Questions of the Week for 10/3/2023
Authors: Christian Gerhart and Katherine Stuart
A 30 yo male presents with altered mental status. He has a history of depression and takes a first-generation anti-psychotic medication. His exam is notable for rigidity in all four extremities, mild confusion, and agitation. His vitals are HR 140, BP 160/110, RR 28, O2 sat 94% on RA, T 41C. POC glucose is normal. Describe your initial stabilization package and workup for this patient.
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This hyperthermic patient requires aggressive supportive care. The initial stabilization package for this patient should include IV access, cardiac/respiratory monitoring and IV fluids. Aggressive cooling should be pursued with ice packs and fans. Benzodiazepines are generally preferred for initial management. Dantrolene can also be considered. Given this patient's history/exam, which raises concern for neuroleptic malignant syndrome, anti-psychotics should be avoided. Anti-pyretics can be given but likely won’t be particularly helpful. Although NMS is suspected, a broad workup including CBC/CMP/TSH, CK, blood cultures, UA, lactate, CT head and an LP should probably be pursued.
A patient presents with seizure-like activity. What features can help you distinguish between epileptic and non-epileptic seizures?
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A few key distinguishing features include eye movements, eyelid activity, vocalization and post ictal state. If a patient has forced eye closing, purposeful eye movements without gaze deviation or is crying/yelling during the episodes this is likely to be a non-epileptic event. Patients with horizontal gaze deviation, prolonged post-ictal state are more likely to have an epileptiform seizure.
A 22-year-old male presents for an ankle injury while playing football. What physical exam findings/decision rules would prompt you to obtain imaging of the ankle in this patient?
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The Ottawa ankle rules were developed to help clinicians know when a patient with an ankle injury might have an underlying bony fracture. The criteria state an ankle radiograph is required when the patient has pain in any malleolar zone and one of the following findings: bone tenderness over the distal 6 cm of the posterior border or tip of the medial malleolus, bone tenderness over the distal 6 cm of the posterior edge or tip of the lateral malleolus, or inability to bear weight both immediately and in the emergency department. Radiographs of the foot are indicated when a patient has pain in the midfoot zone and has either bone tenderness to palpation at the base of the fifth metatarsal or navicular or they are unable to bear weight both immediately and in the emergency department.
A 22 year old male presents after an MVC. He has a right small pneumothorax and three right sided rib fractures as well as a small liver laceration. He is also complaining of left ankle pain. He has a normal neurovascular exam but cannot bear weight on his ankle and has significant overlying swelling. There are no lacerations present. His compartments are soft. His ankle and tibia/fibula X rays are negative for fracture. What diagnosis should be considered to explain his ankle pain?
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This patient has a compelling story for a talus fracture given his high mechanism trauma (rib fractures, pneumothorax, liver laceration). Some authors have labeled the talus the “scaphoid bone of the ankle”, given that fractures are commonly missed on X ray and the bone has a high rate of avascular necrosis when fractured. The sensitivity of X ray for talus fractures is estimated to be about 75%. Consider a CT without contrast of the ankle if you have a high suspicion for a talus fracture as many of these injuries are operative.
References:
1) Schwartz AM, Runge WO, Hsu AR, Bariteau JT. Fractures of the Talus: Current Concepts. Foot & Ankle Orthopaedics. 2020;5(1). doi:10.1177/2473011419900766.
2) Helman A. EP 105 Commonly missed ankle injuries. Emergency Medicine Cases. October 2022. https://emergencymedicinecases.com/commonly-missed-ankle-injuries/.