acute Pericarditis – Future Study
• Future study• RCTs to guide choice and duration of anti-inflammatory agent
• Role of CRP level
• Role of novel immunomodulators
• immune globulins, anti–tumor necrosis factor α antibody, azathioprine, or interleukin-1β antagonists
1/11/2018
11
Acute Pericarditis – Case
A previously healthy 25-year-old man presents with pleuritic pain in the left side of the chest of 3 hours’ duration, radiating to the left trapezius ridge and relieved by sitting forward. On physical examination, he appears anxious. His pulse is 104 beats per minute and regular, his blood pressure is 125/80 mm Hg without a paradoxical pulse, and his temperature is 37.8°C. A three-component friction rub is auscultated along the left sternal border. An electrocardiogram (ECG) reveals ST-segment elevations in multiple leads, which are consistent with acute pericarditis. How should this case be managed?
Acute Pericarditis – Case
• Author recommends treatment with :
• *NSAID — (600 to 800 mg of ibuprofen every 6 to 8 h) for 10 to 14 days, with tapering based on clinical response —
• *and
• *Colchicine for 3 months
1/11/2018
12
Executive Summary: Heart Disease and Stroke Statistics - 2015 Update
• Circulation. 2015;131(4):434-441. American Heart Association 2015
Cardiovascular Health in the US
1/11/2018
13
Health Behaviors
Heath Factors
1/11/2018
14
Cardiovascular conditionsCardiovascular disease accounts for 1 in 3 deaths
That’s 1 death every 40 seconds!
That’s 900 people dead over one 10 hour shift!!!
On average, every 40 seconds someone has a stroke
Approximately every 34 seconds someone has an acute coronary event
1/11/2018
15
Pediatric ECMO
Journal of Emergency Medicine : 49;4 – February 2015
Pediatric ECMO
• Extracorporeal Membrane Oxygenation
• Standard of care in NICU
• Survival rates > 85% in neonates as a final rescue therapy
• severe and refractory hypoxemia secondary to meconium aspiration, respiratory distress syndrome, and primary pulmonary hypertension
• Option for EM patients?
1/11/2018
16
Pediatric ECMO
• Vascular access
• Peripheral – neck or femoral vessels
• Central – right atrium or aorta
• Seldinger, open surgical, direct central canalization via sternotomy or thoracotomy
• Adolescents – femoral vessels
Pediatric ECMO
• History
• 1936 – John Gibbon invented the bypass machine.
• 1950s – Silicone membrane enables prolonged use.
• 1971 – ECMO for ARDS in a adult with chest trauma.
• Late 1970s – RCTs on neonates yield survival of 56%
• 1980s – Technology adapted from neonates to peds.
1/11/2018
17
Pediatric ECMO
Pediatric ECMO
*Hemoglobin is saturated with oxygen as blood passed through the membrane oxygenator
1/11/2018
18
Pediatric ECMO
• VA ECMO : primary cardiac dysfunction
• VV ECMO : *reversible severe acute respiratory failure
Pediatric ECMO
• Selection
• ECMO considered a last option
• Highly invasive, life-threatening complications
• Guidelines vary by institution, no specific indications
• Goal is tissue perfusion and oxygenation, allowing for pulmonary and cardiac rest
• Neonates / infants : sepsis, bronchiolitis, CHDs
• Peds / Adolescents: *status asthmaticus, pneumonia, ARDS, near drowning, acute chest syndrome, post-traumatic lung injury, myocarditis, intractable dysrhythmia, βB / Ca-Channel blocker overdose
1/11/2018
19
Pediatric ECMO
• Inclusion• 1. PaO2/FiO2 <100 mm Hg
• 2. Respiratory acidosis due to severe hypercapnia
• 3. Pulmonary compliance < 30 mm Hg
• 4. Any child who does not meet the exclusion criteria and is in severe distress and near cardiac arrest
• Exclusion
• 1. End-stage malignancies or advanced AIDS
• 2. Contraindications to the use of systemic anticoagulation
• 3. Cardiac arrest without neurologic function
• 4. *Traumatic cardiac arrest
• 5. Severe pulmonary disease ventilated aggressively for >10 d
Pediatric ECMO – Indications
• Respiratory failure • Pneumonia, asthma, ARDS, aspiration, burns
• Sepsis
• Cardiac arrest
• Hypothermic cardiac arrest
1/11/2018
20
Pediatric ECMO
• Complications • Blood clots in circuit (most common) in 19%
• Air embolism
• Blood loss
• Platelet consumption and DIC
• Intracranial hemorrhage – 7.4%
• CVA - 5.7%
• Myocardial stunning - 7%
• Hypertension – 13%
• Pneumothorax – 6%
Pediatric ECMO
• Management
• Standard resuscitation
• ECMO initiated in ED• *Blood products and heparin bedside
• Vent setting on ECMO
• Monitoring
• Circulation
• Sedation
1/11/2018
21
Pediatric ECMO
• Transport• Three centers have mobile ECMO
• Decision is difficult, early consultation important
• Emergency physicians have a unique opportunity to initiate treatment with ECMO
• Key is to have a transfer plan in place prior to presentation
Colorado Cannabis Legalization and its Effect on Emergency Care
• Annals of Emergency Medicine 2016
• Colorado legalized medical marijuana in 2000
• Stopped prosecution of growers and suppliers in 2009
• From 2009 to 2011 the number of medical marijuana licenses increased from 5,051 to 118,895
• Colorado legalized recreational marijuana in 2014
1/11/2018
22
It’s no big thing…
Marijuana Intoxication
1/11/2018
23
Marijuana Intoxication
Edibles
1/11/2018
24
Synthetics
Cannabinoid Hyperemesis Syndrome
1/11/2018
25
Pediatric Exposures
Therapeutic Benefits
1/11/2018
26
TXA for Traumatic Brain Injury
•
American Journal of Emergency Medicine : 32 – 2014
TXA for Traumatic Brain Injury
• In patients with or at risk of ICH
secondary to TBI, does TXA compared
to placebo improve outcomes?
• 1.4 million ER visits annually for TBI
• Secondary brain injury
1/11/2018
27
TXA for Traumatic Brain Injury
• Primary outcome measures• Death due to any cause after TBI assessed
• Neurologic outcomes
• Secondary outcome measures
• Hemorrhage progression, transfusion requirement,
neurosurgical intervention, & adverse effects
TXA for Traumatic Brain Injury
Two trials identified after search:
Study Patients Intervention Outcomes
CRASH-2 - 10 hospitals in India and
Colombia
- 270 adults
- Inclusion : trauma with or
at risk for significant
hemorrhage & TBI
TXA 1g IV over
10 min then 1 g
IV infusion over
8 hours
Primary – total hemorrhage growth from 1st to 2nd CT
at 24 – 48 h
Secondary – increase > 25% of total ICH, new ICH,
change in SAH grade, mass effect, new focal
ischemia, clinical outcomes
Yutthakase
-msunt et
al
- Single center in Thailand
- 240 adults
- Inclusion: non-
penetrating TBI
TXA 1g IV over
30 min then 1 g
IV infusion over
8 hours
Primary – progression of ICH by CT at 24 h, increase in
pressure effect
Secondary – in-hospital mortality, GCS at discharge,
transfusion requirement, neurosurgical intervention,
in-hospital thromboembolic events.
1/11/2018
28
TXA for Traumatic Brain Injury
TXA for Traumatic Brain Injury
• CRASH-2 & Yutthakasemsunt et al - Pooled data• In-hospital mortality relative risk of 0.64
• (95% CI, 0.41-1.02)
• Unfavorable functional status relative risk of 0.77
• (95% CI, 0.59-1.02)
• ICH progression, a relative risk of 0.76
• (95% CI, 0.58-0.98).
• *No serious adverse effects associated with TXA group
1/11/2018
29
TXA for Traumatic Brain Injury
• Take home point:
• Hypothesis : administration of TXA to patients with TBI would reduce hematoma growth compared with placebo.
• This meta-analysis revealed a statistically significant reduction in hemorrhage progression in TBI patients receiving TXA.
• The pooled relative risks for in-hospital mortality and functional status were not statistically significant.
TXA for Traumatic Brain Injury
• TXA Mechanism of Action
• *Minimizing secondary injury
• Thromboplastin released in TBI - disturbs coagulation
• *TXA is a antifibrinolytic agent
• limits fibrinolysis & intracranial hemorrhage
TXA inhibits tissue
plasminogen activator
1/11/2018
30
TXA for Traumatic Brain Injury
• Limitations
• No studies found were adequately powered to detect any clinical outcomes
• CRASH-2 had extensive extracranial injuries
• Neither trial examined isolated TBIs
• Neither trial accounted for anticoagulants / antiplatlets
TXA for Traumatic Brain Injury
• Conclusions
• Pooled results from the 2 RCTs demonstrated statistically significant reduction in ICH progression with TXA.
• TXA has excellent safety profile.
• No statistical significant improvement in clinical outcome.
• Further evidence required – CRASH-3 trial ongoing.
1/11/2018
31
Amiodarone, Lidocaine, or Placebo in Out-of-Hospital Cardiac Arrest
• New England Journal of Medicine 2016
• Randomized, double-blinded trial comparing amiodarone, lidocaine, and placebo use in shock refractory ventricular fibrillation and pulseless ventricular tachycardia
• Primary outcome was survival to hospital discharge
• Secondary outcome was favorable neurologic function at discharge
Survival to Discharge
24.4% 23.7% 21.0%
0.0%
25.0%
50.0%
75.0%
100.0%
Survival to Hosp. Discharge
Amio
Lido
Placebo
1/11/2018
32
Survival with Favorable Outcome
18.8% 17.5% 16.6%
0.0%
50.0%
100.0%
survical with favorable neurologic status
Amiodarone
Lidocaine
Placebo
Survival?
1/11/2018
33
Trial of Continuous or Interrupted Chest Compressions during CPR
Trial of Continuous or Interrupted Chest Compressions during CPR
• *Background
• 2015 AHA BLS guidelines : chest compressions is primary emphasis
• High quality CPR allow full chest recoil
• Recommended adult compression rate = 100-120 per minute
• Upper limit for compression depth in adult CPR is 2.4 inches
• Mechanical piston CPR devices no superiority over conventional CPR
• 25-33% of normal cardiac output with high quality CPR
1/11/2018
34
Trial of Continuous or Interrupted Chest Compressions during CPR
• Study design
• Intervention group - continuous chest compressions
• continuous chest compressions - 100 / min
• asynchronous positive-pressure ventilations – 10 / min
• Control group - Interrupted chest compressions
• Interrupted for ventilations at a ratio of 30 : 2
• positive pressure during a pause in compressions of less than 5 seconds
Trial of Continuous or Interrupted Chest Compressions during CPR
• Study design
• Resuscitation Outcomes Consortium (ROC)
• 114 EMS agencies
• Cluster randomizations
• Inclusions : adult nontraumatic cardiac arrest
• Exclusions : trauma, pregnancy, bystander CPR…
• Protocols monitored
1/11/2018
35
Trial of Continuous or Interrupted Chest Compressions during CPR
• Primary outcome • rate of survival to hospital discharge
• Secondary outcomes • neurologic function at discharge
• Rankin scale score ≤3 as favorable
Trial of Continuous or Interrupted Chest Compressions during CPR
• Primary outcome
• 12,613 patients in intervention group (continuous CPR)
• 9.0% survived to discharge
• 11,035 patients in control group (interrupted CPR)
• 9.7% survived to discharge
• *95% [CI], −1.5 to 0.1
1/11/2018
36
Trial of Continuous or Interrupted Chest Compressions during CPR
• Secondary outcome – favorable neurologic function
• 883 of 12,560 patients (7.0%) in the intervention group
• 844 of 10,995 (7.7%) in the control group
• 95% CI, −1.4 to 0.1; P = 0.09
Trial of Continuous or Interrupted Chest Compressions during CPR
• Conclusion
• Continuous chest compressions with positive-pressure ventilation did not result in significantly higher rates of survival or favorable neurologic status than the rates with a strategy of chest compressions interrupted for ventilation
1/11/2018
37
Management of sickle cell disease summary of the 2014 evidence-based report by expert panel members
• JAMA 2014
Start the screening early
1/11/2018
38
Vaso-occlusive Crisis
Acute Chest Syndrome
1/11/2018
39
Acute Stroke
Other Acute Complications
1/11/2018
40
Chronic Complications
Hydroxyurea
1/11/2018
41
Blood Transfusion
Opiates and Sickle Cell Disease
• December 2017, Jeffery Glassberg, MD, MA ACEP Now
1/11/2018
42
Ischemic Limb Gangrene with Pulses
New England Journal of Medicine : 373;7 – August 2015
Ischemic Limb Gangrene with Pulses
• Two Distinct Syndromes
• Venous limb gangrene • *Acral necrosis in a limb with a DVT
• Cancer-Associated DIC• Heparin-Induced Thrombocytopenia
• Systemic peripheral gangrene • Acral necrosis in all limbs
• DIC• Pathologic thrombin generation • Impaired fibrinolysis & fibrin deposition
1/11/2018
43
Ischemic Limb Gangrene with Pulses
Ischemic Limb Gangrene with Pulses
• Venous Limb Gangrene - Cancer associated
1/11/2018
44
Ischemic Limb Gangrene with Pulses
• Venous Limb Gangrene - Heparin-Induced Thrombocytopenia
Ischemic Limb Gangrene with Pulses
• Venous Limb Gangrene
• Pathophysiology
• *Procoagulant factor VII and anticoagulant protein C have short half lives susceptible to depletion in consumptive coagulopathy
• Prothrombin has a much higher half life
• therefore….
• Despite high INR, microthrombosis persists
1/11/2018
45
Ischemic Limb Gangrene with Pulses
Ischemic Limb Gangrene with Pulses
• Prevention and Treatment
• Avoidance of warfarin in cancer associated DVT
• Avoidance of warfarin during the acute phase of HIT
• Vitamin K infusion for high INR
1/11/2018
46
Ischemic Limb Gangrene with Pulses
• Symmetric peripheral gangrene • Acral necrosis distal extremities
• Purpura fulminans • Multicentric, non-acral necrosis
• Septecemia associated DIC• Fever, hypotension, petechial rash confluent purpura
ischemia
Ischemic Limb Gangrene with Pulses
1/11/2018
47
Ischemic Limb Gangrene with Pulses
• Symmetric peripheral gangrene & Purpura Fulminans
Ischemic Limb Gangrene with Pulses
1/11/2018
48
Ischemic Limb Gangrene with Pulses
• Symmetric peripheral gangrene & Purpura Fulminans
• Microorganisms
• Neisseria meningitidis – children
• Streptococcus pneumoniae – adults
• Encapsulated bacteria – asplenic
• Group A strep, staphylococcus, gram-negatives
• Rickettsia, malaria, TB, rubeola, varicella
• Capnocytophagia from bites
Ischemic Limb Gangrene with Pulses
• Symmetric peripheral gangrene & Purpura Fulminans
• Acute ischemic hepatitis (shock liver)
• Can cause symmetric peripheral gangrene
• Limb necrosis 2 – 5 days after elevation of liver enzymes
1/11/2018
49
Ischemic Limb Gangrene with Pulses
• Treatment for venous limb gangrene and symmetric peripheral gangrene• Heparin
• Natural anticoagulant repletion (protein C)
• Maximize limb perfusion
• Surgical consideration and wound care
Ischemic Limb Gangrene with Pulses
• Summary • Venous limb gangrene and symmetric peripheral
gangrene are usually associated with microvascular thrombosis with underlying DIC.
• Prevention and treatment of venous gangrene requires correction of abnormalities associated with the use of vitamin K antagonists and aggressive anticoagulation
• Treatment of symmetric peripheral gangrene (with or without purpura fulminans) theoretically involves heparin-based anticoagulation and the substitution of natural anticoagulants.
1/11/2018
50
Contact us with any questions:
`
• Pediatric Extracorporeal Membrane Oxygenation: Am Introduction for Emergency Physicians. Journal of Emergency Medicine. Gehrmann, Lynn P. MD; Hafner, John W., MD. October 1, 2015. Volume 49, Issue 4. Pgs 552-560
• Tranexamic acid for traumatic brain injury: a systematic review and meta- analysis. American Journal of Emergency Medicine. Zehtabchi, Shahriar, MD; Abdel Baki, Samah G., MD; Falzon , Louise, BA; Nishijima, Daniel K., MD; December 1, 2014
• Immune Thrombocytopenic Purpura (ITP) Medscape. Craig M Kessler, MD. Updated December 2, 2016 http://emedicine.medscape.com/article/202158-overview
• Management of sickle cell disease summary of the 2014 evidence-based report by expert panel members; JAMA. 2014;312 (10): 1033-1048
• Colorado Cannabis Legalization and its Effect on Emergency Care. Ann Emerg Med. Kim, Howard S., MD; Monte, Andrew A., MD 2016; 68; 71-75
• Ischemic Limb Gangrene with Pulses. N Engl J Med. Warkentin, Theodore E., MD. 2015; 373; 642-655
• Amiodarone, Lidocaine, or Placebo in Out-of-Hospital Cardiac Arrest. P.J. Kudeunchuk et al. N Engl J Med. 2016; 374; 1711-1722
• Acute Pericarditis. N Engl J Med. LeWinter, Martin M., MD. 2014; 371; 2410- 6
• Trial of Continuous or Interrupted Chest Compressions During CPR. N Egl J Med. 2015; 373: 2203-14 1.
• Mozaffarian D, Benjamin EJ, Go AS, et al. Executive summary. Circulation. 2015;131(4):434-441. (AHA 2015 Update-Executive Summary)