Volume 30 Number 12 December 2016

Fever Pitch
Febrile seizures are common occurrences in the pediatric
population, particularly in the winter and early spring,
when concomitant infections peak. Emergency clinicians
must be adept at differentiating between simple and
complex seizures, understand the scope of each child’s
medical workup, know when a specialty evaluation is
warranted, and provide anticipatory guidance to parents
and caregivers.

Insult to Injury
Geriatric trauma patients often are much sicker than
meets the eye, and deadly complications can arise
without warning. Frailty, a decreased physiological
reserve,puncture
Lumbar and medical
(LP) comorbidities all complicate their
is used in the diagnostic
clinical course, and seemingly benign
evaluation of central nervous system (CNS) mechanisms
processes,
suchcommonly
most as ground-level falls
in cases can lead toinfection
of suspected repeat visits
and and
potentially catastrophic outcomes.
subarachnoid hemorrhage. Less commonly, the
procedure is used for therapeutic purposes (eg, in cases
of idiopathic intracranial hypertension).

THE OFFICIAL CME PUBLICATION OF THE AMERICAN COLLEGE OF EMERGENCY PHYSICIANS

IN THIS ISSUE
Lesson 23 n Geriatric Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Critical ECG . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Critical Decisions in Emergency Medicine is the official
LLSA Literature Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 CME publication of the American College of Emergency
Physicians. Additional volumes are available to keep
Critical Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 emergency medicine professionals up to date on
Lesson 24 n Febrile Seizures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 relevant clinical issues.

Critical Image . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
EDITOR-IN-CHIEF
CME Questions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Michael S. Beeson, MD, MBA, FACEP
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Rootstown, OH
NEXT MONTH SECTION EDITORS
n Pregnancy-Related Emergencies Andrew J. Eyre, MD
n Fibromyalgia and Complex Regional Pain Syndrome Brigham & Women’s Hospital/Harvard Medical School,
Boston, MA

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Christian A. Tomaszewski, MD, MS, MBA, FACEP
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 Insult to Injury
Geriatric Trauma

LESSON 23

By A. Travis Manasco, MD; Casper Reske-Nielsen, MD;

and Ron Medzon, MD
Dr. Manasco is a chief resident in the Department of Emergency Medicine at
Boston Medical Center, Boston University School of Medicine in Massachusetts. Dr.
Reske-Nielsen is an attending physician in the Department of Emergency Medicine
at Lahey Medical Center in Burlington, Massachusetts. Dr. Medzon is an associate
professor of emergency medicine and the director of the Solomont Center for
Simulation and Nursing Education at Boston Medical Center, Boston University
School of Medicine.
Reviewed by George Sternbach, MD, FACEP

OBJECTIVES
On completion of this lesson, you should be able to: CRITICAL DECISIONS
1. Describe the most common risk factors and mechanisms
n How can frailty be used to predict the outcome
of injury in elderly trauma patients.
2. Apply the concept of frailty to the workup of the geriatric of a geriatric trauma patient?
trauma patient. n What age-related physiological changes should
3. Differentiate the need for liberal diagnostic and laboratory
be considered when managing elderly patients?
testing for geriatric trauma patients compared to the
general population. n What mechanisms of trauma pose the greatest
4. Explain the seriousness of falls in the elderly, particularly risk to elderly patients?
ground-level falls.
n How should resuscitation be approached?
5. Apply clinical decision rules and guidelines to the elderly
patient population. n Which injuries are most concerning in the

FROM THE EM MODEL geriatric population, and how should they be

18.0 Traumatic Disorders managed?
18.1 Trauma

The US population is aging in spades. By the year 2030, more than 20% of Americans will be 65 years
or older; by 2050, an estimated 40% of trauma patients will fall within the geriatric age group.1,2 In 2014
unintentional injury was the seventh leading cause of death in elderly patients, who comprise 10% of trauma cases yet
account for 25% of total costs related to hospital trauma care.3,4 Poor physiological reserves, unique injury characteristics,
frailty, medical comorbidities, and in-hospital complications such as pneumonia, venous thromboembolism, and/or organ
failure all contribute to the complexity of care.5-7

December 2016 n Volume 30 Number 12 3

 CASE PRESENTATIONS
■ CASE ONE
A 75-year-old woman with a
history of osteoporosis, coronary
artery disease, and insulin-
dependent diabetes mellitus presents
after a fall. She reports tripping on a
rug, but did not hit her head or neck
and denies loss of consciousness.
She is unable to walk or bear weight
on her right hip and complains of
diffuse right knee pain.
■ CASE TWO
An 80-year-old woman
arrives via ambulance after
being struck by a vehicle while
crossing the street. The car was
going an estimated 35 miles
per hour, and the patient flew
onto the hood and windshield
after being struck. She is
tachycardic, normotensive, and
moaning in pain.
■ CASE THREE
An 84-year-old man with a past medical
history of atrial fibrillation, diabetes, and
hypertension presents after a witnessed fall. He
reports suddenly collapsing while walking away
from the dinner table. He does not remember
any presyncopal symptoms such as chest pain,
shortness of breath, palpitations, sweats, or
headache. His neurological examination is
normal; however, he has a large abrasion to his
forehead and complains of a headache.

Advancing age correlates with increased CRITICAL DECISION CRITICAL DECISION

mortality in trauma victims, in whom the
odds of dying increase by 6.8% for every
year they are over the age of 65. Research
indicates that elderly patients frequently
are undertriaged because their underlying
comorbidities and low physiologic reserves
go unappreciated.8 All told, geriatric
trauma patients often are much sicker than
meets the eye, and it is incumbent upon
the emergency physician to recognize and
manage their life-threatening injuries.
CRITICAL DECISION
How can frailty be used to predict
the outcome of a geriatric trauma
patient?
Frailty, defined as a decreased
physiological reserve and resistance to
stressors, is a significant predictor for
complications in the geriatric trauma
population.9,10 Simply put, frail patients get
sicker faster and remain sick longer.
Although frailty may be more
definitively gauged using a 50-point index
that measures the proportion of deficits
against the total number of age-related
health variables considered, this complex
system is impractical in the emergency
department.11 There are a variety of
simplified clinical assessment tools that
may be more useful for assessing patients
in the acute setting (Figure 1).
In addition, surrogate markers such
as sarcopenia and baseline functional
status can help pinpoint frailty.12 Of note,
geriatric trauma patients with sarcopenia
admitted to the intensive care unit (ICU)
spend more days on the ventilator and
demonstrate an increased need for post-
hospital medical care and rehabilitation.13
What age-related physiological
changes should be considered
when managing elderly patients?
A progressive loss of functional
reserve in each organ system
combined with the likelihood of
concomitant disease (eg, hypertension,
hyperlipidemia, coronary artery disease,
arthritis, and vision and hearing
impairments), can reduce the elderly
patient’s ability to withstand and recover
from a physical insult (Table 1). Cardiac
output decreases and blood pressure
increases with age, often leading to the
development of arteriosclerosis. Gas
exchange in the lungs is impaired, which
diminishes vital capacity and expiratory
flow rates. Functional changes in the
gastrointestinal system often result
in senescence, atrophic gastritis, and
altered hepatic drug metabolism.
Elderly patients frequently experience
a progressive elevation of blood glucose;
and osteoporosis, which results from a
linear decline in bone mass, can increase
the risk of fractures. Lean body mass
also dwindles, muscle cells atrophy,
and joints degenerate. In addition,
decreased water in the cartilage of
the intervertebral discs, tendons, and
ligaments can reduce compressibility
and flexibility. These changes can hinder
mobility, further increasing the risk of
traumatic injury, particularly from falls.
In addition, changes in metabolism
can alter a geriatric patient’s response
to commonly used drugs, necessitating
dosage adjustments.
What mechanisms of trauma
pose the greatest risk to elderly
patients?
When evaluating a geriatric patient,
it is important to remember that a
medical event may have precipitated the
trauma, or vice versa. In addition, the
mechanisms of injury often are different
in the elderly than in younger patients,
as is their response to trauma. Suspicion
should remain high for serious injury,
even with seemingly minor or low-
mechanism trauma.
Falls
It is not surprising that falls are the
most common mechanism of injury and
the leading cause of traumatic death in
this fragile population (between 7% to
11%).14 Forty-four percent of geriatric
patients are readmitted to the hospital
after a ground-level fall, a clinical
course that carries a staggering one-year
mortality rate of 33%.15
Falls also are the most common cause
of traumatic brain injuries (TBI) in the
elderly.16 As patients age, the dura adheres
more firmly to the skull and becomes
more susceptible to tearing, increasing
the risk of mortality. The increased use of
anticoagulants and/or antiplatelet agents
in these patients further complicates the
risk of significant sequelae.17
The incidence of fall-related injuries,
which continues to rise, is highest in
white women.18,19 Roughly 25% of
these incidents, most of which occur at
home, can be attributed to underlying
medical problems, including stroke,

4 Critical Decisions in Emergency Medicine

syncope or near-syncope, elder abuse,
and hypovolemia (often related to
gastrointestinal bleeding, ruptured
abdominal aortic aneurysm, sepsis,
or dehydration). Other risk factors
include arthritis and other mobility-
restricting conditions, cognitive or
visual impairment, stroke, and the use
of sedatives (Table 2).
Vehicular Accidents
Approximately 12% of geriatric
trauma patients present after being
struck by a motor vehicle, the second
most common mechanism of injury in
this population. 20 Elderly pedestrians
are at greater risk of being struck due
to frailty, decreased reaction time,
lack of depth perception, physical
instability, and poor hearing. 20,21
Motor vehicle collisions (MVCs) are
the largest traumatic contributor to the
number of ICU days in patients 65 years
or older. Older adults in MVCs are more
likely to require admission and receive
more diagnostic imaging than their
younger counterparts. 22 An underlying
medical problem should be suspected

TABLE 1. Age-Related Changes

Organ System Anatomic Changes
General Decreased organ and muscle
mass
Cardiovascular Fibrosis and thickening of
arteries, sclerosis of cardiac
valves, elongation and
tortuosity of aorta
Lungs Decreased lung elasticity,
decreased activity of cilia,
reduced cough reflex
Kidneys Increased number of abnormal
glomeruli
Genitourinary Prostatic enlargement, vaginal/
urethral mucosal atrophy
Gastrointestinal Atrophic mucosa, atrophic taste
buds, anorectal incompetence
Hematological/ Bone marrow fibrosis,
Immunological metaplasia
Musculoskeletal Decreased height, weight,
muscle mass, and bone density
Endocrine Osteoporosis, vertebral
collapse, changes in fluid
volumes
Nervous Reduced brain mass, decreased
cortical cell count
Eyes Decreased translucency of lens,
decreased size of pupil, increased for increased illumination,
intraocular pressure, macular
degeneration, arcus senilis
Ears Loss of auditory neurons,
atrophy of cochlear hair cells
Skin Flattening, atrophy, and
attenuation in dermal collagen,
rete pegs, and cytoplasm of
basal keratinocytes
Physiologic Changes
Decreased organ function,
decreased oxygen consumption
Decreased maximal heart rate
each decade of life, decreased
β-adrenergic responses, decreased
arterial compliance
Decreased vital capacity,
microaspiration
Decreased glomerular filtration
rate, decreased renal blood flow,
decreased urine concentration,
proteinuria
Increased urine residual volume,
bacteriuria, atrophic vaginitis
Decreased salivary flow, decreased
gastric acid production, decreased
hepatic function, decreased motility incontinence, modified appetite, food
Decreased bone marrow reserve,
decreased T-cell function, antibody
dysfunction
Loss of skeletal calcium, reduced
elasticity in connective tissue,
decreased viscosity of synovial
fluid
Altered glucose homeostasis;
decreases in thyroid and testosterone diabetes mellitus, hyponatremia,
hormones, renin and aldosterone
production, and vitamin D absorption; osteoporosis, impotence
increased antidiuretic hormone
Decreased brain catechol and
dopamine synthesis, impaired
thermal regulation
Decreased accommodation, need
susceptibility to glare
Decreased hearing, especially
higher frequency tones; decreased
directional discrimination;
vestibular dysfunction
Decreased skin thickness, risk for
dermo-epidermal separation, loss
of elasticity
Functional Consequences
Decreased flexibility, endurance,
and maximal performance
Decreased cardiac output, decreased
physical work capacity, orthostatic
hypotension, decreased endurance,
syncope, shortness of breath
Shortness of breath, cough, aspiration
pneumonia
Delayed response to salt or fluid
restriction, nocturia
Nocturia, tenesmus, incontinence,
urinary tract infection
Regurgitation with aspiration,
food intolerances, constipation,
intake, and gut motility
False-negative immunological skin
tests, false-positive laboratory
immunological tests
Loss of cartilaginous surfaces,
hypertrophic changes in joints,
increased ratio of fat to muscle mass,
osteoporosis, failure to thrive, loss of
muscle strength
Hyperglycemic response to stress,
hyperkalemia, osteopenia,
Decreased nerve conduction, impaired
cerebral and cognitive functions,
dementia, depression, sleep changes,
hypothermia, hyperthermia, global
sensory impairment
Decreased vision, including color and
night vision; impaired accommodation,
presbyopia
Loss of hearing, balance impairment
with falls
Decreased resistance to tearing

December 2016 n Volume 30 Number 12 5

 in any patient who presents following a
single-vehicle accident.
Abuse
An estimated 5% to 10% of elderly
patients report abuse; and perhaps even
more concerning, 5% of caregivers and
family members admit to physically
abusing their care recipients (Figure 2).23
It is imperative to consider the possibility
of intentionally inflicted trauma when
assessing a patient’s history, especially when
there are signs of neglect or injuries that are
inconsistent with the reported mechanism.
While one sign does not necessarily
indicate abuse, red flags include the
following.24
• Bruises around the breasts or genital
area can be signs of sexual abuse.
• Bruises, pressure marks, broken
bones, abrasions, and burns may be an
indication of physical abuse, neglect, or
mistreatment.
• Bedsores, unattended medical needs,
poor hygiene, and unusual weight loss
are indicators of possible neglect.
• An obviously strained or tense
relationship between the caregiver
and elderly person may be cause for
concern.
TABLE 2. Risk Factors Associated With Falls
Category Examples
Intrinsic factors Acute illness, cardiovascular impairment, confusion,
deconditioning, dehydration, difficulty rising from a chair,
dizziness, fatigue, impaired balance, impaired hearing,
medications (especially use of four or more prescription
drugs), muscle weakness, postural instability, seizures,
syncope, vestibular disease, deficits, fear of falling
Extrinsic factors Dim lighting or glare, slippery surfaces, steep stairways,
unstable furnishings, obstructed pathways, missing handrails,
misuse of assistive devices, or tripping hazards
Situational factors Rushing to the bathroom in the middle of the night, walking
in high heels on uneven pavement
Adapted from the Centers for Disease Control
CRITICAL DECISION can be approached by using clinical
end points of resuscitation (eg, heart
How should resuscitation be
rate, blood pressure, and urine
approached? output). However, these parameters
The adequate resuscitation of can be complicated by factors such as
geriatric trauma patients begins with the use of beta-blockers, hypertension,
prioritizing care based on the severity and preexisting organ dysfunction.8
of injuries; a timely diagnosis and Anatomic changes in the elderly can
treatment are key.8 Hypovolemic complicate endotracheal intubation; a
shock is the most common type of decreased mouth opening secondary
shock in trauma patients, and goal- to temporomandibular joint disease
directed fluid resuscitation can reverse and poor dentition warrant careful
hypoperfusion while minimizing the laryngoscope placement. When
risk of fluid overload. This strategy considering intubation medications,

FIGURE 1. Clinical Frailty Scale

1. Very Fit — Patients who are robust, active, energetic and
motivated. These people exercise regularly and are among
the fittest for their age.
2. Well — Patients who have no active disease symptoms,
but are less fit than those in category 1. They may exercise or
are occasionally very active (eg, seasonally).
3. Managing Well — Patients whose medical problems are
well controlled, but are not regularly active beyond routine
walking.
4. Vulnerable — While not dependent on others for daily
help, these patients have symptoms that may limit activities.
They commonly complain of being “slowed down” and/or
tired during the day.
5. Mildly Frail — Slowing is more evident. These
patients require help with daily activities such as finances,
transportation, heavy housework, medications. Typically, mild
frailty progressively impairs shopping and walking outside
alone, meal preparation, and housework.
6. Moderately Frail — Require help with household chores
and all outside activities. Inside, these patients often have
difficulty navigating stairs and need minimal assistance with
dressing (cuing, standby) and bathing.
7. Severely Frail — Completely dependent on
caregivers for cognitive and physical help with personal
care. Even so, these patients seem stable and are not
at high risk of dying (within ~6 months).
8. Very Severely Frail — Completely dependent and
approaching the end of life. Recovery, even from a
minor illness, is unlikely.
9. Terminally Ill — Approaching the end of life. This
category applies to patients with a life expectancy less
than 6 months, who are not otherwise evidently frail.
Scoring frailty in people with dementia
The degree of frailty corresponds to the degree of dementia.
Common symptoms in mild dementia include forgetting the
details of a recent event (though still remembering the event
itself), repeating the same question/story, and social withdrawal.
Patients with moderate dementia can complete personal care
tasks with prompting. Although their recent memory is very
impaired, they seemingly can remember past life events. Patients
with severe dementia cannot handle personal care without help.
Adapted from Geriatric Medicine Research, Dalhousie University, Halifax, Canada.

6 Critical Decisions in Emergency Medicine

 be unreliable because of decreased pain
FIGURE 2. Reporters of Elder Abuse perception, dementia, or minimization by
the geriatric patient.27,28

3% 5% Head Injury
Head injuries are the leading cause
15%
of death in geriatric trauma patients.
15% Compared to younger adults, individuals
65 years or older with TBI are admitted
more frequently, have longer hospital
stays, and require more post-hospital
6% 23% medical care.29 Cortical atrophy
(common in the elderly) can delay the
clinical signs of serious intracranial
hemorrhage, which may be clinically
16% occult.
5% American College of Emergency
4% Physicians (ACEP) clinical practice
8%
Adapted from the National Center on guidelines recommend a non-contrast
Elder Abuse CT scan for patients older than 60 years
with loss of consciousness (LOC) or in
patients 65 years or older without LOC.30
FIGURE 3. Pedestrians Injured by Automobiles: Injuries by Age Group45 Magnetic resonance imaging (MRI) may
be warranted if the injury is subacute
and an isodense subdural hematoma is
suspected.
In patients not taking anticoagulation
medications, repeat CT scans may be
reserved for those with neurological
changes and/or unreliable examination
findings.31 One study of head trauma
patients taking warfarin or clopidogrel
showed that out of the 930 individuals
with an initial normal head CT scan, four
6.3% 15.5% 15% 0.4% had a delayed intracranial hemorrhage
71 / 1136 1761 1136 170 / 1136 5 / 1136 (ICH), two of whom died.32 Another
13% 8.3% 27.3% 5.7% evaluation of a 24-hour observation
487 / 3741 309 / 3741 1023 / 3741 214 / 3741
protocol for patients on warfarin with
16 .2% 8.3% 34.8% 7.1% minor head trauma found five out of 97
681420 35/ 420 146 / 420 30 / 420
patients suffered a delayed ICH within
22.6% 9.8% 32% 8.5%
122/541 53/541 173 / 541 46 / 541
the 24-hour window, and another two
had an ICH the following week. All
benzodiazepine and etomidate doses CRITICAL DECISION patients with delayed ICH were older
should be reduced by 20% to 40% to than 65 years.33
Which injuries are most concern­ Although controversy exists, it seems
decrease their hemodynamic effects.25
ing in the geriatric population, and reasonable — given the low incidence of
Ketamine may be used as an alternative
sedative; however, due to the agent’s how should they be managed? delayed ICH in anticoagulated geriatric
effect of increasing myocardial oxygen patients — to discharge those with
When assessing any elderly patient
a normal CT scan with clear return
demand, it should not be used in for trauma, the emergency clinician
precautions.
patients with ischemic heart disease.26 should remain suspicious of “normal”
Older patients may require oxygen vital signs and physical examination Cervical Spine
supplementation and aggressive findings and maintain a low threshold Geriatric trauma patients suffer a high
blood and fluid resuscitation with for diagnostic imaging. For example, rate of cervical spine injuries (CSIs), most
frequent reevaluation. A lower beta- or calcium-channel blockers frequently involving the C1 and C2 ver-
threshold for advanced airway control may blunt compensatory tachycardia tebrae — a serious risk that likely arises
(endotracheal intubation) also should secondary to hemorrhage or volume loss, from degenerative changes that decrease
be maintained. and the abdominal examination may mobility of the lower cervical spine.34,35

December 2016 n Volume 30 Number 12 7


n Maintain a high clinical suspicion for serious injury in geriatric patients with
seemingly low-risk trauma.
n Any patient older than years 65 with a suspected TBI should be evaluated with
a CT scan of the head and neck.
n Consider frailty as a significant predictor for complications in the geriatric
trauma population.
n If intubation is required, reduce the dose of benzodiazepine and etomidate by
20% to 40% to decrease the drugs’ hemodynamic effects.
If a brain CT is ordered, imaging of the
cervical spine also is recommended.
Because elderly patients are
susceptible to CSIs with lower-risk
mechanisms of injury, there is debate
about using the National Emergency
X-Radiography Utilization Study
(NEXUS) Low-Risk Criteria to clear
the cervical spine in this population;
however, the tool has demonstrated equal
reliability in assessing older patients.35 It
is important to note that the Canadian
C-Spine Rule excludes patients 65 years
and older and/or taking anticoagulant
medications because of the elevated risk
of injury in these patients.36,37
Thorax
Thoracic trauma is the second leading
cause of death in elderly trauma victims.
Ventilatory failure, respiratory arrest,
and blunt aortic injury can be triggered
by chest or abdominal trauma, despite
the absence of conventional symptoms. It
is important to maintain a low threshold
for CT imaging in any elderly patient
who has sustained a blow to the thorax.
Rib fractures are the most common
injury in blunt chest trauma. Each
additional broken rib raises mortality by
19% and the likelihood of pneumonia
by 27%; however, this danger extends
beyond the immediate thoracic injury.38
Adverse events (most commonly pneu­
monia) are reported to complicate 16%
of hospitalizations in geriatric patients
with isolated blunt thoracic injury.39
Fractures
Musculoskeletal injuries are very
common in the elderly, particularly
upper-extremity fractures, including
distal radius, proximal humeral, and
8 Critical Decisions in Emergency Medicine
of significant complications, are best
managed by an inpatient care team
consisting of a geriatrician or medical
physician and orthopedic surgeon.44
Summary
Frailty, a decreased physiological
reserve, and medical comorbidities all
complicate the clinical course of geriatric
trauma patients, who are at greater risk
of morbidity and mortality than their
younger counterparts. Seemingly benign
mechanisms such as ground-level falls
can lead to repeat emergency department
elbow injuries. Among the most common visits and potentially catastrophic
lower-extremity injuries are fractures outcomes. Clinicians must maintain a
of the tibial plateau, patella, and ankle high index of suspicion for low-impact
(most commonly the lateral malleolus). traumas and abuse, and use laboratory
Osteoporosis is a leading risk factor and diagnostic imaging studies liberally.
for hip fractures, the most common
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Pain management is a significant 7. Hildebrand F, Pape HC, Horst K, et al. Impact of
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n Overlooking a hip fracture by relying on x-rays to confirm the diagnosis. Patients
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n Failing to consider signs of elder abuse or neglect, including bruises around the
breasts or genital area, pressure marks, broken bones, abrasions, and burns.
n Relying on the abdominal examination when evaluating for trauma. Decreased
pain perception, dementia, or minimization by the elderly patient can mask life-
threatening complications.
n Failing to consider underlying medical conditions that may have precipitated the
trauma.
 CASE RESOLUTIONS
■ CASE ONE
Despite the woman’s right hip
pain and inability to walk, x-rays
of her chest, hip, pelvis, and knee
were negative; basic laboratory
tests were normal. A pelvic CT
without contrast was performed,
which revealed an intertrochanteric
neck fracture. Orthopedics was
consulted, and the patient was
admitted to a co-management hip
fracture service.
■ CASE TWO
The pedestrian hit by a vehicle
was triaged immediately into a
resuscitation room. Her airway
was intact, and she demonstrated
bilateral breath sounds and strong
10. Joseph B, Pandit V, Zangbar B, Kulvatunyou N, Hashmi
A, Green DJ, O’Keeffe T, Tang A, Vercruysse G, Fain
MJ, Friese RS, Rhee P. Superiority of frailty over age
in predicting outcomes among geriatric trauma
patients: a prospective analysis. JAMA Surg. 2014
Aug;149(8):766-72. doi: 10.1001/jamasurg.2014.296.
PubMed PMID:
11. Searle SD,Mitnitski A, Gahbauer EA, Gill TM,
Rockwood K. A standard procedure for creating afrailty
index. BMC Geriatr. 2008;8:24. doi:10.1186: 1471-2318-
8-24.
12. Dodds R, Sayer AA. Sarcopenia and frailty: new
challenges for clinical practice. Clin Med (Lond). 2015
Dec;15 Suppl 6:s88-91. doi: 10.7861/clinmedicine.15-
6-s88. PubMed PMID: 26634689.
13. Moisey LL, Mourtzakis M, Cotton BA, Premji T,
Heyland DK,Wade CE, Bulger E, Kozar RA. Skeletal
muscle predicts ventilator-free days, ICU-free days,
and mortality in elderly ICU patients. Crit Care.
2013;17(5):R206.
14. Tinetti  ME, Speechley  M, Ginter  SF. Risk factors for
falls among elderly persons living in the community. N
Engl J Med. 1988;319(26):1701-1707.
15. Ayoung-Chee P, McIntyre L, Ebel BE, Mack CD,
McCormick W, Maier RV. Long-term outcomes of
ground-level falls in the elderly. J Trauma Acute Care
Surg 2014;76:498–503.
16. Langlois JA, Rutland-Brown W, Thomas KE. Traumatic
Brain Injury in the United States: Emergency
Department Visits, Hospitalizations, and Deaths.
Atlanta, GA: National Center for Injury Prevention and
Control, 2004.
17. Thompson HJ, McCormick WC, Kagan SH. Traumatic
brain injury in older adults: epidemiology, outcomes,
and future implications. J Am Geriatr Soc. 2006
Oct;54(10):1590-5.
18. Cigolle CT, Ha J, Min LC, Lee PG, Gure TR, Alexander
NB, Blaum CS. The epidemiologic data on falls,
1998-2010: more older Americans report falling.
JAMA Intern Med. 2015 Mar;175(3):443-5. doi: 10.1001/
jamainternmed.2014.7533. PubMed PMID: 25599461.
19. Nordell E, Jarnlo GB, Jetsén C, Nordström L,
Thorngren KG. Accidental falls and related fractures in
65-74 year olds: a retrospective study of 332 patients.
Acta Orthop Scand. 2000 Apr;71(2):175-9. PubMed
PMID: 10852324.
20. Reith G, Lefering R, Wafaisade A, Hensel KO, Paffrath
T, Bouillon B, Probst C; TraumaRegister DGU. Injury
pattern, outcome and characteristics of severely
injured pedestrian. Scand J Trauma Resusc Emerg
Med. 2015 Aug 5;23:56. doi: 10.1186/s13049-015-0137-8.
PubMed PMID: 26242394; PubMed Central PMCID:
PMC4524010.
21. O’Hern S, Oxley J, Logan D. Older Adults at
Increased Risk as Pedestrians in Victoria, Australia:
An Examination of Crash Characteristics and Injury
Outcomes. Traffic Inj Prev. 2015;16 Suppl 2:S161-7. doi:
2+ distal pulses in all extremities.
A full body examination revealed
diffuse back and abdominal pain. A
CT scan of the head/neck revealed
multiple cervical and thoracic spinous
process fractures, a right renal
laceration, and a minimally displaced
left femoral neck facture without
active extravasation. Trauma surgery,
orthopedics, and neurosurgery
were consulted. After a neurologic
examination, the patient received
an ultrasound-guided femoral nerve
block for pain and was admitted to
the surgical ICU.
■ CASE THREE
The fall victim’s ECG showed
stable atrial fibrillation, and
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26436227.
22. MacKenzie EJ, Morris JA, Smith GS. Acute hospital
costs of traumain the United States: Implications
for regionalized systems of care. J Trauma.
1990;30:1096-1101.
23. National Center on Elder Abuse. Administration on
aging. Available at: http://www.ncea.aoa.gov/librar/
data. Accessed August, 2016.
24. What is Elder Abuse? Administration for
Community Living Web site. http://www.aoa.acl.
gov/AoA_Programs/Elder_Rights/EA_Prevention/
whatIsEA.aspx. Accessed November 22, 2016.
25. Narang AT, Sikka R. Resuscitation of the elderly.
Emerg Med Clin North Am. 2006 May;24(2):261-72,
v. Review. PubMed PMID: 16584957.
26. Craven R. Ketamine. Anaesthesia. 2007 Dec;62
Suppl 1:48-53. Review. PubMed PMID: 17937714.
27. Aschkenasy MT, Rothenhaus TC. Trauma and falls
in the elderly. Emerg Med Clin North Am. 2006
May;24(2):413-32, vii. Review.
28. Marco CA, Schoenfeld CN, Keyl PM, Menkes
ED, Doehring MC. Abdominal pain in geriatric
emergency patients: variables associated with
adverse outcomes. Acad Emerg Med. 1998
Dec;5(12):1163-8. PubMed PMID: 9864129.
29. Dams-O’Connor K, Cuthbert JP, Whyte J, Corrigan
JD, Faul M, Harrison-Felix C. Traumatic brain injury
among older adults at level I and II trauma centers.
J Neurotrauma. 2013 Dec 15;30(24):2001-13. doi:
10.1089/neu.2013.3047. Epub 2013 Nov 26. PubMed
PMID: 23962046; PubMed Central.
30. Jagoda A, Bazarian J, Bruns J, Cantrill S, et al.
Clinical Policy: Neuroimaging and Decisionmaking
in Adult Mild Traumatic Brain Injury in the Acute
Setting. Ann Emerg Med. 2008;52:714-748.]
31. Haider AA, Rhee P, Orouji T, Kulvatunyou N,
Hassanzadeh T, Tang A, Farman A, O’Keeffe T,
Latifi R, Joseph B. A second look at the utility
of serial routine repeat computed tomographic
scans in patients with traumatic brain injury. Am
J Surg. 2015 Dec;210(6):1088-94. doi: 10.1016/j.
amjsurg.2015.07.004. Epub 2015 Sep 18. PubMed
PMID: 26482515.
32. Nishijima DK, Offerman SR, Ballard DW, Vinson
DR, Chettipally UK, Rauchwerger AS, Reed ME,
Holmes JF; Clinical Research in Emergency
Services and Treatment (CREST) Network.
Immediate and delayed traumatic intracranial
hemorrhage in patients with head trauma and
preinjury warfarin or clopidogrel use. Ann Emerg
Med. 2012 Jun;59(6):460-8.e1-7. doi: 10.1016/j.
annemergmed.2012.04.007. PubMed PMID:
22626015.
33. Menditto VG, Lucci M, Polonara S. et al.
Management of minor head injury in patients
receiving oral antiocoagulant therapy: a
laboratory data revelaed an
international normalized ratio of
4.5. A head and cervical spine CT
scan demonstrated a large subdural
hematoma with midline shift. The
monitor showed an 8-round run
of ventricular tachycardia (VT).
The man spontaneously reverted
back to atrial fibrillation and was
loaded with amiodarone. His mental
status decompensated and he again
devolved into VT.
No pulse could be detected, and
advanced cardiac life support was
initiated. After three subsequent
shocks, the family was consulted;
given the patient’s grave prognosis,
resuscitation was terminated.
prospective study of a 24-hour observation protocol.
Ann Emerg Med 2012;59:451-455. 
34. Touger M, Gennis P, Nathanson N, Lowery DW,
Pollack CV Jr, Hoffman JR, Mower WR. Validity of a
decision rule to reduce cervical spine radiography in
elderly patients with blunt trauma. Ann Emerg Med.
2002 Sep;40(3):287-93. PubMed PMID: 12192352
35. Wang H, Coppola M, Robinson RD, Scribner JT,
Vithalani V, de Moor CE, Gandhi RR, Burton M,
Delaney KA. Geriatric Trauma Patients With Cervical
Spine Fractures due to Ground Level Fall: Five Years
Experience in a Level One Trauma Center. J Clin Med
Res. 2013 Apr;5(2):75-83. doi: 10.4021/jocmr1227w.
Epub 2013 Feb 25. PubMed PMID: 23519239
36. Stiell, IG, Wells G, Vandemheen KL, et al.The
Canadian C-Spine Rule for Radiography in Alert and
Stable Trauma Patients.JAMA. 2001;286(15):1841-
1848. doi:10.1001/jama.286.15.1841.
37. Stiell IG, Wells GA, Vandemheen K, Clement C,
Lesiuk H, Laupacis A, McKnight RD, Verbeek R,
Brison R, Cass D, Eisenhauer ME, Greenberg G,
Worthington J. The Canadian CT Head Rule for
patients with minor head injury. Lancet. 2001 May
5;357(9266):1391-6.
38. Bulger EM, Arneson MA, Mock CN, Jurkovich GJ. Rib
fractures in the elderly. J Trauma. 2000;48:1040-104
39. Lotfipour S, Kaku SK, Vaca FE, Patel C, Anderson CL,
Ahmed SS, Menchine MD. Factors associated with
complications in older adults with isolated blunt
chest trauma. West J Emerg Med. 2009 May;10(2):79-
84. PubMed PMID: 19561823; PubMed Central.
40. Johnell O, Kanis JA. An estimate of the worldwide
prevalence and disability associated with
osteoporotic fractures. Osteoporos Int. 2006
Dec;17(12):1726-33. Epub 2006 Sep 16. PubMed
PMID: 16983459.
41. Switzer JA, Gammon SR. High-energy skeletal
trauma in the elderly. J Bone Joint Surg
Am. 2012;94(23):2195-2204.
42. Ward R, Weissman B, Kransforf M, et al. Acute
Hip Pain – Suspected Fracture Appropriateness
Criteria® Acute Trauma to the Foot. Available
at https://acsearch.acr.org/docs/70546/Narrative.
American College of Radiology. Accessed 9/1.
43. Fletcher AK, Rigby AS, Heyes FL (2003) Three-in-one
femoral nerve block as analgesia for fractured neck of
femur in the emergency department: a randomized,
controlled trial. Ann Emerg Med 41(2):227–233
44. Friedman SM et al (2008) Geriatric co-management
of proximal femur fractures: total quality
management and protocol-driven care result in
better outcomes for a frail patient population. J Am
Geriatr Soc 56(7):1349–1356
45. Switzer JA, Gammon SR. High-energy skeletal
trauma in the elderly. J Bone Joint Surg
Am. 2012;94(23):2195-2204.
December 2016 n Volume 30 Number 12 9
 A 54-year-old woman with chest pain and dyspnea.

The Critical ECG

Sinus tachycardia, rate 110, right ventricular hypertrophy (RVH), T-wave By Amal Mattu, MD, FACEP
abnormality consistent with inferior and anteroseptal ischemia, consider Dr. Mattu is a professor, vice chair, and
director of the Emergency Cardiology
acute pulmonary embolism. There are many ECG manifestations associated Fellowship in the Department of
with acute pulmonary embolism (PE), including sinus tachycardia rightward axis; Emergency Medicine at the University
of Maryland School of Medicine in
tall R waves in the right precordial leads (often attributed to right heart strain); Baltimore.
T-wave inversions; and, of course, the “classic” SIQIIITIII (large S in lead I, Q wave
in lead III, and T-wave inversion in lead III). The majority of these findings have been found to be neither sensitive nor specific.
However, as noted previously, the combination of T-wave inversions in the inferior and the anteroseptal leads has been described
as highly specific for acute pulmonary hypertension, often the result of acute PE. Further supporting the diagnosis of acute PE
in this patient is the presence of a rightward axis (differential diagnosis includes left posterior fascicular block, right ventricular
hypertrophy, lateral myocardial infarction, acute pulmonary embolism, emphysema, ventricular ectopy, hyperkalemia, sodium-
channel blocking drug toxicity, and misplaced leads). Right ventricular hypertrophy is diagnosed by the presence of rightward
axis, tall R wave in the lead V1 ≥7 mm, and qR pattern in lead V1. This patient had developed RVH and pulmonary hypertension
because of multiple prior PEs. During this current episode, she developed a saddle embolus and died soon after her arrival.

Electrocardiographic findings suggestive of pulmonary

embolism include sinus tachycardia, RVH, and the classic
SIQIIITIII pattern.

a) RVH is diagnosed by the demonstration of right-axis

deviation (QRS complex downward in lead I, variable in
lead II, and upright in lead III) and prominent R wave
(≥7 mm, large arrow) and qR pattern (small arrow) in lead V1.
b) The SIQIIITIII pattern with an S wave in lead I (large
arrow), Q wave in lead III (small arrow), and inverted
T wave in lead III (circle).

From Mattu A, Brady W, ECGs for the Emergency Physician 2. London: BMJ Publishing; 2008:11,23. Reprinted with permission.

10 Critical Decisions in Emergency Medicine


With increasing frequency,
emergency medicine clinicians are
called to care for patients with
chronic underlying diseases who are
in the final stages of their lives. The
number of these terminally ill patients
in “crisis” is expected to rise as the
incidence of sudden death declines,
and the treatment plan set forth in the
emergency department often defines the
trajectory of an individual’s care.
Palliative care is focused on the
relief of suffering (physical, spiritual, or
psychological). It is based on the patient’s
personal goals and is appropriate for all
phases of treatment; it is not just for the
actively dying. Palliative care can run
parallel to traditional care; however,
it is best integrated early, as opposed
to waiting until “nothing more can be
done.” The timely implementation of a
simultaneous care model may improve
quality of life, or even prolong it.
Four models exist for the clinical
integration of palliative medicine into
the emergency department. The first,
the traditional consultation model,
requires clinicians to request an expert
palliative care consultation. The
basic integration model dictates that
emergency and palliative medicine
teams work collectively toward the same
goals. Finally, the advanced integration
and ED-focused advanced integration
models stress established protocols and
a collaboration between emergency
clinicians (perhaps under the direction of
Critical Decisions in Emergency Medicine’s series of LLSA reviews features articles articles from ABEM’s 2016 Lifelong Learning and
Self-Assessment Reading List. Available online at acep.org/llsa and on the ABEM website.
The LLSA
Literature Review
By Liam Delahanty, MD, LT(MC) and Daphne Morrison-Ponce, MD, LT(MC),
Naval Medical Center, Portsmouth, Virginia
Reviewed by Andrew J. Eyre, MD
Integration of Palliative Care
into Emergency Medicine
Lamba S, DeSandre PL, Todd KH, et al. Improving Palliative Care in Emergency
Medicine Board (IPAL-EM) Collaboration. J Emerg Med. 2014;46(2):264-270.
a dual EM-palliative care board-certified
physician), a member of the nursing staff,
and the palliative care team.
Potential screening criteria for a
palliative care consultation include
the presence of a life-threatening/life-
limiting condition, as well as one or more
global indicators of an unmet palliative
care need (eg, frequent hospitalizations,
functional decline, failure to thrive,
complex care requirements).
Starting a palliative care initiative
requires substantial effort; however,
these four steps can help set the plan in
motion:
1. Identify a palliative care “champion”
within the emergency department.
This can be any clinician interested
in improving end-of-life care.
2. Explore the existing literature.
The Improving Palliative Care in
Emergency Medicine (IPAL-EM)
project and the Education in Palliative
and End-of-Life Care for Emergency
Medicine (EPEC-EM) curriculum
are among the web-based educational
resources available.
3. Pinpoint local palliative care and
hospice resources, either within your
institution or the broader community.
It is important to develop clear
screening criteria for the activation
of these resources.
4. Perform a needs assessment
to identify areas that require
improvement.
It should be noted that there is a
lack of evidence regarding the clinical
outcomes or strain on hospital staff/
processes following implementation of an
integrated palliative care program. As the
specialty grows so, too, will research in
end-of-life and palliative care issues.
***
The views expressed in this article are those of
the author(s) and do not necessarily reflect the
official policy or position of the Department of the
Navy, Department of Defense or the United States
Government.
***
I am (a military service member) (an employee of the
U.S. Government). This work was prepared as part of
my official duties. Title 17 U.S.C. 105 provides that
‘Copyright protection under this title is not available
for any work of the United States Government.’
Title 17 U.S.C. 101 defines a United States
Government work as a work prepared by a military
service member or employee of the United States
Government as part of that person’s official duties.
KEY POINTS
n Broadly defined, palliative care
is patient care that is focused
on relieving suffering (physical,
spiritual, or psychological), based
on patients’ goals.
n Palliative care can supplement and
function parallel to conventional
medical programs.
n Emergency clinicians can lead
the integration of palliative
care programs into emergency
departments by performing a
needs assessment, identifying a
champion, conducting a literature
review, and identifying community
resources.
December 2016 n Volume 30 Number 12 11
 The Critical
Procedure
Retrograde urethrography is a valuable diagnostic tool for
determining the presence or absence of urethral injury.

By Steven J. Warrington, MD, MEd

Dr. Warrington is a core faculty member of the general
surgery and emergency medicine residency programs, and
the associate medical director for emergency department
outreach and education at Kaweah Delta Medical Center in
Visalia, California.

RETROGRADE URETHROGRAM
Risks and Benefits
Quick and simple, retrograde
urethrography can be used as a
standard first step in the emergency
department evaluation of the urinary
system. The only contraindication
to the procedure is an allergy to the
specific contrast material being used.
Risks include iatrogenic urethral
injury and infection. The extravasation
of contrast material into the tissue also
can occur if a urethral injury is present.
Although this complication generally
doesn’t cause significant harm, tissue
may become inflamed if the contrast
material is highly concentrated.
While some clinicians have access to
real-time radiology reports, many are
responsible for the initial interpretation
of plain films. Misinterpreting a positive
study as negative may lead to the
unnecessary insertion of a Foley catheter
and significant worsening of a urethral
injury. Conversely, a negative film that
has been misread as positive poses little
potential for patient harm; however, it
may result in an additional consultation.
Alternatives
Retrograde urethrography may be
performed in a variety of ways with
either a Toomey-type syringe (catheter-
tipped) or a Foley catheter inserted into
the urethral meatus. While commonly
performed in the emergency
department or radiology suite, the
procedure also may be done in the
operating room under fluoroscopy.
Sonourethrography is comparable
to retrograde urethrography in non-
trauma settings for the detection
of blind passages and strictures.
However, there is limited literature on
the efficacy of sonourethrography for
the diagnosis of traumatic injuries,
making the test of limited value in the
emergent setting.
Reducing Side Effects
If using a Foley catheter left
distally in the urethra to inject
contrast, risk can be decreased by
pinching the skin at the meatus to
secure the catheter, instead of inflating
the balloon. Using a Toomey-type
syringe instead of a Foley also may
reduce side effects.
Special Considerations
Multiple contrast agents are
available, all with different dilution
requirements. Diatrizoate may be
used without dilution. On the other
hand, iohexol generally is diluted to
1:1, and iodixanol is diluted to 1:10.
Contrast should be injected using
slow, gentle pressure, as high pressure
can cause venous intravasation that
may mimic a urethral injury.
TECHNIQUE
1. Obtain consent if possible.
2. Prepare the room and patient.
a. Have contrast and injection
equipment ready at the
bedside.
b. Wear a lead apron so you may
maintain your position while
the image is being taken.
c. Ensure that an individual
from radiology is present and
prepared to capture the image.
3. Prepare and sterilize the site.
4. Insert the tip of the injection
device into the urethra and gently
pinch the tissue around the device
to prevent leakage or backflow.
5. Slowly inject the contrast.
6. Hold the urethra around the
injection device while the image is
being taken.
7. Repeat the image in 10 minutes if
the presence of a urethral injury is
in doubt, or if the test results were
complicated by a venous plexus.

12 Critical Decisions in Emergency Medicine

 Fever Pitch
Febrile Seizures

LESSON 24

By Stephanie Ruest, MD; Siraj Amanullah, MD, MPH;

and Jonathan Valente, MD, FACEP
Dr. Ruest is a pediatric emergency medicine fellow, and Drs. Amanullah and
Valente are associate professors in the Departments of Emergency Medicine and
Pediatrics at the Alpert Medical School of Brown University, Division of Pediatric
Emergency Medicine at Hasbro Children’s Hospital in Providence, Rhode Island.
Reviewed by Sharon E. Mace, MD, FACEP

OBJECTIVES
On completion of this lesson, you should be able to: CRITICAL DECISIONS
1. Explain the difference between simple and complex
n How should children with febrile seizures be evaluated
febrile seizures.
in the emergency department?
2. Initiate an appropriate medical evaluation and workup
based on a child’s history and physical examination. n How should febrile seizures be treated in the
emergency department?
3. Identify children who require pediatric specialty
evaluations. n When is a neurological evaluation and/or consultation
4. Provide appropriate anticipatory guidance and warranted?
discharge recommendations to parents/guardians. n What is the appropriate disposition for children with
febrile seizures?
FROM THE EM MODEL
n What anticipatory guidance should be given to the
12.0 Nervous System Disorders
parents of children with first-time febrile seizures?
12.9 Seizure Disorders

The American Academy of Pediatrics (AAP) defines febrile seizures as those that occur in infants and children
between 6 and 60 months old with fever (temperature ≥38.0°C, [≥100.4°F]), but without a known neurologic
condition or any evidence of a central nervous system infection.1 Febrile seizures, which affect between 2% and
5% of the pediatric population, can be subdivided into two categories: simple and complex (Table 1).

December 2016 n Volume 30 Number 12 13

 CASE PRESENTATIONS
■ CASE ONE
An 18-month-old boy is brought
in by ambulance for evaluation of
a seizure. His parents explain that
he had a staring spell while sitting
on the couch that involved his eyes
“rolling back.” The episode, which
included generalized shaking,
lasted approximately two minutes.
When the paramedics arrived,
the patient was awake and fussy.
Blood glucose was 87 mg/dL and a
temporal temperature was 39.6°C
(103.2°F). A rectal antipyretic
was administered and he was
transported to the emergency
department.
The boy’s history is significant
for rhinorrhea and mild cough for
two days. He is fully vaccinated,
and there is no self or family
history of seizures. His vital signs
on arrival are blood pressure
95/64, heart rate 155, respiratory
rate 40, temperature 39.1°C
(102.4°F), and oxygen saturation
99% on room air. He is mildly
fussy but interactive with his
parents.
Pupils are 4 mm and
briskly reactive bilaterally.
The oropharynx and tympanic
membranes are normal. The nose
has copious clear rhinorrhea.
Breath sounds are clear and the
heart sounds are regular, with
sinus tachycardia and without
murmur. The abdomen is soft and
non-tender. The patient is moving
all extremities and has no skin
rashes. His parents note that he has
been more awake since arriving at
the hospital and is returning back
to his neurological baseline.
■ CASE TWO
A 21-month-old girl is brought
in by ambulance for altered
mental status and seizure-like
movements. Her grandmother
explains that the child was playing
14 Critical Decisions in Emergency Medicine
on a carpeted floor when she
became unresponsive with head
and eye deviation and left upper-
extremity shaking. She appeared
to be breathing during the event
and showed no facial cyanosis. The
episode lasted about 10 minutes.
By the time paramedics arrived,
she was sleepy but would localize
to painful stimuli. Her blood
glucose was 74 mg/dL and temporal
temperature was 38.9°C (102.1°F).
During the previous 24 hours
the girl had four episodes of
non-bloody watery diarrhea; one
episode of non-bloody, non-bilious
vomiting; and subjective fevers.
Her parents have been treating
her at home with over-the-counter
antipyretic medications. Her sibling
has been sick with vomiting and
diarrhea.
The patient had one prior febrile
seizure at 16 months of age; her
father reportedly experienced
similar episodes during his child­
hood. She is fully vaccinated, and
her vital signs on arrival are blood
pressure 101/67, heart rate 145,
respiratory rate 36, temperature
39.4°C (102.9°F), and oxygen
saturation 100% on room air.
She is sleepy but can be easily
awakened, and her pupils are equal
and briskly reactive. Her lips and
oral mucosa are dry, and she has
normal tympanic membranes.
She has clear breath sounds,
sinus tachycardia with a 1/6 soft
systolic ejection murmur, and a
capillary refill of 3 seconds. The
abdomen is soft and non-tender
with hyperactive bowel sounds,
and there are no rashes or bruises.
She opens her eyes to her parents’
voices, tracks, has normal tone
for her age, and is moving all
extremities equally.
■ CASE THREE
A 9-month-old girl presents with
fever and altered mental status. Her
mother reports an onset of fever
a few days earlier with worsening
over the last 24 hours. Her highest
reported rectal temperature at
home was 39.6°C (103.2°F). She
has been taking over-the-counter
antipyretics, but only responds to
them for a few hours. On the day
of arrival she has been sleepy and
difficult to arouse, and she has
consumed only 4 ounces of fluid
over the last 12 hours.
She attends day care, her
immunizations are up to date,
there are no sick contacts at home,
and she has no significant medical
history other than a prior febrile
urinary tract infection (UTI).
The patient’s vital signs are blood
pressure 80/52, heart rate 170,
respiratory rate 32, temperature
38.8°C (102.0°F), and oxygen
saturation 98% on room air.
She experiences a generalized
tonic-clonic seizure while in triage,
and is immediately moved to the
critical care room and placed on
supplemental oxygen. The seizure
resolves without intervention
in 2 minutes, but she remains
sleepy. Rectal acetaminophen is
administered and intravenous access
is established. Her blood glucose
level is 96 mg/dL. The patient
develops another generalized tonic-
clonic seizure shortly thereafter.
The child’s airway is managed
using the jaw-thrust maneuver,
supplemental oxygenation, and
a nasal trumpet. An intravenous
dose of lorazepam (0.1 mg/kg) is
administered without resolution
of the seizure. A second dose of
lorazepam (0.1 mg/kg) and a bolus
of normal saline (20 mL/kg) are
initiated.
 Simple febrile seizures are
defined as generalized tonic seizures
in neurodevelopmentally normal
children that last fewer than 15
minutes and do not recur within 24
hours.1 Approximately two-thirds
of febrile seizures fall into this
category. 3 Conversely, complex febrile
seizures are defined as either focal
or generalized episodes that last 15
minutes or longer and/or recur within
24 hours. Furthermore, complex
episodes may be associated with
a prolonged postictal state and/or
abnormal neurologic findings (eg, Todd
paresis).1,2 The most common feature of
complex febrile seizures appears to be
a focal finding, followed by recurrence
and a prolonged duration. 2
Of note, the incidence of febrile
seizures also tends to peak during
times of the year that are consistent
with an increased rate of respiratory
and gastrointestinal infections
(winter and early spring). 2 With
this epidemiology in mind, it is
important for emergency clinicians to
differentiate between the two types of
febrile seizures, understand the scope
of the medical workup, know when
specialty evaluation is of potential
benefit, determine the most appropriate
patient disposition, and provide
anticipatory guidance to parents and
caregivers.
TABLE 1. Classification of Febrile Seizures
Simple Febrile Seizure
(all criteria must be met)
Duration Short (<15 minutes)
Self-limiting
Phenotype Generalized tonic-clonic
Recurrence/ No recurrence in 24 hours
frequency
Prior neurologic None
diagnosis
CRITICAL DECISION
How should children with febrile
seizures be evaluated in the
emergency department?
It is critically important to obtain
a detailed history about the seizure(s),
including duration, recurrence,
appearance, and postictal symptoms. 2
A thorough review of the patient’s
medical history, systems, immunization
status, and any recent or ongoing
antibiotic treatment will help guide the
workup. 2,3 A family history, including
details about febrile and afebrile
seizures, also should be obtained.
Clinical Assessment
A complete physical examination
with full skin exposure should be
performed as soon as possible, even
if somewhat limited by the patient’s
mental status. Localizing signs may
identify a source of infection such as
acute otitis media. A detailed neurologic
examination and serial reassessments of
the patient’s mental status also should
be completed.
A detailed history and physical
examination usually are all that are
required for the workup of a child
with a simple febrile seizure. The most
recent AAP clinical practice guidelines
recommend against routine testing
(eg, serum chemistries, complete blood
count, urinalysis, urine culture, blood
cultures, and/or lumbar puncture) in
Complex Febrile Seizure
(one or more of the following)
Prolonged febrile seizure
(>15 minutes)
Febrile status epilepticus
(>30 minutes)
Focal onset or features
Clonic and/or tonic
Loss of muscle tone
Focal progressing to general
Head/eye deviation to one side
Recurrence within 24 hours
Present
simple cases.1,3 The risk of serious
bacterial infection among these patients
is similar to that of febrile children
without seizures.4
Diagnostic Tests
When considering laboratory or
radiological testing to investigate
potential sources of infection, clinicians
should use their discretion and existing
fever workup guidelines based on the
patient’s age, sex (ie, females of certain
age have a higher risk of UTI compared
to males), and history. One significant
clinical concern is the potential for
missing a life-threatening pathology
such as meningitis. Although febrile
seizures may be associated with the
serious bacterial illness, multiple
studies have shown that it is extremely
uncommon for meningitis to present
solely as a febrile seizure. 5,6 Therefore,
lumbar puncture (LP) generally is of
little utility in simple cases, and is not
routinely recommended. 3,6-11
There are certain circumstances,
however, in which a complete medical
workup is warranted. Obviously, any
infant or child presenting with a febrile
seizure and a history concerning for
meningitis or symptoms consistent with
meningeal irritation (eg, neck stiffness,
Kernig and/or Brudzinksi signs) should
undergo a lumbar puncture. 3 Although
not required, the procedure also should
be considered for any infant between
6 and 12 months old who presents with
a febrile seizure and has an inadequate
or unknown vaccination status for
Haemophilus influenza type b (Hib) or
Streptococcus pneumoniae.
Similarly, LP may be considered
for an infant or child who has been
pretreated with oral antibiotics. 2 While
this recommendation is based on level
D evidence, antibiotics can mask signs
and symptoms of meningitis. It also
is reasonable to consider an LP in a
patient with febrile status epilepticus or
a complex febrile seizure coupled with
a concerning history or examination
findings.
Blood cultures should be drawn
and an additional targeted laboratory
workup should be performed for any
child who undergoes lumbar puncture.
December 2016 n Volume 30 Number 12 15

TABLE 2. History and physical examination features that increase the
risk of a serious bacterial etiology for febrile seizures
Child <6 months or >60 months with first-time febrile seizure
Child <12 months with inadequate or unknown vaccination status
Febrile status epilepticus
Persistent altered mental status
Presence of meningeal signs
A child presenting out of the typical age
range of 6 to 60 months also should be
approached with scrutiny, and a more
thorough workup should be considered
(Table 2).
There is wide variability in the
presentation of complex febrile
seizures (eg, two brief seizures within
24 hours versus prolonged focal
seizures with persistently abnormal
neurologic findings). This has limited
the develop­ment of clear guidelines
for the management of these patients.
Clinicians must use their judgement
and consider obtaining laboratory
tests, including a complete blood count;
electrolyte measurements; urinalysis;
and blood, urine, and lumbar puncture
cultures.
CRITICAL DECISION
How should febrile seizures
be treated in the emergency
department?
Supportive care is the mainstay
of treatment for all febrile seizures.
Antipyretic agents can be used to help
comfort the child and aid in the clinical
assessment; however, there is no data to
support the use of these medications to
prevent febrile seizures.12
Children who are actively seizing
at the time of presentation or during
the emergency department visit should
be managed in much the same way as
those who present without fever. The
airway must be supported and secured,
a cardiorespiratory monitor should be
applied, supplemental oxygen should be
provided, and intravenous access should
be obtained.
Benzodiazepines are the first-line
agents for the treatment of persistent
febrile and non-febrile seizures alike.
Institutional differences may direct
16 Critical Decisions in Emergency Medicine
the specific medication choice, but
appropriate options include lorazepam
(intravenous, intramuscular, or
intraosseous), diazepam (intravenous,
intramuscular, intraosseous or
rectal), and midazolam (intravenous,
intramuscular, intraosseous, or
intranasal). If a patient continues
to seize despite two doses of
benzodiazepines, a second-line agent
should be administered. Again, there are
various institutional practice patterns,
but options include fosphenytoin,
levetiracetam, and phenobarbital.
CRITICAL DECISION
When is a neurological evaluation
and/or consultation warranted?
Although regional practice patterns
may affect the workup, an appropriate
neurologic evaluation can involve
neuroimaging, electroencephalography
(EEG) and/or a pediatric neurology
consultation.
Neuroimaging
A 2006 study of 71 infants and
children with first-time complex febrile
seizures who underwent neuroimaging
found none with an acute intracranial
process that required emergent
neurosurgical or medical intervention.13
Additionally, a 2012 study of 268
patients between the ages of 6 and 60
months with first-time complex febrile
seizures who underwent emergent
neuroimaging found that only 0.8%
had a clinically significant intracranial
finding.14
The AAP does not recommend the
routine use of emergent neuroimaging
for patients with first-time simple
febrile seizures. 3 Explicit guidelines
for complex cases do not exist;
however, emergent neuroimaging
should be considered for children
with persistently abnormal neurologic
examinations or altered mental status,
signs of increased intracranial pressure,
or status epilepticus. When ordering
neuroimaging studies, clinicians should
assess the benefits and risks, including
radiation exposure and the need for
sedation.
EEG
An EEG performed in the acute
setting may show abnormalities
of unclear clinical significance.15,16
AAP guidelines state that the test
should not be conducted routinely
in the evaluation of an otherwise
“neurologically healthy” child who
presents with a simple febrile seizure. 2
As with neuroimaging, there are no
clear EEG guidelines for complex febrile
seizures at this time; however, patients
with a history of neurologic and/or
developmental abnormalities, a family
history of seizure disorders, recurrent
febrile seizures, or more than one
feature of a complex episode (eg, focal
and recurrence) should be referred for a
possible outpatient EEG.17
Children with simple febrile
seizures who return to their neurologic
baselines and have no other medical
reason for inpatient care do not require
a referral to a specialized pediatric
center. Patients with complex febrile
seizures have a higher risk of developing
afebrile seizures and can benefit from
an outpatient neurologic evaluation.
However, an urgent evaluation by
neurology is not necessarily required
if the child has returned to his or her
baseline and otherwise meets discharge
criteria.18
Outpatient follow up for a routine
EEG and/or neuroimaging may be
arranged with the help of the patient’s
primary care physician or a neurologist.
Children who require admission due to
a persistently abnormal mental status,
abnormal neurologic examination, or
state of status epilepticus requiring
repeated doses of antiepileptic agents
should be evaluated by the neurology
team while still hospitalized.
CRITICAL DECISION
What is the appropriate
disposition for children with
febrile seizures?
Febrile seizures should be managed
based on a clinical assessment and
the etiology of each patient’s fever.
Children with simple febrile seizures
who are tolerating oral liquids, are back
to neurologic baseline, and have no
clinical indications for admission may
be discharged home after a period of
observation.
Similarly, children with complex
febrile seizures who have no persistent
neurological deficits and are back to
baseline may be sent home with close
outpatient care and a discussion of
return precautions. All patients should
follow up with their primary care
providers, ideally within 1 to 2 days
of discharge. It also is essential for the
emergency physician to communicate
with outpatient providers to establish a
clear follow-up plan prior to sending a
patient home.
Prescription Medications
Although there is no data to
support the use of around-the-clock
antipyretics to reduce the risk of
febrile seizure recurrence, these
agents can be given at home to reduce
symptomatic discomfort caused by
the fever.1,12 There also is limited data
to support the routine prescribing
of abortive antiepileptic agents
(eg, rectal, intranasal, and buccal
benzodiazepines); as such, this practice
is not routinely recommended.1
n Failing to consider serious infectious causes of first-time febrile seizures in
children outside of the typical age range (<6 months or >60 months).
n Performing an unnecessary invasive medical workup for a well-appearing child
with a simple febrile seizure who does not meet any high-risk criteria based on
the history or examination.
n Providing inaccurate or incomplete anticipatory guidance and education to
parents and caregivers of children with febrile seizures.
n A detailed history, review of systems, and physical examination can be used
to guide the need for a tailored workup. The routine use of laboratory testing
and neuroimaging are not recommended.
n As many as one-third of children with febrile seizures will experience a
recurrence in their lifetimes. This risk increases by as much as 70% if the first
seizure occurs before 18 months of age, there is a family history of febrile
seizures, the fever occurs in the setting of a lower-grade fever, and the time
between fever onset and seizure is short.
n If a child returns to neurologic baseline without residual deficits and
otherwise meets discharge criteria, an emergent neurology evaluation is not
routinely required. Outpatient neurology follow up can be coordinated by
the primary care physician if needed.
However, emergency clinicians may CRITICAL DECISION
consider prescribing these medications
What anticipatory guidance
to children with a history of febrile
should be given to the parents
status epilepticus or recurrent febrile
of children with first-time febrile
seizures after consulting the patient’s
primary care provider or neurologist. seizures?
Approximately one-third of these
Inpatient Care
children will go on to have another
Children with febrile status
febrile seizure in their lifetimes.19
epilepticus, a prolonged postictal
Patients who are younger than 18
state, or persistently abnormal
months when their first episode occurs,
neurologic findings should be cared have a first-degree relative with febrile
for in a pediatric center with access to seizures, a lower-grade fever when the
neurology experts. seizure occurred (<40°C [104°F]), or a
Patients should be stabilized prior short time period between the onset of
to transfer; intravenous access should fever and the seizure (<1 hour) appear to
be obtained; and, if necessary, the have an increased risk of recurrence.19
airway should be secured. If a serious The two-year risk of recurrence
bacterial infection is suspected based on increases from less than 20% in patients
examination or laboratory test results, with none of these risk factors to
antibiotics should be administered prior greater than 70% when all four of these
to or during transfer. features are present.19
Precautions
Should parents or caregivers witness
another seizure, they should put the
child in a safe position (preferably a
lateral decubitus position) and ensure
that the airway remains unobstructed.
If the child has been prescribed
antiepileptic medications (eg, rectal
diazepam), the drug should be given as
instructed.
Caregivers should be encouraged
to call emergency medical services at
their discretion. If the seizure is very
brief and the child returns to his or her
December 2016 n Volume 30 Number 12 17
 CASE RESOLUTIONS
■ CASE ONE
The 18-month-old boy’s vital
signs normalized following a
dose of ibuprofen, and the fever,
tachycardia, and mild tachypnea
resolved. He was observed in the
emergency department until he was
able to tolerate fluids.
Given the patient’s congestion
and rhinorrhea with an otherwise
normal physical examination and
complete return to his neurologic
baseline, no medical workup was
pursued. The parents were given
appropriate anticipatory guidance
and the boy was discharged to home
with a plan to follow up with his
pediatrician within the next 24 to
48 hours.
■ CASE TWO
The 21-month-old girl was
suspected to have a complex febrile
seizure as evidenced by the unilateral
upper-extremity shaking and head
and eye deviation in the setting of
fever. On arrival, the child appeared
to be in a postictal state but had no
residual focal neurologic findings.
As the patient had a known sick
contact with similar gastrointestinal
symptoms, the febrile seizure was
suspected to be linked to viral
gastroenteritis. Serial examinations
neurologic baseline, a phone call to the
primary care provider or preexisting
neurologist may be enough to satisfy
concerns; in some cases, the health
care provider may recommend taking
the child to the emergency department.
An episode that recurs within the first
24 hours constitutes a complex febrile
seizure; these cases should be evaluated
by a physician or certified advanced
provider.
Risk of Epilepsy
Children with simple febrile
seizures have a similar risk of
developing epilepsy as those without
a history of the disorder. 20 Patients
18 Critical Decisions in Emergency Medicine
were performed before the immediate
workup was undertaken.
The patient was placed on
a cardiopulmonary monitor
and observed in the emergency
department. Over the course of the
next 45 minutes she became alert,
playful, interactive with providers,
and returned to her neurologic
baseline. Her temperature decreased
to 37.9°C (100.3°F) and heart rate
decreased to the 120s. She was given
an oral antiemetic and tolerated an
adequate amount of liquids without
vomiting.
She had no examination findings
concerning for meningitis or persistent
neurologic deficits; however, the
clinician noted the patient’s heightened
risk of developing seizures both with
and without fever, given her personal
and family history of the disorder.
She was discharged with primary care
follow up within the next 24 hours,
and referred to a pediatric neurologist
for an outpatient EEG.
■ CASE THREE
An IV was placed in the 9-month-
old girl with a history of UTIs,
and a complete blood count, basic
metabolic panel, blood cultures, and
venous blood gas measurements were
obtained. The gas showed a pH of
7.20, pCO2 55 mm Hg, pO2 67 mm
who present with a complex febrile
seizure, family history of epilepsy,
preexisting neurologic abnormality or
developmental delay, and a history of
multiple simple febrile seizures before
the age of 1 year are at greater risk of
developing epilepsy than those in the
general population.18 Febrile seizures
marked by eye deviation, lip smacking,
and prolonged (>15 minutes) motor
movement of the extremities also
appear to herald an increased risk of
epilepsy.
Although the use of long-term
continuous antiepileptic drugs may
reduce the recurrence of febrile seizures,
it has not been shown to decrease the
Hg, HCO3 15 mEq/L, Na 133 mEq/L,
K 4.1 mEq/L, glucose 98 mg/dL, and
lactate 2.6 mmol/L.
The girl’s second seizure resolved
with another dose of IV lorazepam
(0.1mg/kg), but she remained
lethargic with poor respiratory
effort. She underwent rapid-sequence
intubation with rocuronium for
airway protection. A urine sample
subsequently was obtained by
straight catheterization, a lumbar
puncture was performed, and
broad-spectrum antibiotics were
initiated while awaiting the urine
and LP results. A CBC revealed
an elevated WBC count, and later
analysis of the cerebrospinal fluid
noted unremarkable cell counts and a
negative Gram stain.
She was admitted to the pediatric
ICU for further management and
was extubated later that day. Urine
cultures were positive for E. coli
(>100,000 cfu), and blood and
CSF cultures were negative. The
patient was evaluated by a pediatric
neurologist and underwent an
inpatient EEG, which was normal.
She was transitioned to oral
antibiotics on hospital day three and
was discharged home with outpatient
pediatric, neurology, and nephrology
follow up.
risk of developing epilepsy in the future.
Given the number of potential adverse
effects, it is not generally recommended
to initiate these agents after a first-time
episode.1,21
Mortality Rate
The risk of death after febrile
seizures is very rare. Although care­
givers may worry about the possibility
of aspiration or suffocation during
an unwitnessed seizure, there are no
published reports known to the AAP
regarding deaths by these mechanisms.1
A population-based cohort study of
more than 1.6 million children found
that the mortality rate of those with
simple febrile seizures is similar to that
of the general population (adjusted
mortality rate ratio 1.09 [95% CI
0.72-1.64]). When adjusting for year
of birth, age, and sex, children with
complex febrile seizures had a slightly
higher adjusted mortality rate ratio of
1.99 (95% CI 1.24-3.21) for the two
years following the episode, a finding
that was attributed to the higher rate
of epilepsy and preexisting neurologic
abnormalities among these patients. 22
Summary
Simple and complex febrile seizures
can be differentiated by their duration
(<15 minutes versus ≥15 minutes), the
presence or absence of focal features,
recurrence within 24 hours, and
prolonged postictal states. The majority
of children presenting with febrile
seizures, both simple and complex,
require only a thorough history and
physical examination at the time of
initial presentation.
The routine use of laboratory and
imaging studies is not recommended.
Children at greater risk of serious
bacterial illness based on age and
sex, those presenting with persistent
neurologic abnormalities or signs
of increased intracranial pressure,
inadequate vaccinations, or recent
antibiotic use should undergo a targeted
medical workup. Most otherwise-
healthy children with febrile seizures
have excellent outcomes without long-
term consequences and do not go on to
develop epilepsy.
REFERENCES
1. Steering Committee on Quality Improvement and
Management; Subcommittee on Febrile Seizures
American Academy of Pediatrics. Febrile seizures:
clinical practice guideline for the long-term
management of the child with simple febrile seizures.
Pediatrics. 2008;121(6):1281-1286.
2. Kimia AA, Bachur RG, Torres A, Harper MB. Febrile
seizures: emergency medicine perspective. Curr
Opin Pediatr. 2015;27(3):292-297.
3. Subcommittee on Febrile Seizures; American
Academy of Pediatrics. Neurodiagnostic evaluation
of the child with a simple febrile seizure. Pediatrics.
2011;127(2):389-394.
4. Teach SJ, Geil PA. Incidence of bacteremia,
urinary tract infections, and unsuspected bacterial
meningitis in children with febrile seizures. Pediatr
Emerg Care. 1999;15(1):9-12.
5. Green SM, Rothrock SG, Clem KJ, et al. Can seizures
be the sole manifestation of meningitis in febrile
children? Pediatrics. 1993;92(4):527-534.
6. Kimia AA, Capraro AJ, Hummel D, et al. Utility of
lumbar puncture for first simple febrile seizure
among children 6 to 18 months of age. Pediatrics.
2009;123(1):6-12.
7. Kimia A, Ben-Joseph EP, Rudloe T, et al. Yield of
lumbar puncture among children who present
with their first complex febrile seizure. Pediatrics.
2010;126(1):62-69.
8. Seltz LB, Cohen E, Weinstein M. Risk of bacterial
or herpes simplex virus meningitis/encephalitis in
children with complex febrile seizures. Pediatr Emerg
Care. 2009;25(8):494-497.
9. Watemberg N, Sarouk I, Fainmesser P. Acute
meningitis among infants and toddlers with febrile
seizures: time for a reappraisal of the value of a
lumbar puncture. Isr Med Assoc J. 2012;14(9):547-549.
10. Fletcher EM, Sharieff G. Necessity of lumbar
puncture in patients presenting with new onset
complex febrile seizures. West J Emerg Med.
2013;14(3):206-211.
11. Batra P, Gupta S, Gomber S, Saha A. Predictors of
meningitis in children presenting with first febrile
seizures. Pediatr Neurol. 2011;44(1):35-39.
12. Rosenbloom E, Finkelstein Y, Adams-Webber T,
Kozer E. Do antipyretics prevent the recurrence of
febrile seizures in children? A systematic review of
randomized controlled trials and meta-analysis. Eur
J Paediatr Neurol. 2013;17(6):585-588. doi: 10.1016/j.
ejpn.2013.04.008.
13. Teng D, Dayan P, Tyler S, et al. Risk of intracranial
pathologic conditions requiring emergency
intervention after a first complex febrile seizure
episode among children. Pediatrics. 2006;117(2):304-
308.
14. Kimia AA, Ben-Joseph E, Prabhu S, et al. Yield of
emergent neuroimaging among children presenting
with a first complex febrile seizure. Pediatr Emerg
Care. 2012;28(4):316-321.
15. Kuang YQ, Kong B, Yang T, et al. Epileptiform
discharges and frontal paroxysmal EEG abnormality
act as predictive marker for subsequent epilepsy
in children with complex febrile seizures. Clin EEG
Neurosci. 2014. [Epub ahead of print] ISSN 1550-0594,
http://www.ncbi.nlm.nih.gov/pubmed/24586108.
16. Shah PB, James S, Elayaraja S. EEG for children with
complex febrile seizures. Cochrane Database Syst
Rev. 2014;(1):CD009196.
17. Patel AD, Viduarre, J. Complex febrile seizures:
a practical guide to evaluation and treatment.
J Child Neurol. 2013;28(6):762-767. doi:
10.1177/0883073813483569.
18. Pavlidou E, Panteliadis C. Prognostic factors for
subsequent epilepsy in children with febrile seizures.
Epilepsia. 2013;54(12):2101-2107. doi: 10.1111/
epi.12429.
19. Berg AT, Shinnar S, Darefsky AS, Holford TR,
et al. Predictors of recurrent febrile seizures. A
prospective cohort study. Arch Pediatr Adolesc Med.
1997;151(4):371-378.
21. Graves RC, Oehler K, Tingle LE. Febrile seizures:
risks, evaluation, and prognosis. Am Fam Physician.
2012;85(2):149-153.
20. Pavlidou E, Hagel C, Panteliadis C. Febrile seizures:
recent developments and unanswered questions.
Child Nerv Syst. 2013;29(11):2011-7. doi 10.1007/
s00381-013-2224-3.
22. Vestergaard M, Pedersen, MG, Ostergaard JR, et al.
Death in children with febrile seizures: a population-
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doi: 10.1016/S0140-6736(08)61198-8.
December 2016 n Volume 30 Number 12 19
 The Critical Image
CASE By Joshua S. Broder, MD, FACEP
A 62-year-old woman presents following a witnessed cardiac arrest Dr. Broder is an associate professor and the
two days after an elective hernia repair. Her husband performed chest residency program director in the Division
of Emergency Medicine at Duke University
compressions after she became unresponsive at home. EMS found the Medical Center in Durham, North Carolina.
patient to be in pulseless electrical activity (PEA) arrest and achieved
return of spontaneous circulation following epinephrine administration.
The patient arrives in the emergency
department with agonal respirations and A Catheter overlies
hypotension. The monitor shows sinus right subclavian vein
rhythm. The patient is intubated, a right
internal jugular central venous catheter
is placed, and an epinephrine infusion is
administered. Her vital signs are blood
pressure 101/52 (on an epinephrine
infusion), heart rate 88, respiratory rate
16 (ventilated), temperature 35.8°C
(96.4°F), and oxygen saturation 100%
on 100% oxygen.
The patient is unresponsive. Faint heart
sounds are audible, with rales in bilateral
lung fields. The abdomen is distended and
has stapled abdominal surgical incisions.
The extremities are cool with faint pulses.
A chest x-ray is performed.

A. Anteroposterior (AP) chest radiograph.

B A central venous catheter is seen overlying
the right neck. However, rather than
traversing the superior vena cava to terminate
at the level of the carina as expected, the
catheter deflects laterally into the position of
the right subclavian vein.

Left
subclavian B. AP chest radiograph following
catheter placement of a left subclavian vein
catheter. The tip of this catheter is positioned
as expected in the distal superior vena cava,
in this case just below the level of the carina.
Ideal placement would be slightly shallower,
Left at or above the level of the carina. The
subclavian misplaced right internal jugular approach
Carina catheter is still visible, overlying the right
catheter tip
subclavian vein.

20 Critical Decisions in Emergency Medicine

 deflection into unintended imaging may be required.
KEY POINTS
branch vessels, placement into Some authors have advocated
n Following attempted central
the pleural space, or inadvertent “if in doubt, don’t take it
venous catheter placement in
arterial placement. A wide variety out.”1 If a malpositioned
the internal jugular or subclavian
of other accidental targets have catheter is confirmed to be
veins, the chest radiograph
should be inspected for been reported, including the within the venous system (by a
pneumothorax, hemothorax, esophagus and aorta. If the variety of measures, including
and catheter position. On frontal patient is stable and the catheter examination for lack of arterial
projection chest radiograph is suspected to lie within an artery pulsatility and confirmation
(AP or PA), a properly placed or other vulnerable structure, of dark color consistent
internal jugular or subclavian the catheter should be left in with venous blood), the
triple lumen catheter should place until appropriate surgical catheter can be repositioned
terminate with the tip overlying or interventional radiology or removed. A pressure
the superior vena cava outside consultation has occurred, as transducer can be connected
of the pericardial sac, at or just removal may result in significant to a catheter to assess for
above the level of the carina. hemorrhage.1 If the position of arterial or venous waveform.
Below the level of the carina, the catheter is suspected to Blood gas analysis also may
the superior vena cava is within be incorrect but the specific differentiate between arterial
the pericardial sac; pericardial location is uncertain, additional and venous placement.
tamponade can result if the
catheter punctures the vena
C Left subclavian
cava within the pericardial sac.
catheter tip
Deeper placement, with the tip
in the right atrium or ventricle,
can induce cardiac ectopy;
therefore, the catheter should be
withdrawn until the tip is within
the superior vena cava. Shallow
placement with the tip in the
proximal superior vena cava may
not require repositioning if the
catheter is functioning, although
shallow placement may lead
to inaccurate measurements
of central venous pressure or
central venous oxygen saturation
and an increased thrombosis risk.
n Atypical position of a central
venous catheter on chest
radiograph may indicate

C. A CT scan performed for the evaluation of possible pulmonary embolism

CASE RESOLUTION shows the initial catheter misplaced in the right subclavian vein. Contrast is seen
infusing through the left subclavian vein.
The internal jugular catheter was
removed and the patient was
admitted to the intensive care unit
for management of her cardiac
arrest. REFERENCE
1. Gibson F, Bodenham A. Misplaced central venous catheters: applied anatomy and practical management. Br J
Anaesth 2013;110:333-346.

December 2016 n Volume 30 Number 12 21

 CME
Reviewed by Lynn Roppolo, MD, FACEP

Qualified, paid subscribers to Critical Decisions in Emergency Medicine may receive

CME certificates for up to 5 ACEP Category I credits, 5 AMA PRA Category 1

QUESTIONS
Credits™, and 5 AOA Category 2-B credits for completing this activity in its entirety.
Submit your answers online at acep.org/newcriticaldecisionstesting; a score of 75%
or better is required. You may receive credit for completing the CME activity any time
within three years of its publication date. Answers to this month’s questions will be
published in next month’s issue.

1 Which physiological parameters most closely

correlate with frailty?
A. Baseline functional status
7 Which factor can contribute to an unreliable
abdominal examination in an elderly trauma patient?
A. Decreased pain perception
B. Ejection fraction on a recent (≤6 months) B. Distrust of medical providers
echocardiogram C. Frailty
C. Oxygen saturation D. Use of anticoagulants
D. Resting heart rate

2 What is the most common cause of death in

elderly trauma patients?
8 What is the most common injury in blunt chest
trauma?
A. Hemothorax
A. Cervical spine injuries B. Pneumothorax
B. Compound fractures C. Pulmonary contusion
C. Head injuries D. Rib fracture
D. Thoracic trauma

3 Bruises, pressure marks, broken bones, and

abrasions should raise clinical suspicion for what?
9 Which test is the most sensitive in diagnosing hip
fractures in the elderly?
A. CT scan
A. Abuse
B. MRI
B. Frailty
C. Ultrasound
C. Osteoporosis
D. X-ray
D. Use of antiplatelet medications

4 Which mechanism of injury contributes to the

greatest number of ICU days in patients 65 years
10 What is the one-year mortality rate in geriatric
patients who are readmitted after ground-level falls?
A. 17%
or older?
A. Assault B. 23%
B. Falls C. 28%
C. Motor vehicle collisions D. 33%
D. Pedestrian accident (struck by a car)

5 Which sedative medication should not be used in

elderly patients with preexisting ischemic heart

11 Which of the following most correctly groups the
features of simple versus complex febrile seizures?
A. Focal, <15 minutes, no recurrence in 24 hours versus
disease? generalized, ≥15 minutes, recurrence in 24 hours
A. Etomidate B. Generalized, <15 minutes, no recurrence in 24 hours
B. Dexmetomedine versus focal, ≥15 minutes, recurrence in 24 hours
C. Diazepam C. Generalized, ≥15 minutes, recurrence in 24 hours
D. Ketamine versus focal, <15 minutes, no recurrence in 24 hours

6 What percentage of caregivers has reported D. Generalized, <15 minutes, recurrence in 24 hours
physically abusing their care recipients? versus focal, ≥15 minutes, recurrence in 24 hours
A. 2%
B. 5%
C. 10%
D. 20%

22 Critical Decisions in Emergency Medicine

12 A 20-month-old boy presents after a simple seizure
triggered by a fever of 39.1°C (102.4°F). He looks
well and has a mild cough and runny nose. He has no
16
medical problems, his immunizations are up to date,
and he has not been on any recent antibiotics. His
examination is unremarkable. Which diagnostic tests
should be initiated?
A. CBC, blood culture, and chest radiograph
B. Consider a lumbar puncture in addition to a full
A febrile 15-month-old child is brought in by
paramedics with a new-onset generalized tonic-
clonic seizure. He is actively seizing on arrival.
What should be the first-line treatment?
A. Intranasal midazolam
B. Intravenous ceftriaxone
C. Oxygen via non-rebreather mask and jaw thrust
D. Rectal acetaminophen

17
laboratory evaluation Which antiepileptic medication is an appropriate
C. Urinalysis and urine culture first-line choice for aborting a complex febrile
D. No further workup is required seizure?
A. Fosphenytoin

13 A patient with one simple febrile seizure is at what
risk of developing epilepsy, as compared to a child
without such a history?
B. Levetiracetam
C. Lorazepam
D. Phenobarbital
A. 32% higher
B. 66% higher
C. Essentially the same
18 Which febrile seizure pattern is associated with an
increased risk of future epilepsy?
D. The risk cannot be deduced from current data in A. Eye deviation, lip smacking, and motor
the literature movement of the right upper extremity lasting for
15 minutes

14
Which antiepileptic drug is best for the long-term
prevention of recurring simple febrile seizures?
A. Benzodiazepine
B. Generalized tonic-clonic seizure lasting for 2
minutes with recurrence in 24 hours
C. Generalized tonic-clonic seizure that requires
B. Levetiracetam antiepileptic medication to abort
C. None are recommended due to the risk of side D. Generalized tonic-clonic seizure that resolves
effects and inability to prevent future epilepsy spontaneously in 5 minutes
D. Valproic acid

15
A lumbar puncture would be most appropriate in
which of the following patients?
19 Which characteristic increases the risk of future
A. A 7-month-old girl with a febrile seizure that
lasted for 10 minutes, is back to neurological
baseline, and is taking an oral antibiotic for recently
diagnosed otitis media
B. A 10-month-old boy with febrile status epilepticus
that required multiple doses of antiepileptic
medications and rapid-sequence intubation to
resolve
20
C. A 12-month-old boy with a simple febrile seizure
that lasted for 2 minutes and who is now back to
neurological baseline
D. An 18-month-old girl with a febrile seizure that
required intravenous benzodiazepines to abort and
who is waking up slowly
febrile seizures in a patient with a first-time
episode?
A. 36 months of age at the time of first seizure
B. History of febrile seizure in a parent
C. Presence of fever for 24 hours before seizure
D. Temperature of 40.6°C (105°F)
An 11-month-old boy presents following a febrile
seizure; his examination findings are normal. In
which scenario is he likely to benefit from an
outpatient electroencephalogram?
A. First-time seizure, which required
benzodiazepines to abort
B. First-time seizure, which resolved spontaneously
C. Second simple febrile seizure within 24 hours
D. Third recurrent febrile seizure within a year

ANSWER KEY FOR NOVEMBER 2016, VOLUME 30, NUMBER 11

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
B C D B B B D B A B B A C A C C A A C B

December 2016 n Volume 30 Number 12 23

 Drug Box
DIGIFAB
By David Watts, DO; and Frank Lovecchio, DO,
Banner University Medical Center, Phoenix, Arizona
Digoxin-specific antibody fragments (DigiFab) can be lifesaving
for patients suffering from toxicity from digoxin or digoxin-like
substances. The antidote is less likely to cause hypersensitivity
reactions and should replace Digibind.
Mechanism Immediately following the IV administration of the Fab
of Action fragments, uncomplexed antibodies become free to
diffuse into interstitial space/tisstaues, where they bind
free intravascular digoxin and then are excreted through
the kidneys.
Indications • Life-threatening dysrhythmias
• K+>5.5 mEq/L with acute toxicity
• Chronic digoxin elevations with dysrhythmias, GI
symptoms, or altered mental status
• Serum digoxin concentration (SDC) >15 ng/mL
• SDC >10 ng/mL at 6 hours post-ingestion
• Acute ingestion >10 mg of digoxin in adults;
>4 mg (0.1 mg/kg) in children
• Poisoning with non-digoxin cardioactive steroids
Dosing 1 vial = 40 mg (1 vial binds 0.5 mg of digoxin)
Acute: 5 vials (may repeat PRN)
Chronic: 3-6 vials for adults; 1-2 vials for children (monitor
for volume overload)
• Ingestion-based dosing (total body load =
# tablets x tablet strength)
• # of vials (round up) = (( # tablets) x (strength) x
(0.8)) ÷ (0.5 mg/vial)
• SDC-based dosing: 6 hours post ingestion
• Quick calculation ~ # vials = ([SDC ng/ml] x (weight (kg))
÷ 100 (round up)
Off-label: Cardiac glycoside/plant toxicity (initial dose:
10-20 vials; subsequent doses based on clinical response)
Side Posteral hypotension, hypokalemia, loss of disease
Effects control, phlebitis, fever (with doses >10 vials), allergic
reactions, and serum sickness.
Precautions Contraindications: Allergies to sheep (ovine) proteins,
papain, papaya extracts, or pineapple enzyme bromelain
Effects due to withdrawal of digitalis: Exacerbation of
heart failure, rapid ventricular response in patients with
atrial fibrillation. Monitor for signs of recurrent toxicity
with acute or chronic renal failure. DigiFab falsely elevates
digoxin concentrations (must trend free-digoxin levels).
Pregnancy: Category C; excretion in milk unknown
Tox Box
LOPERAMIDE
By Daniel Lasoff, MD, University of California, San Diego, California
Reviewed by Christian A. Tomaszewski, MD, MS, MBA, FACEP
Loperamide is a peripherally-acting opioid used to treat diarrhea. It is
increasingly abused recreationally and misused in the self-treatment
of opioid withdrawal symptoms. New reports of cardiotoxicity are
arising in patients who abuse loperamide daily.
Presentation
To self-medicate, patients may chronically ingest >100x the daily
therapeutic dose (16 mg) for weeks prior to presentation. Suspect
toxicity in any patient without a prior cardiac history who presents
with:
• Syncope
• Cardiac dysrhythmias (torsade de pointes, ventricular ectopy)
• Marked QRS widening and prolonged QTc prolongation.
• Coingestants (eg, cimetidine, quinine, and other P-glycoprotein
inhibitors) used to enhance central nervous system (CNS)
delivery
Single Acute Overdoses:
• Generally safe in adults and children (up to 0.5 mg/kg)
• Therapeutic doses (2 mg) have been associated with paralytic
ileus and central and respiratory depression in infants.
Evaluation and Workup
Electrolyte panel with a focus on potassium, magnesium, and calcium
levels. ECG may demonstrate QRS levels >160 ms or QTc levels >700
ms. Symptomatic patients should receive cardiac monitoring for life-
threatening dysrhythmias. Further laboratory testing may be required
if loperamide levels are not readily available.
Treatment
• Isoproterenol (5 mcg/min titrated to 2-20 mcg/min) to overdrive
pace patients with recurring polymorphic ventricular tachycardia
• Sodium bicarbonate 8.4% (1 mEq/kg x 3) boluses for widened QRS
• Naloxone for respiratory and CNS depression
• Replete electrolyte abnormalities
Decontamination/Elimination
• Alert patients who present with massive ingestion (>1 mg/kg)
may be treated orally with activated charcoal (1 gm/kg).
• Dialysis offers no benefit.
Disposition
Admit patients with dysrhythmias, significant ectopy, QRS widening,
or marked QTc prolongation until abnormalities resolve (may take
days due to slow drug elimination). Asymptomatic or clinically
improved patients may be discharged ~6 hours following ingestion
(potential for delayed or continued absorption).