Derivation of a clinical decision instrument to identify patients with status epilepticus who require emergent brain CT.

BACKGROUND: Studies have shown the value of CT brain imaging in adults with first-time seizures, but there are no recommendations regarding emergent brain CTs in persons with an established seizure disorders. Our study aimed to derive a clinical decision instrument (CDI) to determine which patients with status epilepticus (SE) require emergent brain imaging. METHODS: This was a retrospective chart review of patients who presented to our emergency department with SE between 2010 and 2018. Patients with first-time seizures were excluded. A priori, we defined high risk criteria for emergent imaging as well as positive findings on brain CT. High risk criteria included known malignancy, trauma, and immunosuppression. Positive CT scans included findings such as intracranial hemorrhage (ICH) and mass. RESULTS: We identified 214 patients who met inclusion criteria Of the 181 patients without high risk criteria, 3% had positive CT scans. Of the 33 patients with high risk criteria, 10% had positive CT scans. The sensitivity, specificity, PPV, and NPV for our initial CDI were 38%, 85%, 9%, and 97%. Adding the criterion of prior ICH would have lowered our miss rate to 0.6%. Modifying our CDI to 1) History of ICH, 2) Malignancy, 3) Immunosuppression, and 4) Trauma would result in a CDI with sensitivity, specificity, PPV, and NPV of 87.5%, 87.4%, 21.2%, and 99.5%. CONCLUSIONS: By using four criteria to identify high risk patients, we can defer CT scanning in the vast majority of patients with SE and known seizure disorders. This CDI should be prospectively validated before adoption.

An Unlikely Cause of Hypokalemia.

BACKGROUND: Hypokalemia is a common clinical disorder caused by a variety of different mechanisms. Although the most common causes are diuretic use and gastrointestinal losses, elevated cortisol levels can also cause hypokalemia through its effects on the renin-angiotensin-aldosterone system. Cushing's syndrome refers to this general state of hypercortisolemia, which often manifests with symptoms of generalized weakness, high blood pressure, diabetes mellitus, menstrual disorders, and psychiatric changes. This syndrome is most commonly caused by exogenous steroid use, but other etiologies have also been reported in the literature. Ectopic adrenocorticotropic hormone production by small-cell lung cancer is one rare cause of Cushing's syndrome, and may be associated with significant hypokalemia. CASE REPORT: We describe the case of a 62-year-old man who presented to the emergency department with weakness and hypokalemia. The patient was initially misdiagnosed with furosemide toxicity. Despite having a 30-pack-year smoking history, this patient's lack of respiratory complaints allowed him to present for medical attention twice before being diagnosed with lung cancer. It was later determined that this patient's hypokalemia was due to Cushing's syndrome caused by ectopic adrenocorticotropic hormone production from small-cell lung cancer. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case reminds emergency physicians to consider a broad differential when treating patients with hypokalemia. More importantly, it prompts emergency physicians to recognize comorbid conditions and secondary, less common etiologies in patients with repeated visits for the same complaint.

An Unlikely Cause of Abdominal Pain.

Cecal bascule is a rare subtype of cecal volvulus where the cecum folds anterior to the ascending colon causing intestinal obstruction. It is a challenging diagnosis to make in the emergency department, as the mobile nature of the cecum leads to a great deal of variation in its clinical presentation. Our discussion of a 78-year-old female who presented with abdominal pain and was found to have a cecal bascule requiring right hemicolectomy, demonstrates how emergency physicians must expand their differential diagnosis for patients reporting signs of intestinal obstruction. Though cecal bascule does not present often, the need for early surgical intervention necessitates a high level of clinical suspicion to prevent life-threatening complications.