June 2018 | Volume 18 Issue 06
Editor-in-Chief: Mel Herbert, MD
Executive Editor: Stuart Swadron, MD
Associate Editor: Marlowe Majoewsky, MD
June Intro
Stuart Swadron MD and Jan Shoenberger MD
Take Home Points
Air with urination (pneumaturia) may result from gas-
forming organisms or fistulas.
Face-to-face communication can help resolve conflict in
the emergency department.
Direct visualization with a fiberoptic scope demonstrat-
ing a normal airway can help avoid intubation.
CASE
A 20 year old Asian male patient presented with a chief com-
plaint of peeing air.
What is the official term for this? Pneumaturia.
What is the differential diagnosis?
Infection with a gas-forming organism like Proteus. This is
usually an older man with a history of prostate disease or in-
strumentation and staghorn calculi with Proteus. If you do a
plain film, you may identify the staghorn calculus. The pH of
the urine is high.
Fistula. This can happen in Crohn’s disease.
Pneumaturia can happen in scuba divers using a P-valve to
divert urine outside of their dry or wet suit. This can introduce
air into the urine.
The patient was well-appearing with normal vital signs. He
reported a history of irritable bowel syndrome. He had also un-
dergone three courses of antibiotics for a urinary tract infection
that was not clearing. The physical examination was completely
normal. There was no tenderness of the abdomen or costover-
tebral angle tenderness.
EM:RAP Written Summary June 2018: Volume 18, Issue 6
www.emrap.org
The urinalysis showed positive nitrates and leukocytes. The
pH was 6. The presentation was concerning for a fistula.
The next urine sample showed fecal material.
Shoenberger was in the midst of a busy triage shift. She called
the nurse manager to ask for help. The nurse manager was
stressed out and the interaction was negative. Shoenberger
was frustrated.
Shoenberger hung up the phone and felt badly about the in-
teraction. She sought out the nurse and found her in a corner
on the verge of tears. Shoenberger said, “Hey, that was not the
most positive interaction on the phone. Is there anything I can
do to help?”
The nurse thanked her for asking. They talked about the issues
in the emergency department, the shortages and the staffing
limitations. It turned from a negative interaction to a positive and
collegial interaction.
It reminded Shoenberger that face-to-face communication is ir-
replaceable.
CASE
A patient was badly beaten. His entire face was swollen. Al-
though he had oxygen saturation of 99% and he did not have
stridor, he kept saying that he was suffocating. Previously,
Swadron would have intubated the patient. Instead, they nebu-
lized some lidocaine and took a look with the fiberoptic scope.
They evaluated the cords and the airway was unremarkable.
Rather than intubating the patient, they treated him with ket-
amine. They knew that even though he had a feeling of suffo-
cation, he didn’t need to be intubated.
EM:RAP is going to have an increased focus on clinical sce-
narios. Leave comments, questions and concerns on the web-
site. There will be a live show at ACEP this year. Sign up for
ACEP and then sign up for EM:RAP.
1

Medicolegal 101:
The Dreaded AAA
Mike Weinstock MD
Take Home Points
The classic triad of abdominal aortic aneurysm (abdomi-
nal or back pain, pulsatile abdominal mass and hypoten-
sion) is present less than 50% of the time.
Physical exam and history do not have sufficient ability to
exclude an AAA.
Don’t get unnecessary radiologic tests.
For AAA over 6 cm, the risk of rupture is 10-50%.
CASE
A 73 year old man with a history of hypertension developed
back pain and called his primary care physician. The physician
referred him to the emergency department. He arrived at 9:03
PM. He complained of one day of constant abdominal pain
radiating to the back with some loose stools. His vital signs
showed he was afebrile, heart rate was 96 and his blood pres-
sure was 110/60. The physical exam as documented described
him as alert, resting quietly and breathing comfortably. The
exam of the abdomen described a naturally large abdomen
with tenderness to deep palpation in the lower quadrants.
Differential diagnosis?
Constipation. This is still a common cause of abdominal pain.
Lumbosacral sprain or idiopathic low back pain.
Ureteral stone.
Acute pancreatitis. Renal cell carcinoma. Pyelonephritis. Pep-
tic ulcer disease. Perforated gastric or duodenal ulcer. An ex-
panding or ruptured abdominal aortic aneurysm.
Shingles.
What did they do? An EKG was ordered and was fine. Lab work
was all normal except a slightly decreased hemoglobin at 13.4.
An abdominal series was read by the emergency physician as
consistent with constipation.
The patient was told he was “full of shit.” He was prescribed
suppositories and was discharged at 1:15 am.
Diagnosis. 1) Abdominal pain – etiology to be determined. 2)
Possible constipation on x-ray 3) Can’t rule out gastroenteritis
with pain only represented by abdominal spasm.
What happened? The patient returned home and his pain wors-
ened. At 3:50 am, he returned to the emergency department.
2 EM:RAP Written Summary | www.emrap.org
He was triaged but while walking back to the room at 3:51, his
legs buckled and he collapsed to the ground in cardiac arrest.
CPR was started and the vascular surgeon was paged. They
found the patient unresponsive without a pulse. Resuscitation
was unsuccessful. The vascular surgeon spoke with the family
and the code was called.
What did the plaintiffs allege? The defendant negligently
discharged the patient when he had one or two of the three
hallmark signs of abdominal aortic aneurysm. Appropriate di-
agnostic studies would have revealed a large abdominal aortic
aneurysm prompting immediate life-saving surgery.
AAA occurs in about 1% of men between 55-64 years old. It
increases 2-4% per decade. Often when patients present with
a ruptured AAA, they do not have a previous diagnosis of AAA.
The risk increases with size. At 5 cm, the risk of rupture is 5%.
Over 6 cm, the risk of rupture is 10-50%.
The classic triad is abdominal or back pain, pulsatile ab-
dominal mass and hypotension. This triad is present less
than 50% of the time.
How good are we at abdominal palpation? The sensitivity is
about 67%. We will be able to palpate a pulsatile mass in 2 out
of 3 patients with AAA. Missing this a third of the time is not
good enough.
Cullen’s sign (bruising around the umbilicus) and Grey
Turner’s sign (bruising of the flanks indicating retroperito-
neal hematoma) rarely occur.
Physical exam may be limited by obesity.
A bedside ultrasound of the abdominal aorta is thought to be
very sensitive for detection of aneurysm. However, this study
may be limited by body habitus and presence of bowel gas.
The next day, the radiologist reviewed the x-ray and concluded
“11 cm calcified abdominal aortic aneurysm without obvious ra-
diographic evidence of rupture.” An abdominal x-ray was done
on an elderly patient with abdominal pain and had a positive find-
ing. Because the physician was likely looking for evidence of bow-
el obstruction or free air, they did not look at the calcifications.
If you think you are doing yourself or your patient a favor with
inappropriate imaging for back pain or abdominal pain, it may
place you at significant risk if you do not recognize a serious
process.
The plaintiff alleged that the patient’s presentation was con-
cerning for AAA, there was radiologic confirmation and if an ul-
trasound had been performed, it would have confirmed a large
AAA. They alleged the patient had greater than a 50% chance of
survival if this diagnosis had been made. The decedent was the
sole financial provider for his immediate family and was active in
the management and operation of the family business.
 What was the response of the physician? The patient was sta-
ble in the ED and even if the AAA has been diagnosed, the out-
come would not have differed.
The claim was for $250,000 and the case was settled prior to
trial for $150,000.
When patients present to the emergency department, they
ask us a question but what they are really asking may be more
subtle. A 17 year old female who has been amenorrheic for 2
months and has left lower quadrant pain may be asking us for
pain medication but she is really asking us if she has a ruptured
ectopic pregnancy. This patient in his 70s with a history of hy-
pertension and abdominal and back pain was asking if he had a
AAA. We are required to answer that question.
Physical exam and history do not have sufficient ability to ex-
clude an AAA. If you are concerned about this, you need to get
further testing.
We often talk about the golden hour of trauma. There is a
golden 45 minutes for ruptured AAA. This diagnosis needs to
be made quickly. In addition to calling the surgeon, anesthesiol-
ogy and nursing need to be involved.
In this case, there was a claim of both failure to diagnose and
also delay in diagnosis. The defendant claimed that even if the
diagnosis had been made, the patient likely would have died.
This is debatable.
Don’t get unnecessary radiologic tests. It can only harm.
Critical Care Mailbag:
Angiotensin II
Anand Swaminathan MD and Scott Weingart MD
Take Home Points
The FDA recently approved a new drug, angiotensin II,
for the treatment of refractory vasodilatory shock.
There is insufficient evidence to use angiotensin II as a
first choice vasopressor.
This may be a good vasopressor in patients with ARDS.
The FDA recently approved a new drug, angiotensin II, for the
treatment of refractory vasodilatory shock.
This approval is based on one article.
Khanna, A et al. Angiotensin II for the treatment of vaso-
dilatory shock. N Engl J Med. 2017 Aug 3;377(5):419-430.
DOI: 10.1056/NEJMoa1704154
What is refractory vasodilatory shock? The patient is on va-
sopressors and not improving. There is no standardized dose
June 2018: Volume 18, Issue 6 | www.emrap.org
of vasopressors. However, if the patient is receiving 20 mcg of
norepinephrine and they are still hypotensive, Weingart views it
as a refractory shock patient.
What is the deal with angiotensin II? We don’t know yet. It is
expensive. The evidence is scant at this point. It potentially rep-
resents a new path in the treatment with persistent hypotension
due to vasodilation.
At this point, you will have tried the most conventional agents
first. You can think of vasopressors as a three legged stool; al-
pha-agents, vasopressin receptor agonists and now angiotensin II.
You have already tried your alpha-agonist (norepinephrine
or phenylephrine). You have already tried vasopressin. An-
giotensin II may be your next option.
Before you give angiotensin II, Weingart would evaluate the
heart and consider an inotropic issue needing epinephrine,
milrinone or dobutamine.
When should we use angiotensin II? Weingart would not use it
as a first choice for a vasopressor. His first choice would be nor-
epinephrine. There is insufficient evidence to use angiotensin II
as a first choice. However, there seems to be some indication
(although this is mostly from people at the company itself) that it
is a better vasopressor for patients with ARDS. If more evidence
accumulates, it may be an option in this patient population.
Weingart will use this solely when a patient has failure to
improve with norepinephrine, vasopressin and an inotrope
(or if their heart function looks good).
We probably use doses of alpha-agonists that are too low.
Most hospitals have an arbitrary ceiling for norepinephrine
of 20 or 30 mcg. Some of these patients need more. Some
avoid this limit by giving phenylephrine. Phenylephrine does
not make sense as a vasopressor unless you are trying to skirt
limits of norepinephrine by using it. We can consider going up
on our norepinephrine dose.
If you have a patient with profound vasodilatory shock and you
have done everything you can do (given steroids, ruled out
bleeding, and ruled out thyroid or adrenal insufficiency, you may
reach for angiotensin.)
3

MSIR Response
Reuben Strayer MD
Take Home Points
The vast majority of patients currently sent home from
the emergency department with an opioid prescription
would do very well with opioid alternatives.
If you do prescribe opioids, do so for a very brief duration.
The likelihood of long term opioid use increases linearly
with the duration of the first opioid prescription.
Avoid prescription opioids that are thought to be more
prone to abuse.
In March 2017, Strayer had a segment on opiate misuse and
how we can do a better job for our patients. A lot of questions
and conversations resulted from his suggestion to use immedi-
ate release morphine if you are going to prescribe an opiate.
Replacing acetaminophen-oxycodone or acetaminophen-hy-
drocodone with immediate release morphine is not the
most important step for emergency providers who want to
prescribe opioids more responsibly but it has proved to be
Strayer’s most controversial recommendation. The most con-
sequential change you can make in your practice is to prescribe
opioids to fewer patients and keep opioid-naïve patients opi-
oid-naïve.
1. The vast majority of patients currently sent home from the
emergency department with an opioid prescription would do
very well with opioid alternatives. Make it your habit to pre-
scribe 1 gram of acetaminophen and 400 mg of ibuprofen every
six hours. Use other alternatives such a topical NSAIDS, local
anesthetic patches and injections. Non-pharmacologic treat-
ments such as ice, heat, elevation, immobilization, massage,
physio, yoga, medication, religion, distraction. The best distrac-
tion is resumption of usual activities as best they can. Strayer
feels that staying home from school or work rarely benefits any-
one and leads to harm by leaving the patient with nothing to do
other than focus on their pain.
2. If you do prescribe opioids, do so for a very brief duration.
The most painful period in the natural history of acute pain is in
the first day or two. After that, if the patient still has severe pain,
they should be evaluated again. If you feel that the benefit of
an opioid prescription outweighs the harms, prescribe at most
2-3 days. Strayer generally prescribes 7-9 pills and advises that
these are for breakthrough pain if the other strategies aren’t
enough over the next 48 hours.
We know that the likelihood of long term opioid use increas-
es linearly with the duration of the first opioid prescription.
The most commonly used opioids prone to abuse are hy-
drocodone and oxycodone. Strayer recommends immediate
release morphine based on his review of the limited literature
and drug message boards where recreational users share
their experiences and make recommendations. MSIR is the
least prone to abuse and otherwise safest non-combination
oral opioid that is effective for pain.
This is a practice change for most and will raise some eyebrows.
Some pharmacies do not stock immediate release morphine
because pharmacies stock what we prescribe. For the past
30 years, we have been prescribing acetaminophen-hy-
drocodone and acetaminophen-oxycodone.
Many are deterred by the recommended dose of 15 mg. Like
hydromorphone, morphine is much more potent IV than PO.
15 mg IR morphine is equivalent to about 5 mg IV morphine,
which is a relatively small dose. The recommended dose
range is 10-30 mg every 4 hours. Immediate release morphine
is available in 15 and 30 mg tabs. You are unlikely to have
trouble with 15 mg tabs in a normal sized, non-elderly adult.
To convince yourself of this dose, use immediate release mor-
phine as your oral opioid agent of choice in the emergency
department so you can observe its effects. You can do this in
patients with renal colic or fractures who present with severe
pain but are likely to be discharged and do not have an indi-
cation for IV access. This strategy will give you the chance to
see how it works.
Using IR morphine instead of combination oral opioids allows
you to use the optimal dose of acetaminophen which is 1 g.
Sergey Motov and Chris Fromm are currently doing a study of
immediate release morphine in the emergency department.
We will have data soon.
If you do use oral morphine or have alternatives to the combi-
nation medications, share your experience so we can all learn
and develop a menu of best practices to allow us to treat pain
and decrease harm.

3. Avoid prescription opioids that are thought to be more prone

to abuse.

4 EM:RAP Written Summary | www.emrap.org


Stuck Foley
Justin Morgenstern MD and Andrew Arcand MD
Take Home Points
To remove a stuck foley, push the catheter in further to
allow the balloon to drain.
If this doesn’t work, cut the catheter.
You can use a guidewire and central line to try to resolve
the obstruction.
If you do not have access to urology, you can try to rup-
ture the balloon mechanically.
Do not use saline to inflate foley catheter balloons.
CASE
An elderly gentleman with a chronically indwelling foley due
to neurogenic bladder presented after they were unable to re-
move the catheter for a scheduled foley change. No matter
what they tried, it wouldn’t budge.
How should you approach this problem? Often the balloon
won’t deflate so the foley won’t come out. Try to push the foley
farther in. Sometime the balloon will be stuck in the upper ure-
thra and the tube can kink. Make sure the actual balloon is in the
bladder. Morgenstern used bedside ultrasound to confirm the
inflated balloon was in an otherwise normal appearing bladder.
What next? The next step is to cut the catheter. If there is a
problem with the inflation valve, cutting the valve off removes
the problem and the balloon should deflate. Don’t cut the cathe-
ter too close to the meatus. You do not want the catheter to slip
back inside the penis.
If this doesn’t work, you can call urology. However, most of us
practice in places without immediate backup. Once you have
ruled out the valve as a problem, the next likely cause is some-
thing blocking the actual drainage tube. You can try to thread
a guidewire from a central line kit through the lumen. This may
clear the obstruction.
If the guidewire doesn’t improve the obstruction, you can
thread a central line over the wire into the foley and then
remove the wire. This will give the balloon another conduit to
drain out of and the balloon can deflate.
You can try to rupture the balloon.
You can consider overinflating the balloon until it pops al-
though this can be uncomfortable for patients and there may
be pieces left in the bladder.
You can also try to dissolve the balloon in the bladder. Mineral
oil will dissolve the balloon and shouldn’t cause any compli-
cations like cystitis.
June 2018: Volume 18, Issue 6 | www.emrap.org
You can mechanically rupture the balloon. This is best done
by urology with a cystoscope but if you are really stuck, you
could try to do it transcutaneously. Similar to the suprapubic
catheter, you can use a needle, preferably under ultrasound
guidance, find the balloon and pop it.
Often this occurs because someone mistakenly used saline
instead of water to inflate the balloon and it forms crystals.
The DAWN Tial:
An Update on Thrombectomy for Stroke
Anand Swaminathan MD and Evie Marcolini MD
Take Home Points
Multiple studies have shown benefit to endovascular in-
tervention in a highly selected cohort of stroke patients.
The DAWN study found benefit to endovascular interven-
tion in patients with ICA or MCA stroke and a last known
well time of 6 to 24 hours prior to presentation.
The average duration of symptoms was 13 hours.
This was an industry funded study using a single device.
It is unclear how this will impact EMS triage and transport
to stroke centers.
In 1996, NIMS was published and stroke care was altered
forever. The harms and benefits of alteplase were widely dis-
cussed. In 2014, the discussion shifted again and centered
around endovascular therapy for stroke.
In 2014, the MR CLEAN trial was published and followed by
multiple articles over the next 12 months.
Berkhemer, OA et al. A randomized trial of intraarterial treat-
ment for acute ischemic stroke. N Engl J Med. 2015 Jan
1;372(1):11-20. PMID: 25517348
The MR CLEAN trial showed that endovascular therapy im-
proved outcome for patients with acute ischemic stroke.
This was important because three studies were published in
2013 in the New England Journal of Medicine which did not
show improvement in outcome with endovascular therapy.
After the MR CLEAN publication, REVASCAT, EXTEND-IA ,
SWIFT PRIME closed their books early and showed results
with improved outcome. This was a defining moment for
stroke neurology and identified endovascular intervention as
an option in addition to tPA.
Part of the reason they were able to demonstrate benefit is
that they selected the right patients. They used CT and MR
perfusion imaging to select the best patients for endovascular
5
 therapy. They looked for patients with a small core infarct and
a larger penumbra. Tissue in the penumbra may be salvaged.
They also had a short time to groin puncture. In MR CLEAN,
the study was supported by the government which led to
good enrollment.
There were some limitations to these studies. With the ex-
ception of MR CLEAN, all of the other trials were stopped ear-
ly which likely overestimated benefit. They used a very nar-
row group of patients as candidates. At some centers, only 1-2
patients a month were enrolled.
When the NIMS study was published, it led to the creation of
stroke centers and ambulances bypassed hospitals to go to
stroke centers. What has been the impact of these endovas-
cular studies on overall care of strokes? Now that we can show
that endovascular therapy works, every hospital with the capa-
bility wants to be a comprehensive stroke center because they
will catch these patients. This impacts how EMS triages patients
and where they go for care. However, it may be difficult to justi-
fy maintaining an interventional team if only 1-2 of these proce-
dures are performed every month. We may see indication creep.
Nogueira, RG et al. Thrombectomy 6 to 24 hours after stroke
with a mismatch between deficit and infarct. N Engl J Med. 2018
Jan 4;378(1):11-21. DOI: 10.1056/NEJMoa1706442
This study used either diffusion weighted imaging or CT per-
fusion to assess patients with delayed presentation to deter-
mine who would be eligible for intervention.
This addresses the problem of wake-up strokes. Guidelines
currently recommend a consideration of endovascular thera-
py for patients with anterior large vessel obstruction within 6
hours of their last seen normal time.
Now that we can determine the presence of viable tissue, can
we extend the time period even farther?
This study looked at patients 6 to 24 hours out. The trial was
stopped early as they found benefit in the treatment arm over
the control arm. This trial looked at patients with ICA and MCA
stroke only. The patients had to have a mismatch that was
predefined as to volume.
They did find a benefit.
On average, patients enrolled in the study were 13 hours after
the last seen normal time.
There are some limitations to the study.
It was industry funded and only used the Trevo device.
Many of the authors are on their payroll.
The authors used the utility-weighted modified Rankin
scale instead of the traditional modified Rankin scale. The
utility-weighted scale gives more weight to good outcomes
than bad outcomes. This may skew the results toward the
6 EM:RAP Written Summary | www.emrap.org
intervention and makes it difficult to compare results from
this study to others.
The bottom-line: the DAWN group found that using the en-
dovascular intervention resulted in better outcomes up to
24 hours after symptom onset. This is a shift in the paradigm
that time=brain to a perspective that patients may still have
salvageable brain tissue a long time after symptom onset.
Still, in these studies, the earlier we get to these patients,
the better they do.
This study was in large vessel strokes.
Should we be doing diffusion weighted imaging and CT an-
giograms in every stroke patient before considering treat-
ment? This would be unreasonable. We need to be smart about
this. Look at the patient’s function and goals to determine if it
makes sense to do advanced imaging. Marcolini would not do
DWI or CT perfusion on every case. We have to be careful of
indication creep.
We need to be smart regarding administration of tPA as well.
Giving alteplase to patients later on in their disease course has
increased risk. We know that giving it earlier decreases the risk
of bleed.
If you suspect a large vessel stroke, should you obtain the
perfusion study more rapidly to facilitate intervention? If the
patient presents with clinical signs of a large vessel occlusion
anterior stroke, Marcolini has her team activated and they often
receive a CT and CTA prior to transport for intervention. The CT
perfusion or DWI studies are performed in patients where they
are unsure if there is a large ischemic penumbra with a small
infarct. The imaging modalities need to be tailored to the patient
in front of you.
It is important for us to know the area of distribution in consid-
ering eligibility of intervention. For those at smaller hospitals,
you need to be careful in determining which patients are eligible
for intervention and need transfer to a center for additional pro-
cedures.
Does this change how we triage patients in the EMS setting?
This raises questions that have yet to be answered but are under
investigation. Where should EMS bring these patients? If EMS is
closer to a hospital without endovascular capability, should they
stop there for tPA or divert to a comprehensive stroke center?
This is an issue in rural areas. How can EMS differentiate between
a large vessel occlusion and all other strokes encountered? New
stroke scales are in development to help EMS in this process.
Should we still be giving systemic alteplase? In cardiology,
they don’t give systemic alteplase if they are close to a center
where they can receive PCI. If they are more than 90 minutes
away, they are given alteplase and transported for PCI. Is this
where stroke management is heading? There are studies in
 progress examining this question. Is it better to give endovas-
cular therapy with tPA or go directly to a comprehensive stroke
center?
Pediatric Pearls:
Pediatric Psych Policy
Ilene Claudius MD
Take Home Points
Routine laboratory testing in the medical clearance of
psychiatric patients is unlikely to identify any conditions
not suspected based on the history and physical exam.
An ACEP policy statement advises laboratory testing and
imaging should only be performed as indicated based on
the patient’s symptoms.
There are no validated criteria for children and adoles-
cents to assess the risk of subsequent suicide.
Don’t underestimate the power of verbal de-escalation in
children.
Medical clearance of psychiatric patients is a frequent prob-
lem. What workup do we need to do? Labs? Imaging?
Medical clearance in adults was covered in an ACEP policy
statement from 2006.
Lukens, TW et al. Clinical policy: critical issues in the diagnosis
and management of the adult psychiatric patient in the emer-
gency department. Ann Emerg Med. 2006 Jan;47(1):79-99.
PMID: 16387222
In general, they recommend a focused medical assessment
in ED psychiatric patients and basing laboratory testing on the
history and physical exam with some high risk features.
Medical clearance of both adults and children is a topic where
we are odds with most psychiatric facilities. From an emergen-
cy department standpoint, medical clearance implies we have
evaluated whether the patient’s current psychiatric or behavior-
al problems are due to or exacerbated by an underlying med-
ical condition or if there is a concurrent medical condition that
requires acute treatment in the emergency department. It does
not mean we have definitively ruled out everything that could
possibly happen to the child.
To rule out an emergent or contributory condition requires a
very thorough history and physical which can be difficult to
do in patients with behavioral and psychiatric emergencies.
What about urine toxicology screening, routine laboratory
tests or radiographs? Don’t do it.
June 2018: Volume 18, Issue 6 | www.emrap.org
The emergency drug screen is unlikely to significantly impact
the management of the patient in the emergency department.
It may be helpful for psychiatrists managing the patient long
term but the results are not necessary for transfer to a psychi-
atric facility.
Routine laboratory testing is unlikely to identify any conditions
not suspected based on the history and physical exam. This
should only be performed as indicated based on the patient’s
symptoms.
We all want patients experiencing their first episode of symp-
toms consistent with schizophrenia to have some findings on
the head CT to explain it. But they don’t. Between 0 and 1.2%
of patients undergoing head CT for new onset psychosis will
have some finding. Given the risks of radiation, it probably is
not a worthwhile test unless their symptoms indicate there
might be more going on.
We have known this for a while, but it is nice to have a formal
document supporting our clinical gestalt.
Regarding the suicidal child or adolescent, the AAP provides
a policy statement on the evaluation and management of
acute mental health or behavioral problems.
They advise a search of the belongings, changing into a
hospital gown and placing the child into as safe a setting as
possible with close staff supervision.
Interviewing the adolescent and parents separately is helpful.
Reassure the adolescent about confidentiality. However, let
them know that the limits of confidentiality end if there is a
concern for harm of themselves or others or concern for po-
tential abuse.
There are no validated criteria for children and adolescents
to assess the risk for a subsequent suicide. It will be up to
your clinical gestalt and that of your consultants. Consider
common risk factors such as gender and impulsivity.
Discharge planning is important. Make sure they have fol-
low-up and emergency contact information. It is surprising
how few people leaving an emergency department after
an attempted or considered suicide have been questioned
about the accessibility of weapons in the home. Many of
these children are impulsive and if there is a weapon or po-
tentially lethal medication in the home, it could be a significant
problem. Talking with parents about limiting the availability of
potentially lethal means is important.
Important principles of restraint include safety of staff and
patient and using the least restrictive, age appropriate meth-
ods possible. Don’t underestimate the power of verbal de-es-
calation in children. Respect their personal space. Don’t be vi-
sually or verbally confrontational with them. Have a 1-2 people
serve as their verbal contact rather than multiple staff coming
7
 in and out. Give them concise updates and directions in their
therapy. You don’t have to agree with what they want but make
sure you listen to them. If you don’t agree, make sure they
clearly understand the limits and expectations that you are
willing to tolerate. When possible, offer them some choices so
they feel like they have some power in a powerless situation. If
that fails, you may need to move on to chemical restraint.
Chemical restraint in children does not differ much from
adults. However, it is often possible to get children to take
oral medications. In a moderately agitated patient, it is rea-
sonable to offer them an oral medication first.
For severely agitated patients, especially those who are ag-
itated due to a substance intoxication, lorazepam is good
choice. It may be given at the same dose, 0.05-0.1 mg/kg up to
the adult dose. It may be administered orally, intravenously or
intramuscularly. In IV administration, the onset of action is 5-10
minutes compared to 20-30 minutes with oral administration.
For antipsychotics, the IM dose of haloperidol is 0.025 to
0.075 mg/kg. This takes about 20 minutes to start working.
Oral olanzapine is available in a rapidly dissolving tablet. The
dose is 0.1 mg/kg.
45 children and adolescent deaths have been attributed to
the use of physical restraints. This is something that should
serve as a last resort. It is required to evaluate all children,
adolescents and adults within an hour of restraint placement.
Children under the age of 9 should be re-evaluated every
hour and children over 9 and adolescents should be evaluat-
ed every 2 hours as compared to the 4 hours in adults.
Chun, TH et al. Evaluation and management of children and
adolescents with acute mental health or behavioral prob-
lems. Part I: Common clinical challenges of patients with
mental health and/or behavioral emergencies. Pediatrics.
2016 Sep;138(3). Open Access Link
Toxicology Sessions:
Loperamide
Stuart Swadron MD and Sean Nordt MD, PharmD
Take Home Points
Loperamide can cross the blood brain barrier in large
doses or with coingestion of an inhibitor.
` Some patients are misusing loperamide to detox from
opiates.
Loperamide can prolong the QTc and lead to death from
cardiac arrhythmia.
8 EM:RAP Written Summary | www.emrap.org
Loperamide has been in the news. There have been deaths re-
ported in patients who are using large quantities to treat opioid
withdrawal. Loperamide has been referred to as the “poor man’s
methadone”. The FDA has been trying to restrict the quantity of
loperamide that can be purchased.
Loperamide is a mu opioid agonist. Despite what people think,
if it enters the brain, it has opioid effects. However, it is very
hard for it to enter the brain. Massive doses, such as 50 to 100 2
mg tablets can overwhelm the blood-brain barrier. Loperamide
is usually excluded from the intestinal and brain cells by P-glyco-
protein. This serves as the “bouncer” of the cell and effluxes the
drug out of the cell. This can be overwhelmed by taking a large
amount or with co-ingestion of a P-glycoprotein inhibitor.
The classic inhibitor of P-glycoprotein is quinidine, but this
is pretty dangerous. Another strategy is via p450 metabolism.
Loperamide is an active drug that is metabolized to inactive
metabolites. If this metabolism is prevented by cimetidine, it in-
creases the level.
Loperamide is highly protein bound to albumin. There is only
so much albumin available. If the albumin is saturated, there is
more free drug which can cross the blood brain barrier.
What should we look for in a loperamide overdose? This ap-
pears similar to any other opioid overdose. Patients may have
somnolence and respiratory depression. Naloxone should re-
verse this. However, it won’t show up on a urinary toxicology
screen.
Loperamide was found to have QT prolongation in exper-
imental models that could lead to Torsades. There is also a
case report of QRS widening that responded to sodium bicar-
bonate. These patients are taking massive doses. There were
two recent deaths assumed to be cardiac from QT prolongation.
Eggleston, W et al. Loperamide abuse associated with
cardiac dysrhythmia and death. Ann Emerg Med. 2017
Jan;69(1):83-86. PMID: 27140747
What can you do if the EKG shows QT prolongation? There
is little downside to giving magnesium. Methadone is well-de-
scribed to cause QT prolongation and Torsades. How do you
treat the Torsades? You can give magnesium or do overdrive
pacing. Isoproterenol is a drug that we use infrequently. This is
a beta-agonist that serves as a chemical overdrive pacer.
Patients have used this to try to detox.

LIN Session:
Choosing Wisely
Michelle Lin MD and Michelle Lin MD
Take Home Points
Choosing Wisely is a campaign that was started to help
avoid tests and procedures that have no meaningful clin-
ical benefit.
A survey found that providers tend to order advanced
diagnostic imaging because they are concerned about
serious diagnoses whereas providers order antibiotics
for sinusitis or imaging for back pain due to patient and
family expectations.
Lin, MP et al. Emergency physician knowledge, attitudes, and be-
havior regarding ACEP’s Choosing Wisely recommendations: a
survey study. Acad Emerg Med. 2017 Jun;24(6):668-675. This pub-
lication was supported by the Emergency Medicine Foundation.
PMID: 28164409
Lin is researching improvement in the value of emergency
care and health outcomes achieved per dollars spent. This is
a ratio of the amount of quality received for the amount of mon-
ey spent. Value can be improved by improving quality, reducing
costs or both. This is similar to Choosing Wisely.
What is Choosing Wisely? This is a campaign that was started
to promote conversations between clinicians and patients to
help patients avoid tests and procedures that have no meaning-
ful clinical benefit. ACEP joined the Choosing Wisely campaign
in 2013. They have since published 10 recommendations about
common low value tests and procedures that all emergency
physicians should avoid. They are evidence based. They are
typically not controversial from a scientific perspective.
5. Avoid instituting intravenous (IV) fluids before doing a trial of
oral rehydration therapy in uncomplicated emergency depart-
ment cases of mild to moderate dehydration in children.
6. Avoid CT of the head in asymptomatic adult patients in the
emergency department with syncope, insignificant trauma
and a normal neurological evaluation.
7.
Avoid CT pulmonary angiography in emergency department
patients with a low pretest probability of pulmonary embolism
and either a negative Pulmonary Embolism Rule-Out Criteria
(PERC) or a negative D-dimer.
8. Avoid lumbar spine imaging in the emergency department for
adults with non-traumatic back pain unless the patient has se-
vere or progressive neurologic deficits or is suspected of hav-
ing a serious underlying condition (such as vertebral infection,
cauda equina syndrome or cancer with bony metastasis).
9.
Avoid prescribing antibiotics in the emergency department
for uncomplicated sinusitis.
10. Avoid ordering CT of the abdomen and pelvis in young other-
wise healthy emergency department (ED) patients (age <50) with
known histories of kidney stones, or ureterolithiasis, presenting
with symptoms consistent with uncomplicated renal colic.
There haven’t been many studies evaluating what has hap-
pened since the implementation of Choosing Wisely. To their
knowledge, no one had looked at emergency medicine and the
results of ACEP joining the campaign. Lin decided to do a study
of emergency physicians to look at their knowledge, attitudes
and behaviors regarding Choosing Wisely.
What did they do?
They did an anonymous survey of approximately 800 emer-
gency medicine physicians at ACEP in 2015. They didn’t say
that the survey was about Choosing Wisely.

American College of Emergency Physicians. Ten things physi- They chose clinical scenarios that are pretty similar to the
cians and patients should question. October 14, 1013 (1-5) and language in the recommendations. For example, “How often
October 27, 2017 (6-10. PDF Link would you perform a head CT on a 50 year old man who pres-
ents with syncope, has insignificant head trauma and normal
1.
Avoid computed tomography (CT) scans of the head in emer-
neurologic exam? Do you do head CTs frequently, infrequent-
gency department patients with minor head injury who are at
ly, never or always?”
low risk based on validated decision rules.
The next section aimed at the most important reason for pro-
2.
Avoid placing indwelling urinary catheters in the emergency
viding low value or potentially unnecessary care. Are you
department for either urine output monitoring in stable pa-
concerned about serious diagnoses? Is this because of pa-
tients who can void, or for patient or staff convenience.
tient and family expectations? Reduce your malpractice risk?
3. Don’t delay engaging available palliative and hospice care ser-
They asked which of the following options were from Choos-
vices in the emergency department for patients likely to benefit.
ing Wisely.
4.
Avoid antibiotics and wound cultures in emergency depart-
ment patients with uncomplicated skin and soft tissue ab-
scesses after successful incision and drainage and with ade-
quate medical follow-up.

June 2018: Volume 18, Issue 6 | www.emrap.org 9

 What did they find?
They found that we as a specialty are doing well with cer-
tain recommendations. We are not putting in foley catheters
for patients who can urinate. We are not doing much lumbar
spine imaging for patients with atraumatic back pain.
However, about 30% of us still report doing head CTs in low
risk head injury. Another 30% are also prescribing antibiotics
for acute sinusitis. When they looked at the reasons behind
this, they found a pattern suggesting that providers tend to
order advanced diagnostic imaging because they are con-
cerned about serious diagnoses whereas providers ordering
antibiotics for sinusitis or imaging for back pain are largely
driven by patient and family expectations.
How can we improve?
Familiarize yourself with the recommendations and evidence
and practice them. We are often in a rush and it can be easier
to substitute tests for time spent in discussion with the patients
at bedside. Talk to patients and have a conversation. “You
know, there is a lot of radiation associated with that test and I
don’t think it will help you very much. Let’s do this instead.”
Doing quality improvement and measuring how often these
low value tests and procedures are happening can be helpful.
In the near future, the way we get paid will be determined
by these quality metrics. Some of the existing quality metrics
have begun to incorporate CT C-spine utilization based on
NEXUS criteria.
The biggest predictor of patient satisfaction remains time
spent at the bedside. It is partly our job to help reform the
general misinformed mindset that there is a test, pill or proce-
dure for everything that ails us.
They found that fear of malpractice was one of the least fre-
quently identified reasons for low value care. This supports
some evidence looking at what happens when states imple-
ment tort reform and have found minimal impact on utilization or
cost. How does the test help the patient or guide management?
Cardiology Corner:
New Syncope
Rob Orman MD and Amal Mattu MD
Take Home Points
Patients with syncope should have an EKG performed.
The EKG can identify ischemia, heart blocks, arrhythmias,
WPW, prolonged QT, short QT, Brugada syndrome and
signs concerning for hypertrophic cardiomyopathy.
Some causes of prolonged QT may be reversible.
10 EM:RAP Written Summary | www.emrap.org
Syncope is a common presentation to the ED. Most cases are
benign. However, there are a lot of etiologies to consider. The
AHA/ACC recently released a revised set of guidelines for eval-
uation of syncope.
Writing Committee Members, et al. 2017 ACC/AHA/HRS
guideline for the evaluation and management of patients
with syncope: a report of the American College of Cardiolo-
gy/American Heart Association Task Force on Clinical Prac-
tice Guidelines and the Heart Rhythm Society. Heart Rhythm.
2017 Aug;14(8):e155-e217. PMID: 28280232
What is syncope? An abrupt, transient, complete loss of con-
sciousness associated with an inability to maintain postural tone
with rapid and spontaneous recovery. The presumed mecha-
nism is cerebral hypoperfusion. There should not be clinical
features of non-syncope causes such as seizures, antecedent
head trauma or pseudosyncope. Many patients with syncope
will have some myoclonic jerking (about 90%).
The guidelines recommend a history and physical as well as
an EKG.
How can you differentiate between syncope and seizure?
Tongue biting can be helpful. Seizure patients have an in-
crease in tone and bite down whereas syncope patients have
a loss of tone. Generally, syncope patients have tongue lacer-
ations from falling on their face.
Post-ictal period. It is important find out how long they were
confused afterwards.
What are you looking for on the EKG? Ischemia. Arrhythmias.
AV blocks.
WPW.
Prolonged QT.
Short QT syndrome. This is a rare congenital problem. You
need to look at both the PR and QT interval.
Hypertrophic cardiomyopathy.
Brugada syndrome.
Arrhythmogenic right ventricular cardiomyopathy. This is
rare in the US.
“I think arrhythmia is unlikely. EKG shows normal sinus rhythm
with no interval abnormalities such as QT prolongation or
WPW. There are no findings to suggest Brugada syndrome.
Cardiac monitoring in the emergency department reveals no
tachycardic or bradycardic dysrhythmia. Hypertrophic cardio-
myopathy was considered but there are no clear historical el-
ements pointing toward this. EKG is not suggestive. The QRS
voltage is not extremely large and there are no suggestive Q
waves.”
 What does the guideline recommend for additional testing
in the initial evaluation? They use the phrase “targeted blood
testing”. Aside from the EKG, there is no blood test that needs
to be performed routinely unless the history or physical exam
indicates it. For example, if the patient reports a history of heavy
periods, check a hemoglobin. If the patient has a history of renal
failure or is taking a diuretic, they are prone to electrolyte prob-
lems. If the patient has petechiae in their mucous membranes,
check a platelet count. If the patient had severe headache prior
to or after syncope, get a CT head. The history and physical
should determine what testing is necessary.
Should patients with syncope have a d-dimer? D-dimers should
not be sent reflexively. Mattu would only send a d-dimer if the
patient complained of shortness of breath or pleuritic chest pain
before or after syncope, tachypnea after waking or is hypoxic.
If the patient has a normal respiratory rate and does not have
shortness of breath or pleuritic chest pain, Mattu is not worried.
We are worried that patients who are sent home will have
a bad outcome. What do the guidelines say regarding who
should be admitted? The guideline provides some high risk
criteria and short term risk factors. Older age. Absence of
prodrome. Palpitations prior to syncope. Exertional syncope.
Family history of sudden cardiac death. Evidence of bleeding.
Persistently abnormal vital signs. Heart murmur. Abnormal EKG.
These are risk factors for short term adverse outcomes. These
patients should be admitted to the hospital or observation unit.
If you see a patient with prolonged QT or Brugada syndrome,
should they be admitted?
Patients with new onset syncope and a Type 1 Brugada pat-
tern should be admitted to the hospital. If you are unable to
admit the patient, they should have very close follow-up with
an electrophysiologist.
If the patient has prolonged QTc, you should look for cor-
rectable causes such as hypomagnesemia, hypokalemia,
hypocalcemia, medications, etc. We may be able to correct
these in the emergency department. If you are unable to
identify a reversible cause and the patient has syncope with
prolonged QT, they should be admitted to the hospital for
telemetry. Patients on QT prolonging agents are unlikely to
have rapid improvement in their QTc and should probably be
admitted for monitoring.
If you see an EKG concerning for hypertrophic cardiomyop-
athy with giant voltage and deep narrow Q waves, the pa-
tient needs a definitive test of a Doppler echocardiogram. If
you can’t get the Doppler echo immediately, the patient can
receive it as an outpatient in the next few days. The patient
can be placed on a beta-blocker and instructed not to exert
themselves.
June 2018: Volume 18, Issue 6 | www.emrap.org
We are expected to guide discharged patients toward ap-
propriate follow-up. There are many procedures such as
tilt-table testing, cardiac event monitors, stress testing, echo-
cardiogram, etc. How do we know who to send where? They
can follow-up with their primary care physician (if available) for
additional evaluation.
Stress testing does not need to be done routinely unless they
presented with symptoms concerning for ACS. However, you
are likely to admit or observe this patient regardless.
If the patient had palpitations or lack of prodrome, they will
likely receive cardiac event monitoring. However, you proba-
bly won’t be discharging this patient.
If the patient has a pronounced murmur, they will need an
echocardiogram but you probably won’t be discharging this
patient.
The patients may be referred by the cardiologist for tilt-table
testing for frequent vasovagal events.
It is unlikely that you will be arranging these additional investi-
gations from the emergency department. Most of the patients
that need these tests are likely to be admitted or placed in an
observation unit.
The guidelines advise that continuous telemetry monitoring
in the hospital for syncope not suspected to be of cardiac eti-
ology is not cost effective. They cite several studies showing a
low return on investment of telemonitoring. How do we identify
these patients per this guideline? Patients meeting high risk cri-
teria have risk factors for cardiac cause of syncope. If the patient
doesn’t have any risk factors for a cardiac cause, the likelihood
of the patient having an unanticipated cardiac cause identified
on telemetry is low.
If all patients with syncope were admitted for three days of
monitoring and cardiac enzymes, only about 50% of all pa-
tients would end up with a definite diagnosis. 80% of those
patients with a diagnosis are diagnosed in the emergency
department in the first few hours. We make 80% of the diag-
noses in the emergency department. Your admission for three
more days only picks up a few more diagnoses. It is accept-
able to discharge these patients for outpatient work-up if you
are not worried about a cardiac cause.
11

Critical Care Mailbag:
High Flow NC in Acute Pulmonary Edema
Anand Swaminathan MD and Scott Weingart MD
Take Home Points
Commercial high-flow nasal cannula devices create a
small amount of PEEP (about 2-4 cm H20).
This is nowhere near the levels of PEEP generated by
CPAP, EPAP, etc.
Patients unable to tolerate the full face mask of non-inva-
Annals of Emergency Medicine
Jess Mason MD, Andy Grock MD and Guy Carmelli MD
sive positive pressure ventilation may be able to tolerate
the nasal mask.
If the patient is unable to tolerate the full face mask or
nasal mask, the high flow nasal cannulae are probably
better than nothing.
Patients with acute pulmonary edema are sick. Some are unable
to tolerate non-invasive positive pressure ventilation. You can try
ketamine. Can you use high flow nasal cannula? This is not the
wall flow nasal cannula cranked up. This is a commercial device.
Weingart is unsure how high-flow nasal cannula actually
works. He has been experimenting with it (on himself). Don’t try
it, but if you stick it in your mouth, it feels like your lungs are go-
ing to explode. What happens in the mouth is different from the
nose. If you put the device on your nose, you don’t feel much.
Very little of the pressure goes from the nose into the airway.
In the studies, these devices create a little PEEP (about 2-4
cmH20). This might be enough to make your pulmonary ede-
ma patient feel a little better. However, in sick patients with
pulmonary edema, you are starting at 5 and titrating up read-
ily. The high flow nasal cannula is nowhere near the levels of
CPAP, EPAP, etc.
There is some inspiratory support. This might decrease the
patient’s subjective feelings of dyspnea and they might look
better as a result.
However, it is unlikely to be efficacious in patients who
need the objective reality of CPAP rather than the subjec-
tive feeling better of inspiratory pressure augmentation.
Weingart has an alternative. The reason many of these patients
hate non-invasive positive pressure ventilation is that they feel
trapped. Many patients will tolerate the nasal mask rather than
the full face mask. This may be a way to get them through. If
they open their mouth, they will lose the benefit. Tell them to
keep their mouth closed. If they can’t handle it any more, they
can open their mouth and take a normal breath. Reassure them
that they need to close their mouth again. Weingart has found
that almost any patient will tolerate nasal CPAP.
12 EM:RAP Written Summary | www.emrap.org
If you have the money, the helmets are supposed to be
more comfortable.
If the patient is unable to tolerate the full face mask or nasal
mask, the high flow nasal cannulae are probably better than
nothing or a non-rebreather.
Babl, FE et al. Accuracy of clinician practice compared with
three head injury decision rules in children: a prospective co-
hort study. Ann Emerg Med. 2018 Feb 13.
They looked at three different decision rules regarding head
injury in children and need for CT imaging compared to clini-
cal gestalt.
If they had inflexibly used the clinical decision rules, it would
have resulted in more, rather than less testing and it would
not have been more accurate than clinical gestalt.
Clinical decision rules guide us toward clinical features that
factor more significantly into risk stratification for bad out-
comes. They help standardize the approach to a particular ill-
ness. They are a good tool for new learners who are developing
their clinical gestalt. They are key for documentation. They help
support the decisions we make.
Just like any tool, they can be problematic when misapplied.
You don’t use a speculum to intubate. The speculum is a great
tool but when misapplied, it can be a disaster.
What should we watch out for when using clinical decision
rules? We want to make sure we are applying it to the right pa-
tient in the right population. We want to be sure it is a validated
rule and that we are aware of the subjective components that are
often in CDRs. We want it to supplement our clinical gestalt and
not result in overtesting. We want to avoid the clinical decision
tool mashup that incorporates components from multiple tools.
When we apply a CDR to the patient in front of us, we want
to make sure that the patient is similar to or the same as the
population in which the CDR was derived. For example, using
a clinical decision rule for an ACS evaluation may not be useful
if your population has a significantly higher rate of MI or ACS.
You want to be aware of the inclusion and exclusion criteria.
For example, we all know the PERC rule. However, PERC is only
supposed to be used in patients who are low risk for PE. You
can’t have a patient that is moderate or high risk for PE and
PERC negative. The pre-test probability should be less than 15%.
 Before implementing a clinical decision rule, it is important to
know whether it has been validated.
Ian Stiell and George Wells wrote a paper in 1999 that laid out a
checklist for the development of a clinical decision rule.
1. Is there a need for this clinical decision rule?
2. Was the rule derived according to methodologic standards?
3.
Has the rule been prospectively validated and refined?
4.
Has the rule been successfully implemented into clinical practice?
5. Would use of the rule be cost-effective?
6.
How will the rule be disseminated and implemented?
Stiell, IG and Wells, GA. Methodologic standards for the devel-
opment of clinical decision rules in emergency medicine. Ann
Emerg Med. 1999 Apr;33(4):437-47. PMID: 10092723
Many clinical decision rules do not go through this process.
For example, the LRINEC score for necrotizing soft tissue infec-
tion went through the derivation phase only and has never been
prospectively validated. The San Francisco syncope rules had
poor external validation.
Many clinical decision rules have components that are sub-
jective. It is important to be aware of that subjectivity and how
this may change the outcome from one provider to the next.
The HEART score asks you to assess how suspicious you are
for ACS. Two providers talking to the same patient may differ in
their concern for ACS. They will assign a different score for the
same patient with the same history.
How often are clinical decision rules compared to clinical ge-
stalt? Not very often. We don’t want a tool to override our ge-
stalt and result in unnecessary testing.
Clinical decision rules are designed to be more sensitive than
specific because they are designed as screening tools. They
are designed to not miss anything. You don’t want a rule that
says someone doesn’t have a heart attack when they really are
and you discharged them. When you increase sensitivity, you in-
variably decrease specificity. These tests often tell you to image,
treat or admit more. They should not replace clinical gestalt. If
you applied PERC to every patient with shortness of breath or
chest pain, it would clearly result in overtesting. PERC only ap-
plies to patients less than 50 years. Does this mean that every
patient over 50 needs a CTA or d-dimer to evaluate them for
PE? No. Your clinical gestalt and testing threshold matter.
Clinical decision mash-ups. There is a lot of redundancy in clin-
ical decision rules but this can lead to some problems.
What if the Canadian C-spine and NEXUS rules lead you to
different outcomes? Do you just pick the outcome you prefer?
June 2018: Volume 18, Issue 6 | www.emrap.org
What if there are multiple scores available? Do you pick and
choose the part you like? Because there are so many scores
out there, people may forget which variables are assigned
to which score or which risk factors are for which illness. Al-
though it is not a bad thing to know the variables for different
validated scores, if you are combining them into your own de-
cision rule, it is not a validated clinical decision rule.
Example. You have a patient who presents with chest pain and
shortness of breath. You are considering the diagnosis of pulmo-
nary embolism. Should you apply the PERC rule to this patient?
Is it a validated clinical decision rule? Yes. Has it been imple-
mented and shown to be cost effective? Yes.
Is this the right patient? Do you think the patient has a low
pre-test probability? Yes.
Is this going to augment your clinical gestalt and not go
against it?
Are you using the rule correctly? Are you combining compo-
nents from other decision rules?
Pediatric Pearls:
Cool Peds Tricks
Ilene Claudius MD, Sol Behar MD, Erik Hofmann MD,
Genevieve Santillanes MD and Ariel Bowman MD
Take Home Points
Nebulized tranexamic acid may be an option in an unstable
patient with a post-tonsillectomy bleed.
Pediatric central lines may experience complications.
The central lines guidewire has an inner and outer layer
which can result in kinking.
Moving the wire gently in and out of the dilator itself as it
is being advanced can prevent looping and kinking. The
dilator can be rotated as it is advanced.
Pulmonary hypertension can be treated similarly to a TET
spell with treatment to shunt more oxygen to the lungs.
One of the scariest events is to have a situation you haven’t
been in before with a critical patient and have no idea what to
do next. This is especially true in pediatrics.
CASE
A child with a post-tonsillectomy bleed. The patient was an un-
cooperative and altered 5 year old. The child was pale and the
hemoglobin was 6 prior to any hydration. The child was hem-
orrhaging from a tonsillectomy done a week prior.
13
 There is a robust vascular supply to the tonsil. After removal, a
fibrin clot forms and about 5-10 days after the procedure, the
fibrin clot sloughs off and it is not unusual for the patient to start
hemorrhaging. This happens in about 2-7% of post-tonsillecto-
my cases. For most, the clot will detach, the vessels will spasm
and bleeding will resolve. However, in one study, about 40% of
children with bleeding went on to have a major bleed over the
next 24 hours.
Getting a good look at the back of the throat in a 5 year old isn’t
easy in general. Partial visualization in this patient only showed
blood that she was swallowing, spitting out and vomiting.
Classic management of these bleeds is to have the child lean
forward, spit out the blood, type and cross them and get the
ENT in as quickly as possible to cauterize the vessels. If it is
a really desperate situation, some have recommended taking
McGill forceps, soaking gauze in epinephrine and placing the
gauze with direct pressure up against the bleeding tonsil. These
is great if you have a cooperative adult patient but this is impos-
sible to do in a child without sedation and likely intubation. Clau-
dius considered this but the prospect of intubating a completely
unresuscitated child with a hemoglobin of 6 didn’t seem like the
best plan. Transfusion of O negative blood was started but it
didn’t seem to be going in as quickly as the patient was losing it.
Claudius tried nebulizing racemic epinephrine but that didn’t
work well. One of the nurses mentioned that Dr. Billy Mallon had
previously nebulized a gram of tranexamic acid in an adult pa-
tient with an airway cancer with hemoptysis. The bleeding had
resolved in 15 minutes.
Hankerson, MJ et al. Nebulized tranexamic acid as a nonin-
vasive therapy for cancer-related hemoptysis. J Palliat Med.
2015 Dec;18(12):1060-2.
Claudius tried a half gram of tranexamic acid and it worked.
In fact, it worked so well that when the ENT arrived in the emer-
gency department, the patient wasn’t bleeding at all.
The evidence is limited. But if you are in the situation of pediatric
hemoptysis or post-tonsillectomy hemorrhage and nothing else
is working, you might as well try it. Although the case reports are
limited, there have not been any reported complications.
Another potential complication is knotting or looping when the
wire is advanced through the dilator. The dilator can take a di-
vergent path. This can happen intravascularly or extravascularly.
There is a technique where the wire is gently moved in and
out of the dilator itself as it is being advanced as this will
prevent the looping and kinking. The dilator is also rotated to
advance it into the subcutaneous tissue. This prevents it from
taking a divergent path.
CASE
A 16 month old child with respiratory distress was transported
by EMS. The oxygen saturation was in the 70s per EMS despite
bag-valve-mask ventilation. The patient had a tracheostomy,
a history of Trisomy 21 and AV canal defect that had been re-
paired. The child also had pulmonary hypertension.
Pulmonary hypertension can be considered similarly to a Tet
spell with a need to get more oxygen to the lungs. You don’t
want to agitate the child more. The child did not have IV access.
They gave the child IM ketamine with the hope that it would
calm her down and increase the systemic vascular resistance to
allow the blood and oxygen to be shunted to the lungs.
The child ultimately received 12 mg/kg IM ketamine in 15 min-
utes. It worked well.
The issue with oxygenation in pulmonary hypertension is not a
breathing or airway problem but rather a cardiac issue. Simply
intubating the patient won’t fix the situation. RSI medications can
harm these patients by dropping their systemic vascular resis-
tance and shunting even more blood into the systemic circulation.
These patients have inadequate pulmonary circulation and
systemic overcirculation. Anything you can do to decrease
pulmonary hypertension will help. Inhaled nitric oxide can be a
game changer but we don’t often have it available. Increasing
systemic resistance can help shunt more blood to the lungs.
Ketamine can be a lifesaver because it calms the patient and
decreases the pulmonary vascular resistance. This increases
pulmonary vascular circulation and the patient will improve.

Pediatric central lines. For pediatric femoral central lines, it is

very easy to find the vessel but very difficult to complete the
procedure. Anyone who has done more than a few of these pro-
Shared Decision Making
Stuart Swadron MD and Marc Probst MD
cedures has probably had a bad experience when threading
the wire or inserting the dilator. The wire can kink or bend.
Take Home Points
The wire is actually two wires in one. There is an outer coil made
Shared decision making involves two or more medically
of stainless steel and an inner wire made of an alloy. This allows
reasonable options and enlists the patient in determining
for flexibility but also can result in complications. There may be
the course of action.
shearing or fracture of the wire upon advancing it through the
needle. If you form any knot or loop and try to force or pull the It is important to document your discussion with the patient.
wire back through the needle, you can fracture the J point.

14 EM:RAP Written Summary | www.emrap.org

 What is shared decision making? Shared decision making is
more than just good communication between patients and doc-
tors. Shared decision making involves two or more medically
reasonable options that you as the clinician would be happy
with either way.
What is the impact of shared decision making on patient sat-
isfaction? There isn’t much formal evidence in the emergency
department. There is more literature in outpatient care such as
oncology or primary care. However, anecdotally, with the right
patient, they appreciate it.

Are we able to do proper shared decision making in the ER?

CASE
Absolutely.
Probst was working an evening shift. A PA presented a case of a
woman who was 55 years old. She had stood up quickly in the There are some unique challenges in the emergency depart-
kitchen and hit her head on the cabinet door. She has a small ment. We are expected to see a certain number of patients
bruise to the posterior aspect of her head. She arrived with her per shift. We move fast. We have to meet metrics. We can’t
husband and they were insistent on receiving a head CT. The PA take an hour at the bedside to detail all of the options. Howev-
had sat down with the patient and family and despite a discus- er, if you are an effective communicator, you can boil it down
sion with the patient that it was unnecessary, they were insistent. to several minutes. You may be able to decrease length of
stay if the patient opts for a less intensive option.
Probst entered the room and sat down and chatted with the Patients in the emergency department may be in pain,
patient and her husband. He explored their expectations. After
stressed, worried or anxious which may affect their cognitive
building some rapport, they started discussing whether she was
abilities. We have no prior relationship with our patients for
going to receive a head CT. The patient explained that she was
the most part. There is an issue of trust. This is unscheduled
going to be traveling on a ski trip and would not be near any
care so the patients do not have time for preparation.
hospitals for the next 5 days which was her main concern.
How do we do shared decision making?
Compassionate persuasion versus shared decision making.
Go to the bedside and acknowledge that a decision needs
Probst discussed her risk and told the patient that if she was his
to be made. Patients are often unaware of how many deci-
mother, he wouldn’t recommend a CT scan. Probst gave her a
sions we are making behind the scenes. “You came in with
card with his cellphone number and told her she could call him
right lower quadrant pain. Your labs and urinalysis are normal.
if she had any problems the following day but that he anticipat-
We need to make a decision about a CT scan.”
ed she would be fine. This presents the patient with only one
viable option and is an example of compassionate persuasion. Describe the two different options. “One option is a CT scan.”
You can talk about the logistics of the CT scan. “You will go
CASE in another room. You will get an injection of contrast. There is
Probst was working in the emergency department with an some radiation”, etc. If the patient has questions, you can elabo-
off-service intern. He saw a female in her 60s with acute flank rate further. “Another option is to go home with some self-mon-
pain radiating to her groin with colicky pain and hematuria. It itoring and return if the pain gets worse or you have fevers.”
sounded like a kidney stone. The patient had labs and blood
Listen to the patient and ask questions to determine their
work. The patient was given ibuprofen and felt better.
values and preferences. “How far do you live from the emer-
gency department?” “Are you working tomorrow?”
The patient was accompanied by her husband who was a
physician. Probst started talking with them. The patient was Make a mutual decision. As best you can, try not to push
well-appearing and the diagnosis seemed clear. The patient them one way or another.
didn’t necessarily need a CT scan. Probst provided some op-
Documentation of the conversation is important. The options
tions. They could do an ultrasound, a CT scan or discharge
discussed, patient’s understanding of those options and choice
the patient home with pain medication.
made should be included.
The patient felt improved and said that she would rather re-
turn home. They discussed doing a bedside ultrasound which
showed trace hydronephrosis and she was discharged home.
About 5 days later, an administrator approached Probst
and asked if he remembered the woman with the flank
pain. She was so happy with her care, she was writing a letter
to the department thanking him for great care. She specifi-
cally mentioned how wonderful it was to be involved in the
decision making process.

June 2018: Volume 18, Issue 6 | www.emrap.org 15

 was called. He was transported to the emergency room and tak-
Stroke As A Patient en to the CT scanner.
Rob Orman MD and Doug Larsen PA
When he tried to shake the hand of the provider caring for
him, whom he knew, although it felt like he was performing
Take Home Point
the action, he realized that his hand hadn’t moved. His leg
Personally experiencing a serious illness can change then became weak. The entire time from the CT scan to when
your perspective on the practice of medicine. he was transported out in a helicopter was about 45 minutes.
It is important to care for the family of your patient as well The CT scan showed an old infarct in the cerebellum but was
as your patient. otherwise negative.

Everything happened very quickly. Before he knew it, he was

Doug Larsen is a PA specializing in emergency medicine who
facing the decision of whether or not to receive tPA. He was
practices at the Mayo Clinic health system in Minnesota. Lars-
evaluated by the neurologist via Telestroke. Although he hadn’t
en recently suffered an ischemic stroke. His description of his
been a big believer in tPA, his deficit was so great that he was
symptoms and the discussion of tPA can make us reflect on the
willing to risk tPA. He didn’t want to be a burden to his family or
way we approach our patients with ischemic stroke.
kids. He was unable to communicate. He could blink and follow
Larsen had worked late into the night on the shift. The next commands with his left arm. He couldn’t answer the neurolo-
morning, he travelled with his wife to watch his children while gist’s questions.
she had a meeting regarding starting a small business. His wife
After he received tPA, he was transported via helicopter to
is a physical therapist. He sat in a coffee shop and ordered
the regional center. He went in and out of consciousness. He
breakfast with his boys. He noticed when he stood up with his
alternated between somnolence and brief periods of alertness.
one year old in his arm that he felt “off”. When he reached the
He had few memories of the helicopter ride but remembers the
water cooler, he realized he was seeing double. Larsen was 31
ceiling tiles before the CT scanner. By the time he reached the
years old at the time.
CT, he could move his arm and talk a little.
He waited for about 20 minutes and then removed his con-
Within an hour or two after landing, he had regained his
tacts. His symptoms initially seemed to improve when he re-
strength but still had difficulty with word-finding. He still has
moved the contacts but then his symptoms returned. He was
some residual slurred speech now.
worried that he had a brain tumor. His father had died of a glio-
blastoma when Larsen was in high school. He didn’t have a On the second day of his hospitalization, he had an MRI per-
sense of dread or loss. formed. This confirmed a stroke. Why did he have a stroke at
such a young age? He was found to have a patent foramen ova-
As his symptoms worsened, he felt detached. He was analyt-
le on TEE. He later had a repair. The final diagnosis was acute
ical. Was this a stroke? If it wasn’t, what was it? Maybe it was a
thalamic stroke with expressive aphasia and right hemiparesis.
stroke? Where could it be located in the brain?
How has his life changed? After a week of limited activity, he
His wife was supposed to be done with her meeting at 10. It
was allowed to return to his usual activities although he hasn’t
was about 10 minutes to 10. Larsen had previously texted her
fully regained his stamina. He appreciates time spent playing
asking her to come feed the baby. He doesn’t remember much
with his kids.
of what happened next. He remembered that the children, ages
1 and 3, were running amok in the restaurant. He must have Larsen found that his emotions had changed. He is less likely
looked unwell, because one of the women working in the coffee to get emotional.
shop told him not to worry and that she was taking care of the
What was the worst part of his hospitalization? The foley
kids. He sat back down.
catheter.
He tried to text his wife again. He remembered knowing what
One of the things that made a difference for him was the pro-
letters he wanted to hit but they wouldn’t come out right. He
fessionalism he experienced from the treating team. There
tried about two or three times and was unable to get the words
was no fear but a reassuring sense that they were going to take
to come out correctly. Larsen realized he was having an acute
care of him. One of the nurses took his kids aside and kept them
stroke.
busy. They cared for his family as well. This was very difficult for
He could understand everything that was said to him but he his wife but they did a good job of updating her at the initial site.
couldn’t make his words come out correctly. His hand became When they arrived at the regional center however, she didn’t
weak and then it progressed to his whole arm. His hand felt know if he had survived.
thick and he couldn’t make it do what he wanted. An ambulance

16 EM:RAP Written Summary | www.emrap.org

 After having this experience, Larsen is more empathetic with
patients. He tries to take time to talk with the family as soon as
he can. This makes a big difference in how everyone feels about
the case.
Larsen recalled the EM:RAP segment on Commander John
Love who had experienced a PE in January 2012. Both had
initially ignored their symptoms for an hour or more.
Compartment Pressures
Jess Mason MD, Jenny Farah MD and Kenji Inaba MD
Take Home Points
Compartment pressure greater than 30 mg or a delta
perfusion pressure (diastolic blood pressure – compart-
ment pressure) less than 30 mmHg is concerning for
compartment syndrome.
The delta pressure may be helpful in a hypotensive trau-
ma patient.
Maintain a high level of suspicion for compartment syn-
drome.
Compartment syndrome is a dynamic process.
Checking compartment pressures seems like it should be
simple but between the equipment, calibration and anatomy,
it can be intimidating. We recently made a HD video which
demonstrates how to check compartment pressures in the low-
er leg and forearm.
There are two ways to assess whether the patient is at risk for
developing compartment syndrome. Once you get the mea-
surement, you can look at the absolute number of the pressure
in the compartment or the delta pressure.
Put in the needle and measure the pressure.
If the pressure is over 30 mmHg, it could be compartment
syndrome. Normal pressures are less than 10 mmHg.
If you have the diastolic blood pressure, subtract the compart-
ment pressure and if the difference is less than 30 mmHg,
it is also concerning for compartment syndrome. Basically, if
the compartment pressure is reaching the diastolic pressure,
it represents decreased perfusion. The delta pressure can
be important, especially if you have a hypotensive trauma
patient. If the blood pressure is 90 mmHg with a diastolic of
50 mmHg and the compartment pressure is 25 mmHg, it is
concerning for compartment syndrome.
Inaba is now using the delta perfusion pressure to assess for com-
partment syndrome. You want this value to be at least 30 mmHg.
Maintain a high level of suspicion for compartment syndrome.
The consequence of missing compartment syndrome is muscle
loss. The associated disability is huge. Be aggressive in ruling it
out. Sometimes the mechanism isn’t obvious and there may not
be a history of direct trauma.
Why is this missed? Compartment syndrome is a dynamic pro-
cess. The patient may be assessed initially with a normal per-
fusion pressure. However, rather than send them home, keep
them for observation. It is important to reassess them. If the pa-
tient is not improving or is worsening, check again.
Should you worry about the small amount of saline that is in-
jected during the compartment pressure? It is a tiny amount to
clear the bore of the needle. It is unlikely to cause an artificially
elevated pressure. Injection of superficial lidocaine to facilitate
the comfort of insertion won’t affect the compartment pressure.
Not everyone has the commercially available product avail-
able such as the Stryker. However, there are other ways to
check the pressure. Some use an arterial line. If this is the only
thing available, it is worth trying. There are several studies look-
ing at the validity of the arterial line and the evidence is varied.
Always err on the side of transfer if necessary.
Low Dose Ketamine
Matthew DeLaney MD
Take Home Points
Most of the literature on low dose ketamine for pain stud-
ied it as an adjunct to traditional analgesics.
The subdissociative dose is usually reported between 0.1
mg/kg and 0.3 mg/kg IV.
This is a great medication for patients with short term
pain.
Ketamine is a good option in opioid tolerant patients.
Nausea is a frequent side effect but true emergence re-
actions are rare with subdissociative dosing.
Low dose ketamine for pain. DeLaney had to take multiple
steps in his department to get this going. They started the pro-
cess two years ago.
Does low dose ketamine work as well as traditional analge-
sics such as the opioids? Much of the literature looks at ket-
amine as an adjunct to traditional analgesics.
The best study was by Beaudoin et al.
They gave patients with acute pain morphine or morphine
17
 along with a dose of 0.15 mg/kg IV of ketamine. A third group
received morphine and a dose of 0.3 mg/kg of ketamine.
They found that ketamine seemed to be a viable adjunct
along with morphine.
Beaudoin, FL et al. Low-dose ketamine improves pain
relief in patients receiving intravenous opioids for acute
pain in the emergency department: results of a random-
ized, double-blind, clinical trial. Acad Emerg Med. 2014
Nov;21(11):1193-202.
Motov et al randomized patients to either receive ketamine
at a dose of 0.3 mg/kg or morphine at 0.1 mg/kg.
They found the results were equivalent in short term pain relief.
Motov, S et al. Intravenous subdissociative-dose ketamine
versus morphine for analgesia in the emergency depart-
ment: a randomized controlled trial. Ann Emerg Med. 2015
Sep;66(3):222-229.
There is an emerging body of literature that shows low
dose ketamine is a reasonable analgesic.
Safety doesn’t seem to be an issue. We have years of litera-
ture on ketamine as a sedative and it seems to be really safe
in that setting. Most of the studies on low dose ketamine ar-
en’t sufficiently powered to evaluate safety but we know that it
preserves blood pressure and protects the airway. There aren’t
many issues that arise with its use in sedation and it is likely safe
at a lower dose.
How do you enact the use of low dose ketamine at your site?
What is the optimal dose? The subdissociative dose is re-
ported between 0.1 mg/kg and 0.3 mg/kg IV. Unfortunately
there is no good literature to identify the proper dose. Most
of the lower doses in the literature were when ketamine was
used as an adjunct to morphine. The lower doses were not
used alone. Some studies that used ketamine as a sole agent
used a dose of 0.3 mg/kg IV. However, this is a dose when
you start to worry about reaching the limits of subdissociation.
We do not want to be sedating patients.
Patients received a dose of 10 mg of ketamine. DeLaney’s
group set a target dose of 0.1 mg/kg. If the patient was be-
tween 50-150 kg, they would round up or down. Patients at
50 kg rounded up to 10 mg would receive a dose of no more
than 0.2 mg/kg. This is well within the subdissociative dosing
range. Patients at 150 kg were rounded down to 10 mg which
was a dose of 0.07 mg/kg. Their available formulation was 10
mg/mL. This was simple for the nurses. Patients were given 1
mL of solution.
They identified multiple systems issues. 1) How was the drug
categorized in the hospital? 2) How was the drug given in the
department? 3) Who was allowed to give the medication?
18 EM:RAP Written Summary | www.emrap.org
1. Most of the literature categorizes ketamine as a sedative or
anesthetic. This typically falls under anesthesia’s jurisdiction.
The hospital considered this outside of conscious sedation.
They met with hospital administration and the sedation com-
mittee and provided literature. They received approval to re-
categorize ketamine at this dose. It was shifted from a seda-
tive to an analgesic. You need to determine the classification
of ketamine at your hospital and who makes that decision. It
is much easier to ask permission to reclassify ketamine than
to ask forgiveness after the fact.
2. Who can give this drug and how? This will vary between hos-
pitals and state. DeLaney’s group had a goal that this be ad-
ministered by nursing staff just like any other pain medication.
However, in their state, the board of nursing was unwilling to
let nurses push this like an analgesic. Initially, it had to be ad-
ministered by the physician.
3. How is the medication given? They started giving it as a push
dose or bolus. They found that patients had a quicker effect
with pushes but also experienced more altered sensorium.
Some literature describes a bolus followed by a drip for a lon-
ger effect. However, this is labor intensive and many of the
nurses were unwilling to do this. They settled on a low dose
given as a bolus. This is worth discussing with nursing.
Once they started using the medication, it became obvious
it was a great medication in a certain subset of patients. This
is a great medication for patients with short term pain, such as
patient who falls and sustains a distal radius fracture. The onset
of action is quick and the offset is quick. The patient with a distal
radius fracture is given the medication, then reduced and splint-
ed and feels better. The pain stimulus should be decreased at
that point.
They found it does not work as well in patients who will
have a longer period of pain such as multiple rib fractures
or hip fractures. These patients would get some initial relief
but then would require additional pain medication.
There is emerging literature to say that it is a great pain
medication in patients who are opioid tolerant. DeLaney
has found this to be the case. He had a patient with end stage
cancer treated by fentanyl patches and oxycodone. They
tried high dose morphine and hydromorphone but nothing
was working. They gave 10 mg of IV ketamine and the patient
later walked out of the room and said it was the best he had
felt in a year.
This medication didn’t seem to work for drug seekers.
Ketamine should probably be avoided in patients who are
acutely psychotic or have a significant psychiatric history.
Most of these patients have been excluded from the studies.
Ketamine should also probably be avoided in pregnant pa-
tients or those with obvious increased intracranial or intraoc-
 ular pressure. It is probably safe but isn’t worth trying in these
populations.
Anticipate how the patient will react to the medication. At a
low dose of 0.1 mg/kg, the side effects are pretty minimal.
Nausea seems to be a frequent side effect in studies. It is
thought that 1 in 17 children will develop nausea secondary to
the ketamine.
True emergence reactions are exceedingly rare when us-
ing subdissociative dosing. Patients will develop an altered
sensorium more often with ketamine than opioids. Patients
may say things like they feel like they are on the moon or feel
like the skin is sliding off their neck. About 60% of DeLaney’s
patients reported having some type of subjective altered sen-
sorium while on the medication. Most of them did not find it
unpleasant and reported that they would take the medication
again. It seems to be self-limited.
Anticipate how others will perceive this medication. DeLaney
had his hospital and anesthesiologists on board. However, the
inpatient teams would freak out upstairs. This is a newer ther-
apy. If you are going to do it, it is worth spreading the word
around the hospital to prevent emails and confusion.
DeLaney is a big fan of subdissociative ketamine. He found
some hurdles up front to get the hospital on board. There are
some ongoing issues to get the state board of nursing to let
nurses administer the medication. Once you start using this, pick
the right patients. Consider it in patients who are opioid tolerant.
Avoid it in drug seekers or psychiatric patients.
Syphilis On The Rise
Jess Mason MD and Anneli von Reinhart MD
Take Home Points
Syphilis is on the rise, especially in the west and south.
You need to test for it and treat it.
The dose for the treatment of syphilis is 2.4 million units
of long-acting penicillin G benzathine.
We need to proactively test and treat pregnant women.
Warn patients about the Jarisch-Herxheimer reaction.
Why are we talking about syphilis? Syphilis is on the rise, es-
pecially in the South and West in the United States. It is increas-
ing in young men who have sex with men. There is frequent
co-infection with HIV and syphilis as well as gonorrhea and chla-
mydia. Syphilis is increasing in all populations. There are also
increasing rates of congenital syphilis.
The stages of syphilis. This is clinically relevant in the emer-
gency department .The stage determines your treatment plan.
You need to be able to recognize the clinical entities of primary,
secondary and latent syphilis.
Primary syphilis results from close contact with an infected
lesion. 3 to 21 days later, primary syphilis develops. This is a
painless chancre. The chancre is usually on the genitals al-
though it can also be oral. Chancres aren’t inherently painful
but it can sting when manipulated or washed. It is not numb.
Secondary syphilis. If primary syphilis remains untreated, it
can develop into secondary syphilis. Secondary syphilis can
manifest in different ways. There is a classic rash that involves
the palms and soles. It can also cause lymphadenopathy, fe-
ver, fatigue, constitutional symptoms, myalgias etc.
Secondary syphilis can cause condylomata lata. This can
appear similar in appearance to the warts associated with
HPV. Any time you see a new case of warts in a patient that
has not previously been tested or treated in the past, you
need to consider the possibility of syphilis.
Tertiary or latent syphilis. If the secondary syphilis remains
untreated, it will progress to latent syphilis. These patients are
asymptomatic. Latent syphilis can be divided into early latent
syphilis (in the first year) and late latent syphilis (greater than
a year). If latent syphilis goes untreated for years (about 5-20
years), it can lead to tertiary syphilis. This can cause multiple
problems. Patients may develop neurosyphilis (which may
present like dementia), meningoencephalitis, tabes dorsalis,
Argyll Robertson pupils, ocular syphilis, and aortitis which
can result in dissection. Patients can develop gummas (or
gummata), which are tumor-like lesions that can develop any-
where on the body and ulcerate, appearing like an abscess.
These improve with treatment.
Who should we test for syphilis? Mason and von Reinhart work
in an area where syphilis is so prevalent that they include it
when testing for other STDs such as HIV, gonorrhea, chlamydia
and trichomonas. von Reinhart gives penicillin along with ceftri-
axone and azithromycin for empiric treatment.
How do you diagnose syphilis? At von Reinhart’s hospital, they
have a syphilis screen cascade. This automatically triggers the
next test in line.
The first test is IgG. Has this person’s immune system ever
encountered syphilis? If they return positive and have never
been treated for syphilis before, treat and you are done. This
will also be positive if the patient had a prior exposure and
has been treated.
The RPR is a titer and returns as a ratio. This can be con-
fusing. The utility of the RPR is tracking over time. When you
have successfully treated syphilis, the RPR decreases four-
fold. For example, a patient presents with syphilis and a RPR
of 1:16. They are treated with penicillin. In six months, when it
19
 is checked again, the RPR should have decreased four-fold
to 1:4. If they get a new infection and the RPR is the same or
increased, they will need treatment again.
After the RPR is obtained, you need a treponemal confirma-
tory study. There are many treponemal confirmatory studies
such as FTA, PCR, EIA, etc, these are beyond the scope of
emergency medicine and should be interpreted by an infec-
tious disease doctor.
What is the treatment? 2.4 million units of penicillin G benza-
thine long-acting formulation. It is not the continuous release or
CR. This is given intramuscularly. It has a long half-life.
Oral penicillin is inadequate.
There is a national shortage of intramuscular penicillin. Don’t
use IM penicillin for other conditions where there are other
available treatment options such as strep pharyngitis.
If you are treating someone for a recurrent infection, the treat-
ment is the same.
This is the treatment for primary, secondary and early latent
syphilis. If you have late latent syphilis, it is the same dose
but the patient needs two more doses a week apart over 3
weeks. The health department can help make sure patients
get adequate treatment.
If a patient tests positive for syphilis, it is important to do a
thorough physical exam to identify primary or secondary
syphilis. If there are no findings on exam, it is latent and you
20 EM:RAP Written Summary | www.emrap.org
must assume that it is late latent syphilis and err on the side of
overtreating.
It can be difficult to identify a chancre in women. It is import-
ant to do a thorough speculum exam, check the vaginal mu-
cosa, check the introitus and between the labia. In both men
and women, check the perianal area. If there is a chancre and
the patient is positive for syphilis, treatment is a single dose of
penicillin.
Counseling. What do you say to your patients?
The syphilis will be treated with the single dose of penicillin.
It is extremely important that all sexual partners get tested
and treated. Any sexual partners over the last year should be
informed. Anyone that has had sexual contact with someone
with known syphilis in the prior 90 days needs to get treated
regardless of serologies.
Warn patients about the Jarisch-Herxheimer reaction.
Practice safe sex practices.
Jarisch-Herxheimer reaction. This is not that bad but you
should warn your patients about it. Some sources cite a rate of
up to 90% in the treatment of primary syphilis. About 24 hours
after the penicillin shot, the patient may develop fever, myalgias,
worsening of the rash on the palms and soles. This is self-limited
and lasts about 24 hours. Most patients only require supportive
care. Warn the patients so they don’t rush back to your ED think-
ing they are dying.