Questions of the Week for 11/21/2023

Author: Christian Gerhart

You have a 70 yo patient who presents with lower abdominal pain. His CT A/P shows a 5.7 cm abdominal aortic aneurysm without CT evidence of instability. His workup otherwise shows no abnormalities. He has normal vitals but continues to complain of lower abdominal pain. How should this patient be managed?

  • This patient likely has a symptomatic abdominal aortic aneurysm and the case should be discussed with vascular surgery for expedited repair. Symptomatic abdominal aortic aneurysms require urgent repair and the patient should be admitted for preoperative optimization and urgent surgery1.

You get sign out on a 75 yo female with a history of hypertension who presented with upper abdominal pain and vomiting. Her CT shows evidence of gastroenteritis. She has an incidentally found 6.0 cm abdominal aortic aneurysm on her CT. How should this patient be managed?

  • It is generally recommended that patients with a AAA >6.0cm be admitted for expedited repair even if they are asymptomatic1. For males with a AAA >5.5 cm or females with a AAA >5.0 cm repair is recommended however the timing depends on the patient’s presentation and comorbidities. It is probably best to discuss the case with vascular for all of these patients in the ED to discuss either admission for expedited repair or prompt outpatient follow up for elective repair.

A 46 yo female with a history of hypertension presents with two hours of neck pain and left facial droop. She undergoes a CTA head and neck which demonstrates a right common carotid artery dissection. How should this be managed?

  • tPA is indicated for patients with acute ischemic stroke from cervical artery dissection assuming there are no other contraindications and no involvement of the aorta. The AHA gives a Class 2a recommendation for tPA administration for stroke from extracranial cervical artery dissection. The evidence is not as definitive for patients with intracranial dissections or intracranial extension.

List 5 factors that worsen right heart failure.

  • Hypoxemia, hypercapnia, acidemia, tachydysrhythmias, positive pressure ventilation, hypotension, volume overload. These should be aggressively corrected in patients with pulmonary hypertension. Sometimes intubation may be necessary but if possible, it is generally best to avoid it in these patients.

You have a patient who presented with shortness of breath. Their initial vitals were notable for tachycardia and borderline low blood pressure. You go with them to the CT scanner where they have a saddle pulmonary embolism. When you get back to TCC with the patient they look increasingly toxic and become bradycardic. They then go into cardiac arrest in front of you. How should they be treated?

  • The “code dose” of alteplase is controversial however the most evidence-based dose seems to be 50 mg given as an IV push over one minute4. 100 mg as an IV push is also a potentially valid option though is not as well studied. If alteplase is given to a patient who codes from a PE, it is recommended that CPR continue for at least 60-90 minutes5,6 before the resuscitation be terminated.

You are working in the community and have a patient who presents after a fall with ankle pain. You obtain an x-ray which demonstrates a Weber A fibular fracture. There is no clear space widening. The patient has a normal neurovascular examination without any skin tenting or evidence of an open fracture. How should this patient be managed?

  • Generally, patients with an uncomplicated Weber A ankle fracture can be managed with early weight bearing as tolerated in a CAM boot. Some authors recommend a stress view to ensure no ankle instability prior to recommending weight bearing status especially if there is any medial malleolar tenderness. If there is clear space widening on x-ray, these patients should be immobilized in a short leg splint and be made non-weight bearing until they see orthopedics.

You are in TCC and have a patient who has a generalized, tonic-clonic seizure. They receive 4 mg of lorazepam x2 and are still seizing after 15 minutes in the room. You are preparing for an airway as the patient is unable to protect their airway and still actively seizing. Describe your induction/paralytic medications.

  • Either ketamine or propofol are excellent induction agents as both have anti-epileptic properties. Propofol (1-2 mg/kg) may be preferred for extremely hypertensive patients whereas ketamine may be preferred for normotensive (1-2 mg/kg)/hypotensive (0.5-1 mg/kg) patients. Depending on the patient’s hemodynamics, both agents can be utilized as part of the induction cocktail. Regarding paralytics, succinylcholine has the advantage of being shorter acting but carries the risk of hyperkalemia and is usually avoided if there is concern for rhabdomyolysis or a chronic neurological disorder which could predispose to this. These are complications as possible in patients with prolonged seizure and therefore some authors favor rocuronium for paralysis in patients who have prolonged seizure (usually over 10-15 minutes). It is crucial to be aggressive with propofol (usually doses in the 50-60 mcg/kg/min range) or benzodiazepine sedation following intubation to stop the seizure. This is especially important if rocuronium is used as there may be a delay in the patient getting hooked up to EEG and you won’t be able to reliably tell if the patient is seizing without EEG once they are paralyzed. You may need to start the patient on vasopressors in order for them to tolerate the high doses of sedation needed for this.

After you intubate the patient and start them on a propofol infusion you go to your computer to put in additional anti-epileptic medication orders. What second line agent should you administer?

  • Levetiracetam or Keppra is usually the safest and easiest anti-epileptic medication for status epilepticus. The ESETT8 trial showed that there was no statistically significant difference in seizure termination between Levetiracetam, Phenytoin or Valproic Acid. Levetiracetam has less drug-drug interactions and so is a good default option. Remember that your dose for status is much higher than usual Levetiracetam dosing. For status you will dose Levetiracetam at 60 mg/kg with a maximum dose of 4.5 g. That means anybody over 75 kg will receive a full 4.5 g. The dosing for Phenytoin in status is 20 mg/kg with a max of 1500 mg. The Valproic Acid dose is 40 mg/kg with a max of 3000 mg.

 References: 

  1. Chaikof EL, Dalman RL, Eskandari MK, et al. The Society for Vascular Surgery practice guidelines on the care of patients with an abdominal aortic aneurysm. J Vasc Surg. 2018;67(1):2-77.e2. doi:10.1016/j.jvs.2017.10.044 

  2. Engelter ST, Dallongeville J, Kloss M, et al. Thrombolysis in cervical artery dissection--data from the Cervical Artery Dissection and Ischaemic Stroke Patients (CADISP) database. Eur J Neurol. 2012;19(9):1199-1206. doi:10.1111/j.1468-1331.2012.03704.x 

  3. Powers WJ, Rabinstein AA, Ackerson T, et al. 2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association [published correction appears in Stroke. 2018 Mar;49(3):e138] [published correction appears in Stroke. 2018 Apr 18;:]. Stroke. 2018;49(3):e46-e110. doi:10.1161/STR.0000000000000158 

  4. Sharifi M, Berger J, Beeston P, et al. Pulseless electrical activity in pulmonary embolism treated with thrombolysis (from the "PEAPETT" study). Am J Emerg Med. 2016;34(10):1963-1967. doi:10.1016/j.ajem.2016.06.094 

  5. Böttiger BW, Wetsch WA. Pulmonary Embolism Cardiac Arrest: Thrombolysis During Cardiopulmonary Resuscitation and Improved Survival. Chest. 2019;156(6):1035-1036. doi:10.1016/j.chest.2019.08.1922 

  6. Truhlář A, Deakin CD, Soar J, et al. European Resuscitation Council Guidelines for Resuscitation 2015: Section 4. Cardiac arrest in special circumstances. Resuscitation. 2015;95:148-201. doi:10.1016/j.resuscitation.2015.07.017 

  7. Mehta SS, Rees K, Cutler L, Mangwani J. Understanding risks and complications in the management of ankle fractures. Indian J Orthop. 2014;48(5):445-452. doi:10.4103/0019-5413.139829 

  8. Kapur J, Elm J, Chamberlain JM, et al. Randomized Trial of Three Anticonvulsant Medications for Status Epilepticus. N Engl J Med. 2019;381(22):2103-2113. doi:10.1056/NEJMoa1905795 

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