Welcome back,

Based on some feedback and content initiatives I’ve decided to trial the asynchronous content here in one large document for the month and block topic as opposed to the previous weekly formats in order to allow one central source for content. If you prefer this format let me know in the comments or in stream during conference and we will keep it going.

But First

We’ve begun our recruitment for this years residency applicants. We have multiple meet and greet sessions for applying students going forward. Reach out to the Chiefs or Dr K. Holmes for more information if you would like to take part.

Attention EM Bound MS4s! Come join us for a virtual meet and greet this Thursday at 1pm! @FortWorthEM #HeyMedStu @emresidents @ACEPNow @SAEMonline @TexACEP #whyJPS pic.twitter.com/Xp5nnb0jCb

— Vietvuong Vo (@VvVEMDoc) August 10, 2020

Also we started resident profiles! Please check out these profiles of some of our PGY1’s this year. Much more to come!

Meet our residents!! #WhyJPS #FortWorthEM Introducing our PGY-1, Dr. Kaitlin Sweeney From @coschoolofmines and @CUMedicalSchool She rotated with us as a medical student & we all knew she was a perfect fit! Welcome to the family! pic.twitter.com/GWrgOMJlOk

— JPS EM Residency (@FortWorthEM) August 10, 2020

Meet our residents!! #WhyJPS #FortWorthEM Introducing our PGY-1, Dr. Josh Riechers @JoshuaRiechers ! From @OralRobertsU & @UTSWNews another awesome resident to add to the family! pic.twitter.com/i89Di1Yr2U

— JPS EM Residency (@FortWorthEM) August 7, 2020

Next up

July was our introductory month for new interns and we presented the National Difficult Airway Course and the Ultrasound Workshop. Opportunities for hands on learning with advanced airway methods and diagnostic sonography in an emergency setting.

Had a blast during the Difficult Airway Course today! Got to practice DL, VL, SGA, crics, fiber optic nasal intubations, pediatric intubations, and run through some difficult cases! Thanks faculty and guest attending for sharing their expertise! pic.twitter.com/T7khhtKt9H

— Vietvuong Vo (@VvVEMDoc) July 22, 2020

Ultrasound day!! Thx @GiffordTx for the video! @IESHealthcare @JByrdEM @wolf_bytes @SonoShedd @HaoWangEM @canuck4199 @StefanMeyering #EMConf pic.twitter.com/gNKAsUy6jf

— JPS EM Residency (@FortWorthEM) July 30, 2020

Next up

Shoutout to all our new Interns who have hit the ground running and are off to a great start! keep up the strong work!

Onto business

Hematology/Oncology can be a challenging topic in Emergency Medicine. Lets get into a few topics:

Transfusion reactions:

Acute febrile Reactions:
– Most common. Occurs at time of transfusion or typically < 8 hrs. Pt develops fever/chills commonly. Typically benign.
– Due to recipient antibodies against donor leukocytes.
– Treat with Antipyretics
– Diagnosis of exclusion: Mimics acute hemolytic reaction – must be ruled out.

Acute Hemolytic reactions:
– ABO incompatibility –> human vs systematic error. Typically occurs within minutes of transfusion. Can be life threatening!
– Fever, chills, abdominal or back pain, progresses to jaundice, bleeding due to coagulopathy/DIC and dark colored urine with renal dysfunction
– Workup shows –> +Schisocytes, High LDH, elevated TBili. You need to check coags (PT, aPTT) fibrinogen, haptoglobin (DIC workup).
– Treatment: IVF resus with goal urine output 1cc/kg/hr.
– If DIC is suspected, the use of replacement therapy should be used as follows: FFP used if PT greater than 1.5. Cryoprecipitate if fibrinogen levels below 1g/L. Platelets replaced if count is below 50,000/uL. Dialysis can be used to remove the immune complexes. Red Blood Cell Exchange Transfusion has been successful in a few case reports. (2,3,4)

TRALI (transfusion related acute lung injury):
– Mimics ARDS on CXR. Associated with hypotension, fever/chills, dyspnea, tachypnea and hypoxia. Caused by Neutrophil injury to pulmonary epithelium
– 70-90% require intubation and mechanical ventilation
– Treatment–> Stop transfusion, ARDSnet strategy for ventilation (4-8ml/kg and low plateau pressures). Little/no role for steroids/diuretics.

TACO (Transfusion associated circulatory overload):
– Typically seen <6hrs of transfusion with signs of acute pulmonary edema and heart failure: new respiratory distress, hypertension, new pulmonary edema, widened pulse pressure, and increased JVD. 
– CXR similar to TRALI, sometimes difficult to distinguish between the two.
– Treatment–> Similar to Acute CHF – Diuretics, NIPPV, nitrates

Next

Tumor lysis syndrome

What is it and who is at risk? –> When tumor cells lyse they release phosphate, K+ and Uric acid. Accumulation of these products causes acute renal injury because they are excreted renally. Any cancer theoretically is at risk, however some are higher prevalence than others:
– Non hodgkins lymphoma
– AML with wbc >100
– ALL
– Solid tumors that are bulky and sensitive to chemo –> Small cell lung cancer, germ cell tumors, neuroblastomas
– CLL

Clinical findings and treatment:
– Will manifest itself with elevated sCr –> like an AKI
– LDH typically elevated
– Consider checking G6PD in high risk groups as G6PD can mimic TLS.
– Tx: IVF, Allopurinol or rasburicase (Uric acid modifiers), Treat and correct abnormal electrolytes. Typically requires hospital admission. Sometimes oncology will place tumor patients on allopurinol for prophylaxis preemptively.

Next

Hypercalcemia of malignancy

Occurs for a variety of reasons –>osteolysis w/bone mets, humoral hypercalcemia of malignancy (PTHrP related), 1,25-OHD secreting lymphomas, ectopic hyperparathyroidism.

“Bones, stone, groans, abdominal moans” –> Hypercalcemia concentrates H20 and excretion –> increased dehydration. CNS confusion, QT shortening on EKG, Seizures, N/V and abd pain, renal failure are seen.

Evaluation and Tx:
– Normal Ca2+ 9-12 g/dL, normal Ionized 1.05-1.44 mmol/L
– Remember to correct Ca2+ for hypoalbuminemia https://www.mdcalc.com/calcium-correction-hypoalbuminemia
– Tx: Stop thiazides, IVF resus, Start lasix 80-100mg/ IV daily – once renal function improved, Add calcitonin (inhibits osteoclasts but can cause tachyphylaxis), consider bisphosphonate ie Zoledronate 4mg. Consider adding Prednisone for lymphoma patients.

Next

Brain mets –> Consider expanding workup to staging CT’s to look for primary cancer –> CT chest/abd/pelvis if found incidentally on head CT.
– Start Dexamethasone 10mg IV in ED. Neurosurgery consult. PPI for GI prophylaxis, +possible seizure prophylaxis medications. If extensive may need to consult Rad Onc for whole brain radiation.

Hyperleukocytosis/Leukostasis –> Seen with WBC >100k in leukemias/lymphomas. Accumulation of blast cells –> Hypoperfusion of end organs. Causes fever, renal failure, CNS symptoms ie confusion or coma. Tx–> Call Heme/onc, initiate leukopheresis (phlebolomy blood draws), start hydroxyurea. (5)

SVC syndrome –> SVC occlusion secondary to malignancy, can occur from thromboembolization but more commonly from mediastinal and lung malignancies or metastases that cause SVC constriction. Causes R upper extremity and R facial Plethora clinically with distended neck and chest veins. Tx – elevate head, +Steroids if leukemia/lymphoma, IR likely indicated – thrombolysis vs stent. Likely Radiation Tx or chemo indicated to shrink surrounding tumor.

Neutropenic fever –> Fever >100.4 in active chemo patients most likely prevalence. ANC (Absolute neutrophil count <500) Although ANC has been revised as <1500 (mild), <1000 (moderate), <500 (severe) classifications. (6). Tx –> Culture everything, +Cefepime 2g IV or Meropenem or Zosyn. Also add Vancomycin IV. Start Abx within 1 hr of presentation.

Next

Sickle Cell Anemia

Autosoma recessive inherited. Affecting nearly 100,000 individuals in the US, and approximately 2 million Americans carry the sickle cell trait. Prevalent in persons of African, Mediterranean, Indian, and Middle Eastern descent. (7) Sickling of cells occur due to mutation under states of increased oxygen demand. (8)

Acute pain crisis –> “acute vasoocclusive crisis”. Symptoms include bone pain, headache, chest pain, abd pain. Can present with fever and leukocytosis. Tx –> NSAIDS, escalating to Narcotics if required.

Acute chest syndrome –> Evaluate in any SCC patient with chest pain/dyspnea/hemoptysis. CXR will typically show infiltrate. Treat like CAP –> ceftriaxone/axithro/doxy (unless MDR risk factors) and +pain control. Always admission. Can progress rapidly to ARDS and require exchange transfusion.

Stroke –> major complication of SCC. Adult patients should be considered for tPA and/or IR thrombolysis. Pediatric patients with SCD should receive IVFs and exchange transfusion to achieve a hemoglobin S level of <30% (9).

Aplastic crisis –> Reticulocyte count <2% is diagnostic. Commonly seen with Parvovirus 19 co-infection. Can be ICU admission. Requires transfusion.

Lastly

Lets end on a wellness note, another performance from the very talented Dr Anant Patel!

To battle the challenges of working in healthcare during a pandemic I enjoy creating music on days off!#bigbandband #physicianwellness #morethanmedicine pic.twitter.com/OQ9xNlJ5AG

— Anant Patel (@anantpatels) July 26, 2020

References

1. EMDOCS.net – Transfusion reactions
2. Strobel, E. (2008). Hemolytic Transfusion Reactions. Transfusion Medicine and Hemotherapy, 35(5), 346–353. http://doi.org/10.1159/000154811
3. Adewoyin, A., & Oyewale, O. (2015). Complications of Allogeneic Blood Transfusion: Current Approach to Diagnosis and Management. International Blood Research & Reviews, 3(4), 135-151. doi:10.9734/ibrr/2015/17874
4. Rose, S. S., George, S., Wong, S., Tenorino, G., & Kuriyan, M. (2007). Red Blood Cell Exchange Transfusion (RBCET) in the Management of Acute Hemolytic Transfusion Reaction (AHTR).. Blood, 110(11), 4021. Accessed February 05, 2017. Retrieved from http://www.bloodjournal.org/content/110/11/4021.
5. Wei et al. Blood 2016; 127: 296-302.
6. Mazzucconi et al. Blood 2007; 109: 1401-7.
7. Lanzkron S, Domm J, Sweet K. Sickle cell disease. First Consult. Elsevier BV, 2010.
8. Williams-Johnson J, Williams E. Chapter 231: Sickle cell disease and other hereditary hemolytic anemias. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide 7e.  Chapel Hill, NC, McGraw-Hill Holdings, LLC, 2011.
9. Elbers J, Wainwright M, Amlie-Lefond C. The pediatric stroke code: early management of the child with stroke. J Pediatr. 2015; 167(1): 19-24e4.

Image Credits:
Stefan Meyering DO FAAEM
Unsplash – NCI, Robin Weemeijer
Social media as individually referenced above