Cool case

[EMEDPA]

Well known iv drug user in our community presents with temp 105 per ems with cbg > 600(critical high, actual was 1050).

pmh: ivdu, type 1 dm(always poor control), hx of multiple pe's on lovenox bid as she can't do coumadin right and has had inr's as high as 14 several times.

recently txd by pcp for "pneumonia" with a z-pak( don't do that, if it's a real pneumonia they need more than a z-pak...).

anyway, cough/fever/"stiff neck" but no meningismus(and I was hesitant to do an lp with pt on lovenox bid). no peripheral iv access x4 attempts(ems+ our rn's). no central access as she has had multiple central lines and is scarred everywhere(subclavian, ij, ej, femoral). when I told her I was going to put in 2 IO's she showed me the "special veins" that she only uses on rare occassion.....b/l breast veins...yup, we got 22's in both, drew labs and hydrated her through those.

chest xray showed a persistent infiltrate, lactate around 4, bicarb 15. cbc not terribly impressive. Urine clean, not pregnant, uds + opiates and meth.

tx with iv hydration , rocephin 2 gm iv/zithromax 500 iv, admitted to icu for dka, pneumonia with ddx to include early meningitis. blood c+s still pending.

kinda cool....it's dka..oh, and maybe sepsis, from pneumonia, or maybe meningitis(but can't do an lp). intensivist knew this pt well and basically wanted her completely wrapped up before he would accept her. he also refused to even attempt a central line(wisely, most likely..the last time they managed to get one pt eloped with it and shot meth through it...).

he added something of interest to the ddx, malignant hyperthermia from street drugs, but she defervesced quicly with standard tx so didn't receive dantrolene.

[jmj11]

Was interesting. It is sad what people do to themselves. I'm glad they relegate the easy stuff to the simpleton PA (wink, wink). At what point would you consider an LP in that context? Continuing fever + CNS symptoms? I know that you are trying to cover the basics with the antibiotics including bac meningitis, but if she wasn't getting well (and thank goodness she is) in people like her I would guess you would have to start worrying about more exotic infection sources.

 

Speaking of antibiotics, could you attach a few Cipro to an email, I think I've been bitten by the E Coli bug and I'm flat on my back. I usually take it with me to the third world but things go so hectic trying to close down the whole practice for two weeks that I forgot it. I did just send my wife into the souk to by some (probably will be paracetamal with "CIPRO" hand-carved on each pill . . . or who knows what).

[EMEDPA]

if you hold the lovenox for 12-15 hrs you could probably do the LP if needed (and worth the trade off for risk of PE). often the organism from meningitis will grow out in the blood culture as well.

hope you get over your gi bug. there should be some cipro available at the local market. I know in Haiti you can buy everything under the sun at the local market...for a price...

[ajnelson]

She'd be a good candidate for bacterial endocarditis as well, no? While it's sad what these patients do to themselves, I enjoy the medicine and trying to figure it all out!

 

 

 

Well known iv drug user in our community presents with temp 105 per ems with cbg > 600(critical high, actual was 1050).

pmh: ivdu, type 1 dm(always poor control), hx of multiple pe's on lovenox bid as she can't do coumadin right and has had inr's as high as 14 several times.

recently txd by pcp for "pneumonia" with a z-pak( don't do that, if it's a real pneumonia they need more than a z-pak...).

anyway, cough/fever/"stiff neck" but no meningismus(and I was hesitant to do an lp with pt on lovenox bid). no peripheral iv access x4 attempts(ems+ our rn's). no central access as she has had multiple central lines and is scarred everywhere(subclavian, ij, ej, femoral). when I told her I was going to put in 2 IO's she showed me the "special veins" that she only uses on rare occassion.....b/l breast veins...yup, we got 22's in both, drew labs and hydrated her through those.

chest xray showed a persistent infiltrate, lactate around 4, bicarb 15. cbc not terribly impressive. Urine clean, not pregnant, uds + opiates and meth.

tx with iv hydration , rocephin 2 gm iv/zithromax 500 iv, admitted to icu for dka, pneumonia with ddx to include early meningitis. blood c+s still pending.

kinda cool....it's dka..oh, and maybe sepsis, from pneumonia, or maybe meningitis(but can't do an lp). intensivist knew this pt well and basically wanted her completely wrapped up before he would accept her. he also refused to even attempt a central line(wisely, most likely..the last time they managed to get one pt eloped with it and shot meth through it...).

he added something of interest to the ddx, malignant hyperthermia from street drugs, but she defervesced quicly with standard tx so didn't receive dantrolene.

[EMEDPA]

yup, think she has had it before in fact.

[ajnelson]

Nice! I've had a few interesting patients in the past few weeks, makes all of those coughs, runny noses and I've been throwing up for an hour patients worth it!

[rcdavis]

Tell ya the truth e, If she were cooperative I woulda tapped her..carefully. If done carefully with good attention to landmarks, atraumatic taps should be the rule. And the information in this case is priceless. Any antibiotic intervention ruins further taps after 4hours. So I'd started the abx with the intention of tapping her immediately.

I understand the risks, but I feel very confident in my ability, and woulda risked it. If she were obese, I would do it under Fluoro.

 

Btw, don't you think an IO would bleed a bit? If you'd a done an IO, I would imagine an LP would be okay. Not being critical. Been there and that's been my thinking process. See most def needs a TEE.

as always, nice job

 

Rc

[EMEDPA]

not cooperative in any way. meth tweaking out of her mind and barely able to participate in a conversation.

you are right, the IO would have bled as well. I was running out of options and she needed fluids to cover the dka.

[Hemegroup]

Tell ya the truth e, If she were cooperative I woulda tapped her..carefully. If done carefully with good attention to landmarks, atraumatic taps should be the rule. And the information in this case is priceless. Any antibiotic intervention ruins further taps after 4hours. So I'd started the abx with the intention of tapping her immediately.

I understand the risks, but I feel very confident in my ability, and woulda risked it. If she were obese, I would do it under Fluoro.

 

Btw, don't you think an IO would bleed a bit? If you'd a done an IO, I would imagine an LP would be okay. Not being critical. Been there and that's been my thinking process. See most def needs a TEE.

as always, nice job

 

Rc

 

Man, I've only seen one IO in my life and it looked so easy and the nurse did it. Great case emed and great work.

[EMEDPA]

man, i've only seen one io in my life and it looked so easy and the nurse did it. Great case emed and great work.

it's easier than starting an iv. Take an acls, atls or pals course and they will teach you how to do it.

[Hemegroup]

it's easier than starting an iv. Take an acls, atls or pals course and they will teach you how to do it.

Hey now, I'm ACLS and there ain't no IO lol ... and I already do know how to do it. See one, do one, teach one. Maybe in that ATLS. Always wanted that one.

[Just Steve]

Not to thread high jack but here is one example of an IO being used by those on the tip of the spear aka: military.

 

The language isn't super safe for work as the F bomb gets dropped but just turn down the volume. Keep in mind this is a young 18-20 year old field medic teaching the gun slingers how to save their buddy's life. It ain't pretty, it ain't polished, it's just another training moment for the armed forces.

 

http://m.youtube.com/#/watch?v=iEOLm2e6ovc&desktop_uri=%2Fwatch%3Fv%3DiEOLm2e6ovc

 

i have placed Jashidi IO needles that you had to hand twist in and I have placed IOs using the Ezy IO drill. Complicating factors for those traditional placements include morbid obesity and/or profound edema due to end stage heart failure and the like. The "normal" needle isn't long enough to reach the tibia. For those cases, you can search for the longer needle, drill the malleolus, or go to the humeral head. I am wondering if drilling the sternum with the Ezy IO would work...

[medic25]

I am wondering if drilling the sternum with the Ezy IO would work...

 

I would probably avoid trying this. I took a training course with the doc who created the EZ-IO a few years ago, and he attempted a sternal placement in the animal lab. When we pushed the IV dye under flouro, the needle had passed right through the sternum; it's just not designed for such a thin bone. I'd stick with using the longer needle and use the humeral head.

[EMEDPA]

apparently the military uses the ez IO for sternal placement but it's not an approved site. when someone has a flak jacket on and is exposed to blast it is not uncommon to have long bone fxs x 4 ext so you can't use traditional sites.

[flyingsquirrel]

Vidacare makes a sternal IO for the military but it's manual, not drilled.

The video that Steve posted uses the Fast-1 which is the only sternal IO that I know of that is approved for civilian (and military) use.

 

I see people drill through infants' tibias on a regular basis with the EZIO...I can only imagine how easy it would be to drill right through the sternum.

[EMEDPA]

Hey now, I'm ACLS and there ain't no IO lol ... and I already do know how to do it. See one, do one, teach one. Maybe in that ATLS. Always wanted that one.

huh, weird. they teach IO's with acls in my part of the world. ATLS is definitely a worthwhile course to take. I have taken it 4 times and will recert again next yr.

[EMEDPA]

Vidacare makes a sternal IO for the military but it's manual, not drilled.

The video that Steve posted uses the Fast-1 which is the only sternal IO that I know of that is approved for civilian (and military) use.

 

I see people drill through infants' tibias on a regular basis with the EZIO...I can only imagine how easy it would be to drill right through the sternum.

thanks for the clarification. I knew they had a military IO product.

have you guys seen this one:

http://www.actnt.com/BIG/Bone_Injection_Gun.htm

single use but no battery and a lot less per use than the EZ IO.

[flyingsquirrel]

thanks for the clarification. I knew they had a military IO product.

have you guys seen this one:

http://www.actnt.com/BIG/Bone_Injection_Gun.htm

single use but no battery and a lot less per use than the EZ IO.

 

They were popular in my neck of the woods when they first came out, but then there was concern that they caused microfractures in healthy bones (and therefore might cause worse in osteoporotic bones) so they fell out of favor.

[meaux]

Sorry, I couldnt post a URL link for this, but I wanted to give a little insight on when/when not to do LPs... generally.

 

Lumbar Puncture and Anticoagulants – Should I?

 

November 7, 2012

 

Russ Rudy, MD, FACEP and Jeanie Taylor, RN, BSN, MS

 

 

A lumbar puncture (LP) can be very frightening to patients. Most of us have heard a story or two about a patient that refused an LP because they were worried about paralysis. And, the concern is real, as there is a reported 1-2% risk of spinal epidural hematoma following an LP; the risk is increased for patients with a bleeding diathesis and those taking anticoagulant medications.

 

With the advent of newer blood-thinning medications it behooves the emergency physician to be aware of these medications and the associated bleeding risk when performing an LP on patients taking these drugs. The following is a list of anticoagulants and recommendations on when it is safe to perform an LP.

 

[TABLE]

[TR]

[TD]Drug

[/TD]

[TD]Recommendation

[/TD]

[/TR]

[TR]

[TD]Aspirin

[/TD]

[TD]Safe to perform LP

[/TD]

[/TR]

[TR]

[TD]NSAID

[/TD]

[TD]Safe to perform LP

[/TD]

[/TR]

[TR]

[TD]Aggrenox (ASA + dipyridamole)

[/TD]

[TD]Safe to perform LP

[/TD]

[/TR]

[TR]

[TD]Coumadin (warfarin)

[/TD]

[TD]Wait 5-7 days and INR < 1.4

[/TD]

[/TR]

[TR]

[TD]Heparin (subq dose)

[/TD]

[TD]Safe as long as total daily dose < 10,000 units per day

[/TD]

[/TR]

[TR]

[TD]Heparin (systemic dose – heparin drip)

[/TD]

[TD]Stop drip for 2-4 hours, PTT must be in normal range prior to LP

[/TD]

[/TR]

[TR]

[TD]LMWH

Low does - thromboprophylactic dose

High dose - therapeutic dose

[/TD]

[TD]

Wait 12 hours

Wait 24 hours

[/TD]

[/TR]

[TR]

[TD]Thienopyridines

Ticlid (ticlodipine)

Plavix (clopidogrel)

Effient (prasugrel)

[/TD]

[TD]

Wait 10 days

Wait 7 days

Wait 7 days

[/TD]

[/TR]

[TR]

[TD]IIA/IIIB inhibitors

Aggrastat (tirofiban)

Integrilin (eptifibatide)

ReoPro (abciximab)

[/TD]

[TD]

Wait 8 hours

Wait 8 hours

Wait 24-48 hours

[/TD]

[/TR]

[TR]

[TD]Direct thrombin inhibitors

Pradaxa (dabigatran)

Lepirudin (Refludan)

Angiomax (bivalirudin)

Argatroban

[/TD]

[TD]

Unsafe, do not do LP

Wait 8-10 hours

Wait 8-10 hours

Wait 4 hours

[/TD]

[/TR]

[TR]

[TD]Factor Xa inhibitors

Arixtra (fondaparinux)

Xarelto (rivaroxaban)

[/TD]

[TD]

Wait 36 hours

Wait 20 hours

[/TD]

[/TR]

[TR]

[TD]Danaparoid

[/TD]

[TD]Unsafe, do not do LP

[/TD]

[/TR]

[/TABLE]

 

Also remember that patients with liver disease, renal disease, hemophilia and von Willebrand's disease are at risk for bleeding. Most experts believe an LP should not be performed if the platelet count is below 50,000 and the INR is less than 1.4. If an LP must be done emergently consult with a hematologist regarding possible reversal agents. Patients who are at risk of a bleeding complication may also benefit if the LP is done under fluoroscopy by an interventional radiologist.

 

An epidural spinal hematoma may be difficult to detect. Suspect patients with complaints of back pain (which may be severe and at times radicular in nature), lower extremity weakness or numbness (which may be unilateral or bilateral) and bowel or bladder symptoms. Perform an immediate MRI scan of the spine. If an epidural hematoma is present consult neurosurgery for a de-compressive laminectomy which may spare spinal cord function.

 

Sources

 

1. Vandermeulen, Erik MD. Best practice and research clinical Anesthesiology. 24 (2010) 121-131
   
2. Johnson, Kimberly MD; Sexton, Daniel J MD; UpToDate. Lumbar Puncture: Technique; Indications; Contraindications and Complications in Adults
   
3. Layton, Kennith MD; Kallries, David MD; Horlocker, Terese MD. AJNR March, 2006. 27: 468-470
   

[rcdavis]

Nice to know info. There are times, however, that te benefits outweight te risk.. And, as I am concerned with life threatening conditions, there are times I will risk it. I cannot think of one emergent condition that I would be willing to wait 7 days to tap. If push comes to shove, I'll reverse that Coumadin, or preload with vitamin k.. But the study is nice to have. Thanks