Guillain Barre

Today a patient presented with b/l LE weakness, something we've all probably seen a couple times in the south side and something that is ofter dismissed by ED providers. One thing to consider and evaluate for is Guillain Barre Syndrome, it is a extremely common MISSED diagnosis.

Only 25% of patients were accurately diagnoses their first visit, with the average of 2 visits needed to be correctly diagnosed!!!

The team this morning, thought of GBS, which of course is the first step, and astutely worked up the patient appropriately. So lets talk GBS!

What is it? Acute immune-mediated polyneuropathy

• Acute monophasic paralyzing illness approx 88% provoked by a preceding infection
• Mcc: C, jejuni, CMV, EBV, HIV, and now Zika!
• Can also be from immunization, trauma, surgery and bone-marrow transplantation

Variants:

Symptoms?

• We all learn the ascending b/l LE weakness, but can start in the arms in 10% of patients
  • 90% of pts will have decreased or absent reflexes in UE or LE
• CAN BE PAINFUL! This is due to nerve root inflammation
• Up to 10-30% develop respiratory failure requiring intubation
• Also a/w dysautonomia and SIADH
• 50% have facial palsies or oropharyngeal weakness

Clinical Course:

• Prodromal illness--> 5-7days then onset of neuromuscular symptoms
• Rapidly progressive weakness/parethesias ( can be difficulty climbing stairs or walking)
• Plateau 2-4 weeks, often bedridden
• Recovery
• Can be rapidly progressive form with quadriplegia and resp failure within 48hrs!
• 4-15% mortality
  • Complications include: sepsis, ARDS, PE, cardiac arrest

Workup:

• PE: AREFLEXIA!
• Basic labs for evaluation of other etiologies of complaints
• LP w/ CSF showing albuminocytologic dissociation (high protein normal wbc)
• EMG testing as inpatient  

Management:

• 25% require intubation! 
• Think of the 20-30-40 Rule when deciding to intubate:
  • FVC <20 
  • Max Inspiratory pressure <30
  • Max Expiratory pressure <40
• Plasma exchange and IVIG are most efficacious if started within the first 2 weeks of symptoms
  • Get CSF first!
• NO ROLE FOR STEROIDS

Sources: EMDocs, Uptodate, EMRAP

Ottawa Aggressive Protocol

For today's POTD, we're dusting off our analytical skills and looking at an important paper from 2010 that attempted to settle the age-old debate of how to best manage symptomatic acute-onset (<48 hr) atrial fibrillation, using a strategy known as the Ottawa Aggressive Protocol. The actual paper is available here (https://www.cambridge.org/core/services/aop-cambridge-core/content/view/S1481803500012227), but here is a bite-sized summary for you all, because 'tis the season of giving.

First things first: What is the Ottawa Aggressive Protocol (OAP)? The OAP study aimed to show that rapid cardioversion followed by discharge home was a safe and effective option for those ED patients presenting with clear acute onset a-fib (defined below as <48 hr duration) who were clinically stable.

Study population: 660 adult patients presenting to a single Ottawa hospital with symptomatic atrial fibrillation for <48 hr

Exclusions: Patients with chronic AF, symptoms > 48 hours or of unknown duration, and/or patients with another primary diagnosis requiring hospital admission.

Intervention: All 660 patients got an initial attempt at pharmacologic conversion with IV procainamide (1 g infused over 1 hour). If the patient had a history of failure to respond to procainamide, an alternative IV antiarrhythmic agent could be used before moving on to electrical cardioversion in the ED. Patients with a history of multiple unsuccessful prior attempts at pharmacologic cardioversion using all available drugs proceeded directly to electrical cardioversion. Attempts at rate control (with IV metoprolol or diltiazem) were performed in those patients who were either highly symptomatic or not planning to undergo cardioversion.

Design: Retrospective, consecutive cohort study

Key results: 58.3% of patients successfully converted with procainamide. 91.7% of patients successfully converted with electrical cardioversion. 96.8% of patients were discharged home; of those 93.3% were in normal sinus rhythm. At the 7-day mark, the relapse rate was only 8.6% (i.e. patient found to be back in a-fib). There were zero cases of thromboembolic events, torsades, or death. Median ED length of stay was 4.9 hours (3.9 hr for those pts who converted after procainamide; 6.5 hr for those requiring electrical cardioversion).

Weaknesses: Not a RCT; no blinding; only 7 days of follow up.

What does it mean for my practice? The Ottawa Aggressive Protocol is a reasonable approach for management of AF of <48 hours duration, and may help decrease lengths of stay and resource utilization (sparing a hospitalization). Patients were safely discharged after cardioversion (procainamide +/- electricity) without need for systemic anticoagulation or antiarrhythmic prophylaxis, with arrangements for outpatient cardiology follow-up.

References: 

Stiell et al. Association of the Ottawa Aggressive Protocol with rapid discharge of emergency department patients with recent-onset atrial fibrillation or flutter. CJEM, 2010 May;12(3):181-91.

CoreEM.net

WikEM.org

Trauma Tooth-day!

I know lame pun... But today lets talk dental trauma. Why? Because while we don't see it often it is ALWAYS on boards and inservice, so lets review the simple stuff we need to know. ( Highlighted stuff is the most commonly seen exam questions!)

A tooth:

• Pulp- vascular, that makes it red/pink colored. If exposed can be painful
• Dentin- Makes up the bulk of the tooth, yellow colored
• Enamel- Outer visible layer, white colored (mostly)

Primary teeth- 20 teeth by age 3, lettered not numbered, don't worry about that..

Permanent teeth- 32 in total and should be there between 6-13 years old

Traumatic Injuries:

• Fracture/Ellis Classification: Remember anatomy from above and think white/yellow/red!

• • Type 1: Supportive care ie pain control soft diet, refer to dentist
  • Type 2: Risk of pulpal necrosis, treat with sealant such as calcium hydroxide and 24 hrs follow up!
  • Type 3: Consider urgent dental consult, pain control and if no dental available at minimum cover with calcium hydroxide and if available glass ionomer. Pt needs URGENT follow up as high risk of abscess and pulp necrosis

• Luxation:
  • Partial displacement from socket and can involve periodontal ligament and alveolar bone
  • TRX: Dental consult for splinting!
• Intrusion:
  • Apical displacement into bone- tooth will look shorter or missing
  • GET XRAY!
    • If >3mm tooth needs to be repositioned by DENTAL!
• Avulsion:
  • Time is tooth- each minute out viability decrease by 1%!!!
    • Best survival if implanted within 15-30min
    • Don't worry if pt is less than 6yrs old
  • Handle only the crown, rinse with sterile saline or tap water for max 10s
    • Irrigate the socket and remove any accumulated clot
    • Place in socket and splint while waiting for URGERY dental consultation
  • If unable to re-implant place in patients mouth- saliva is a great medium = Hanks solution > Milk > Saline. NEVER TAP WATER and DON'T LET THE TOOTH DRY OUT
• Alveolar Fracture:
  • Consider if multiple teeth are dislocated or are loose on palpation
  • Get CT face, urgent dental consult and DON'T implant any loose teeth.

SOURCES: EMDocs, Uptodate, Tintinallis