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MCEP LLSA REVIEW

2019 ARTICLES (9-12)BRIAN FELICE, MD

NOVEMBER 2, 2020

PEDIATRIC NONTRAUMATIC HIP PATHOLOGY

• Neville DN, Zuckerbraun N. Pediatric non traumatic hip pathology. Clin Ped Emerg med.

2016;17:13-28

• Review article looking at etiology of nontraumatic hip pain/pathology in children

PRESENTATION

• Nontraumatic pediatric hip pathology most often presents as hip pain

• Often the hip will be in flexed/externally rotated position at rest

• May have:

• Thigh pain

• Knee pain

• Difficulty/Inability to bear weight

• Altered gait

X-RAYS

• Almost always ordered

• Only 1% of x-rays in children younger than 9

years old show pathology

• Fractures uncommonly seen

• Position of epiphyses becomes important as

children age

• Comparison views to contralateral hip can be

important

Frog-Leg View

Anterior-Posterior

ULTRASOUND

• Used to primarily detect joint effusions

• Hip should be slightly abducted and externally rotated

• Linear probe is placed in parallel to the long axis of the

femoral neck

ULTRASOUND

NORMAL APPEARANCE

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MRI

• Highly detailed pictures

• More difficult to obtain

• May require sedation

• Because of this, reserved for

cases when other modalities

have not provided a diagnosis

LABORATORY STUDIES

• Indicated when infection or malignancy is suspected

• CBC

• C-reactive protein (CRP)

• Erythrocyte Sedimentation Rate (ESR)

• Blood Cultures

• Synovial Fluid Analysis (cell count, bacteria, crystals, cultures)

TRANSIENT SYNOVITIS

• Most common diagnosis of nontraumatic pediatric hip complaints

• Self-limited inflammation and effusion of hip

• Unknown etiology

• 40% had preceding URI, GI illness, UTI or minor trauma in preceding 2 weeks

• Typically unilateral

• Males > Females

• Age range – 3-8 years old

TRANSIENT SYNOVITIS

• History

• Acute onset unilateral hip pain

• Radiates to groin or knee

• Unwilling to bear weight or limp

• Otherwise well appearing

• Physical Exam

• Hip held in flexion, abduction, and external rotation

• Pain on movement and weight-bearing

TRANSIENT SYNOVITIS

• Diagnosis

• Mostly clinical

• Proper age

• No trauma

• No fever

• Symptoms less than 1-2 weeks

• Improved with NSAIDs

• Work-Up

• Labs and x-rays often not helpful

• US if effusion is suspected

TRANSIENT SYNOVITIS

• Clinical Course

• Usually resolves in 3-10 days

• 60% in 7 days

• 100% by 14 days

• Management

• NSAIDs

• WBAT

• Return Instructions: fever, worsening symptoms, etc

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LEGG-CALVE-PERTHES DISEASE (LCPD)

• Aseptic, non-inflammatory, self-limited, idiopathic aseptic necrosis of the capital femoral

epiphysis

• Devascularization restores itself in 1-2 years

• Children aged 3-12 years old

• Males 4x more likely than females

• RISK FACTORS: Obesity and Hypercoagulability

LEGG-CALVES-PERTHES DISEASE (LCPD)

• History

• Usually subacute with weeks to months

• Limp and pain in the hip, groin, thigh, or knee

• Exam

• Limited ROM of hip with abduction and internal rotation seen first

• Trendelenburg gait – leans over affected leg during ambulation

LEGG-CALVES-PERTHES DISEASE (LCPD)

• Diagnosis

• X-rays will show the necrosis

• Initial x-rays could appear normal as it takes time for bony changes to be seen

• MRI can be used

• Acute Management

• Resolution can take years

• Arthritis can be sequelae

• Follow up with peds ortho

LEGG-CALVES-PERTHES

DISEASE (LCPD)

SLIPPED CAPITAL FEMORAL EPIPHYSIS (SCFE)

• Displacement of the capital femoral epiphysis along the epiphyseal plate

• Thought to be related to the fragile blood supply in that area

• 10/100,000 children

• Males >> Females

• Age – 10-16 years old

• Obesity is risk factor

• 6-22% have bilateral disease, 24% will develop SCFE on contralateral side

SLIPPED CAPITAL FEMORAL EPIPHYSIS (SCFE)

• Subacute presentation of hip pain and limp over months

• Knee pain is prominent symptoms in 15-50%

• Altered gait is usually painful

• Held in abduction, flexion, and external rotation

• Limited internal rotation and flexion

• Child is non-toxic

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SLIPPED CAPITAL FEMORAL EPIPHYSIS (SCFE)

• Diagnosis with x-ray/Klein’s Line

• Low sensitivity with a miss rate of 60% leading to recommending other measurements

• Measurement of epiphyseal widths medial to Klein’s line.

• A difference of > 2 mm between the hips has a 79% sensitivity

• Other findings:

• Widening and irregularity of the physis

• Loss the round concavity of the head-neck junction

• ED Management

• Diagnosis and referral to orthopedics for surgery

KLEIN’S LINEKLEIN’S LINE

SEPTIC ARTHRITIS

• Delay in diagnosis can lead to irreversible destruction of the joint

• Occurs in all age groups

• Most common etiology is hematogenous spread from a distant source

• Joints with an intracapsular metaphysis are more susceptible to infection

• Hip, Knee, Shoulder, and Ankle

SEPTIC ARTHRITIS

• HISTORY

• Acute presentation – usually < 1 week

• Fever

• Toxic appearance

• Hot, swollen joint

• ULTRASOUND

• L image has > 5 mm effusion

• Compared to R image (contralateral side)

• > 2 mm difference between L and R

SEPTIC ARTHRITIS

• DIAGNOSIS

• Isolation of pathogen from the site of infection

• Positive blood culture in a patient with inflammation of joint

• Cultures

• Blood Cultures are positive in 14-30% of patients

• Joint Fluid Cultures are positive in 30-50% of patients

• PCR can increase sensitivity of positive results by 20-40%

SEPTIC ARTHRITIS

KOCHER CRITERIA – 99.6% probability if all 4 positive

• Fever

• Refusal to bear weight

• ESR > 40 mm/hr

• WBC > 12 k

• CRP adds to accuracy of these studies

• Joint aspiration should still take place if diagnosis is suspected in atypical cases

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SEPTIC ARTHRITIS

• Synovial Fluid Analysis – Cell count, culture, and gram stain

• CELL COUNT

• A count > 50k should be concerning for septic arthritis

• Septic arthritis in 48% of patients with cell count > 50k

• 17% of patients with septic arthritis had cell count < 17k

• ED MANAGEMENT

• Diagnosis, Stabilization, Emergent Ortho Evaluation

• Antibiotics

• Staph/Strep, Neisseria in appropriate age group; K. kingae (gram neg) most common in kids under age 4 yo

LYME ARTHRITIS

• Few reports of lyme arthritis causing monoarticular hip pain

• Routine testing not recommended

• Most common in kids 5-15 years old, with 1/3 presenting with disseminated disease

• Pain with ROM and bearing weight, but often less severe so kids can often bear some

weight

• Synovial fluid can mimic septic arthritis

• Lab Tests → ELISA with reflex to Western blot

• Treatment is doxycycline, under 8 yo use amoxicillin

MALIGNANCY

• Uncommon cause of nontraumatic hip pain

in children

• OSTEOSARCOMA is most common

pediatric bone cancer

• EWING’s SARCOMA is second most

common

• Peak incidence in adolescence

• Symptoms include: pain, mass, 25% with

minor trauma

• Plain x-rays are first imaging study and are

typically normal

SUMMARY – NONTRAUMATIC HIP PAIN

• Common complaint – often presenting with pain, gait disturbance, and difficulty weight-bearing

• Transient Synovitis – by far the most common etiology in kids aged 3-8 yo

• Male predominance, may have preceding viral illness, non-toxic, improve with NSAID, resolve in < 2

weeks.

• Legg-Calve-Perthes Disease – idiopathic aseptic necrosis that revascularizes over 1-2 years

• Male predominance, ages 2-12 yo, subacute onset, obesity/hypercoaguable are risk factors, x-rays can

be diagnostic

• Slipped Capital Femoral Epiphysis (SCFE)

• Seen in older children, 10-16 yo, painful, x-ray can be diagnostic with Klein’s lines, but not always

definitive

SUMMARY – NONTRAUMATIC HIP PAIN

• Septic Arthritis/Osteomyelitis – devastating infections. Typically patient is toxic, febrile.

• Often hematogenous spread from other source. Joint effusion is common, needs aspiration, cultures,

antibiotics, and surgery

• Cell counts often show >50k wbc, but can be seen at much lower counts as well

• Lyme Arthritis

• ? Exposure, erythema migrans helps make dx. Check ELISA/western blot

• Malignancy

• Uncommon cause of pain

• OSTEOSARCOMA > Ewing’s Sarcoma > Lymphoma

CURRENT CONTROVERSIES IN THROMBOLYTIC USE IN ACUTE PULMONARY EMBOLISM

• Long B, Koyfman A. Current controversies in thrombocytes use in acute pulmonary

embolism. J Engl J Med 2016;51:37-44.

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OVERVIEW

• > 100,000/year with an increasing incidence up to 1/300 in those over age 80

• Overall mortality is 17%, increasing to 30-50% in massive PEs

• Increasing morbidity and mortality with increasing age/co-morbidities

• AHA Classifies Pulmonary Embolism into 3 categories based on vitals, signs of shock, and instability

• Prior classifications were based on anatomy and location of clot, current classification is based on

hemodynamic stability

• NON-MASSIVE

• SUB-MASSIVE

• MASSIVE

MASSIVE PULMONARY EMBOLISM

• Pulseless, or

• Persistent bradycardia < 40 bpm

• Shock or sustained hypotension, SBP < 90 for > 15 minutes

• Or > 40% reduction from baseline

• Not due to dysrhythmia, hypovolemia, sepsis, or LV dysfunction

SUBMASSIVE PULMONARY EMBOLISM

• Normal or near normal SBP (> 90) with evidence of cardiac stress

• RV dysfunction or MI with elevated troponin

• RV dilatation on echo (RV/LV ratio > 0.9)

• BNP elevation

• New RBBB on ECG

• Anteroseptal t-wave inversions

NONMASSIVE PULMONARY EMBOLISM

• No signs of clinical instability

• No hemodynamic compromise

WHY THROMBOLYTICS?

• Reduction in time to thrombus resolution

• Reduce pulmonary vascular hypertension and R heart strain

• Decrease recurrence of PE (present thrombus acts as nidus for clot formation)

• Decreased risk of death

• Improved functional outcomes

• Decreased long-term pulmonary hypertension

CURRENT GUIDELINES

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MEDICATIONS

• Alteplase and Tenecteplase

• Alteplase dosing

• 10 mg IV bolus, then 90 mg infused over 2 hours

• Thrombolytic Contraindications

• Prior ICH

• Known cerebrovascular disease

• Intracranial malignant lesion

• Stroke within 3 months

• Recent major surgery, recent CHI or facial trauma.

THROMBOLYTICS IN CARDIAC ARREST

• CTA is not feasible

• US can demonstrate RV dysfunction

• Consideration given to systemic fibrinolytics

• Other options include catheter-directed fibrinolytics

• Surgical embolectomy

THROMBOLYTICS IN MASSIVE PE

• Thrombolytics are advised in massive PE

• Several studies/trials show improved morbidity/mortality

• Meta-analysis of trials showed:

• Decreased risk of death and recurrent PE from 19% to 9.4%

• NNT to prevent recurrent PE or death was found to be 10, however NNH was 8

• A separate study found NNH to be 17

SUBMASSIVE PE - RECOMMENDATIONS

• Varying outcomes and varying definitions, but overall no benefit has been

demonstrated with administering thrombolytics for submassive PE

• MAPPET-3 – no mortality benefit over placebo group

• PEITHO – any reduction in mortality was erased by increased mortality from bleeding

• TOPCOAT – did show a better result with thrombolytics, but only had 83 patients

CATHETER-DIRECTED THROMBOLYTICS

• Advantage is using less drug, fewer bleeding complications, and able to observe results

• Disadvantage is that it requires access to interventional radiology which may not be

readily accessible in many Eds

• SEATTLE II looked at 31 massive, 119 submassive Pes

• Treatment decreased RV dilatation

• Reduced pulmonary HTN

• Decreased clot burden

• Only 1 major bleed reported and no ICH

SUMMARY

• CARDIAC ARREST and suspected PE – all organizations support empiric use of

thrombolytics

• MASSIVE PE with unstable vitals, shock, etc thrombolytics is recommended either by

systemic infusion, catheter-directed, or surgical intervention for embolectomy

• SUMBMASSIVE PE and relatively stable patient the use of thrombolytics is not well

supported

• In a patient with submassive PE and comorbidities, may have benefit to thrombolysis with

shared decision making of risk/benefit.

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NEW-ONSET SEIZURES IN ADULTS AND ADOLESCENTS

• Gavvala JR, Schnedler SU. New-onset seizure in adults and adolescents: a review. JAMA

2016;316:2657-68.

• Review of articles from 1976 – 2016

OVERVIEW

• About 8-10% of the population will have a seizure at some point in their life

• About 2-3% will develop epilepsy

• ED role is to distinguish actual seizure from mimics

• Migraine, TIA, syncope, factitious event

• Common Definition of Epilepsy

• 2 unprovoked seizures > 24 hours apart

PRESENTATION

• Diagnosis is often based on history as often the actual event is not observed

• Seizures can be classified as generalized or focal

• Differential includes migraines, TIA, movement disorders, sleep disorders, or psychogenic

causes

• Recent studies have the incidence of a single unprovoked seizure at:

• 23-61/100,000 per year

EPILEPSY RISK FACTORS

• Family history of seizures

• Sleep deprivation

• Medications that lower seizure threshold

• Clozapine, cephalosporins, fluroquinolones, buproprion, tramadol, etc

• Metabolic derangements

• Toxin exposures

• Birth complications

• Brain injury – infectious, traumatic, prior neurosurgery

HISTORY AND PHYSICAL

• Largely clinical, so history is important

• Aura, focal seizures, lack of recall, prior staring spells, psychiatric issues

• Physical Exam

• Post-ictal state, oral injury, urinary incontinence

• Asterixis or nuchal rigidity can suggest metabolic or infectious etiology

IMAGING

• Head CT – with a first seizure, head CT should be obtained, but certain lesions may not

be visualized

• MRI – better test to pick up more subtle findings. Epilepsy specific MRI protocol is

suggested.

• EEG – can be safely delayed in most cases and be scheduled as otpt in most cases.

• EEG should be done more promptly if patient does not return to baseline within 30-60

min, waxing/waning LOC, or structural lesion that does not explain symptoms

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LABS

• Chemistry panel and drug screen assessing for hyponatremia, hypoglycemia, or

intoxication

• One study showed this was only helpful in about 4% of cases

• Prolactin level can be elevated 10-20 minutes after a seizure

• Lumbar puncture – low utility unless concern for CNS infection or SAH

RISK OF RECURRENCE

• 35% chance of recurrence within 5 years after first seizure.

• 75% chance of recurrence within 5 years after second seizure.

• Patients with structural brain lesion and/or abnormal EEG, have a higher recurrence rate

• Seizure related to trauma have a 5-year recurrence of 29-48%

• Higher rate of recurrence if seizure happens at night (54%) vs if seizure happens in day

(33%)

TREATMENT

• Majority of patients (66%) do not require anti-epileptic meds being started in ED

• Anti-epileptics can be divided into broad and narrow spectrum agents

• First-Line agents include: fosphenytoin, valproate, and levetiracetam

• Duration of treatment is complex decision with 59% of patients remaining seizure free

after 2 years of treatment

SUMMARY

• Common presentation to the ED, with a number of etiologies

• Diagnosis is highly clinical-based and assessment of risk factors can be helpful

• Exam can have post-ictal state, tongue biting, bruising from fall

• Evidence of infection includes nuchal rigidity/fever

• Neuroimaging for first time seizures, routine labs

• Most patients can have EEG scheduled as otpt

• Most patients do not require anti-seizure medications

CLINICAL POLICY: CRITICAL ISSUES IN THE EVALUATION OF ADULT PATIENTS WITH SUSPECTED TIA IN THE ED

• American College of Emergency Physicians Clinical Policies Subcommittee (Writing

Committee) on suspected transient ischemic attack; Carpenter CR, Hatten BW, Wright

BJ, et al. Clinical policy: critical issues in the evaluation of adult patients with suspected

transient ischemic attack in the emergency department. Ann Emerg Med 2016;68:354-70.

• Policy Statement from ACEP that asks 4 specific questions

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QUESTION 1

In adult patients with suspected TIA, are

there clinical decision rules that can identify

patients at very low short-term risk for

stroke who can safely be discharged from

the emergency department?

QUESTION 1 - RECOMMENDATIONS

• Level A – none specified

• Level B – DO NOT rely on current existing risk stratification instruments to identify TIA

patients who can be safely discharged from the ED, including age, BP, clinical features,

duration, diabetes, or the ABCD2 score.

• Level C – none specified

RISK STRATIFICATION (QUESTION 1)

• 378 articles reviewed, 72 selected, 34 applied to this question

• Pretest probability for short-term risk of stroke can be estimated in 3 ways

• 1) objective criteria with risk stratification tools

• 2) clinical gestalt

• 3) extrapolation from studies reporting on post-TIA patients

• ABCD2 score is the most commonly cited score used for TIA

• 2009 guidelines on TIA was that ABCD2 score be used to decide hospital admission based on

score of 3 or higher.

• A score of 0-2 could follow up as otpt to complete work-up in 2 days

ABCD2

SCORE OF <4 IDENTIFIED 34% OF PTS WITH LOW RISK OF STROKE OCCURRING IN 1% (2 DAYS) AN D1.2% (AT 7 DAYS)

QUESTION 1 -SUMMARY

QUESTION 2• In adult patients with suspected TIA, what imaging can

be safely delayed from the initial ED work up?

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QUESTION 2 - RECOMMENDATIONS

• Level A recommendations – none specified

• Level B recommendations – none specified

• Level C recommendations –

• The safety of delaying neuroimaging is unknown, and it is reasonable when MRI is not available, that

a non-contrast head CT be part of the initial ED work-up, although it should not be used to identify

patients at high risk for short-term stroke.

• When feasible, physicians should obtain MRI with DWI to identify those at short term risk for

stroke

• When feasible, physicians should obtain cervical vascular imaging to identify those at short term

risk for stroke

QUESTION 2 – IMAGING DELAY

• 441 articles, 85 selected, 13 used to address this question

• Primary goal of neuroimaging is to look for serious TIA mimics

• Intracranial bleeding or mass

• Secondary goal is to identify those patients at high risk for stroke in the next 2-7 days

• 3 imaging modalities considered for TIA

• CT, MRI, and carotid vessel imaging

QUESTION 2 – HEAD CT

• In 2, class II studies, where approx. 1700 pts all with TIA symptoms had a head CT

• Both studies found that a new infarct on head CT was not associated with another ischemic

stroke in 2-7 days and could not predict those at short-term risk

• A Canadian study with about 2,000 patients showed the opposite conclusion

• Due to mix of data conclusions, we cannot select a group of low-risk TIA patients in the

ED in who a head CT could be delayed

QUESTION 2 – MRI, CAROTID IMAGING

• When feasible, physicians should obtain MRI with DWI to identify those at short term risk for

stroke

• When feasible, physicians should obtain cervical vascular imaging to identify those at short

term risk for stroke

• Data could not select patients in the ED in whom such imaging could be delayed or low-risk

of post-TIA stroke

QUESTION 2 – IMAGING CONCLUSIONS

1. In patients with a suspected TIA it is likely that an initial non-contrast head CT will

identify some patients with serious alternative diagnoses; however there is no

evidence evaluating the safety of delaying neuroimaging in the ED

2. Initial non-contrast head CT cannot reliably predict early stroke in suspected TIA

patients.

3. Both DWI-MRI and cervical vascular imaging can predict short-term risk for

stroke in patients with suspected TIA

QUESTION 3• In adult patients with suspected TIA, is carotid

ultrasonography as accurate as neck CTA or MRA in

identifying severe carotid stenosis?

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QUESTION 3 – RECOMMENDATIONS

• Level A recommendations – none specified

• Level B recommendations – none specified

• Level C recommendations –

• In adult patients with suspected TIA, carotid ultrasonography may be used to exclude severe

carotid stenosis because it has an accuracy similar to that of MRA or CTA.

QUESTION 3 – CAROTID ULTRASOUND

• 398 articles, 34 selected, 8 included to address this question

• Carotid Endarterectomy has been shown to be beneficial within 2 weeks of patients with

severe stenosis, 70-99%, NNT = 6 to prevent future stroke or death

• In Class III studies carotid doppler US compared to CTA or MRA and is less expensive

and more available in many hospital EDs

QUESTION 4

• In adult patients with suspected TIA, can a rapid ED-

based diagnostic protocol safely identify patients at

short-term risk for stroke?

QUESTION 4 – RECOMMENDATIONS

• Level A recommendations – none specified

• Level B recommendations –

• In adult patients with suspected TIA without high-risk conditions*, a rapid ED-based diagnostic

protocol may be used to evaluate patients at short-term risk for stroke.

• *High-risk conditions include: abnormal head CT, suspected embolic source (a fib, etc),

known carotid stenosis, previous large stroke, and crescendo TIA

• Level C recommendations – none specified

QUESTION 4 – ED DIAGNOSTIC PROTOCOLS

• 349 articles, 60 selected, 8 included to address this question

• Data from multiple class II and III studies demonstrated the safety and feasibility of rapid

ED assessment for short-term stroke risk as opposed to admitting the patient.

• Diagnostic protocols include: carotid imaging, echocardiography, serial clinical evaluations,

and cardiac monitoring for at least 12 hours.

• Patients with recurrent symptoms or a positive test are admitted

• Shortened hospital LOS and lower costs

SUMMARY

• ACEP Clinical Policy for patients with suspected TIA had 4 recommendations (all Level B

or C, no level A recommendations)

1) There are no risk stratification decision rules that adequately identify patients at very low

risk for short-term stroke including the most studied, ABCD2 rule.

2) The safety of delaying imaging from the ED is unknown. DWI-MRI is the best imaging when

available and carotid assessment should also be included to identify high-risk patients.

3) Carotid ultrasound is as good as MRA or CT to identify severe stenosis

4) An accelerated observation TIA protocol for patients without high-risk conditions that

includes carotid imaging, 2d echo, cardiac monitoring, and serial exams is safe and effective to

identify patients at short-term risk for post-TIA stroke.

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