Actually, I've got one more good question about my red flags, based on a discussion with one of our EM faculty this morning:

1. How will the incontinence of cauda equina syndrome typically present first?

What's the speed of sound for $100 Alex.

LOL, alright, I certainly didn't get this one when he asked me, so I'm not going to play "what am I thinking" too much.

There are many different kinds of incontinence, and cauda equina syndrome often starts with overflow incontinence: an inability to urinate causing bladder distention and subsequent leakage due to the buildup of pressure.

This means that the first sign of a cauda equina syndrome may not be obvious leakage, but actually lower abdominal distention and inability to urinate. A worthwhile tidbit to keep in the back of your mind (or so I thought).

OK, now I'm really done. Thanks for participating everyone!

Ender-

This was really very, very good and a valuable exercise - for me anyway. I learned a lot from everyone who posted here.

THANK YOU ALL :lifter

Yes, this case meets the criteria for SIRS (Systemic Inflammatory Response Syndrome), which are two or more of the following:

> 38oC or < 36oC, heart rate
> 90 beats/minute, respiratory rate
> 20 breaths/minute or PaCO2 < 32
white blood cell count > 12,000 or < 4,000, or > 10% band forms.

SIRS isn't the diagnosis by itself, but an extremely important indicator of severity. Yes, this patient is seriously sick and hence the importance of starting treatment immediately in addition to evacuating him.

I think VD is a very good thought here as well, for two different reasons. First, bugs like neisseria gonorrhoeae can go systemic (usually going for joints rather than bone), and also immunocompromise would predispose the PT to development of an osteomyelitis via this mechanism.

I was thinking SIRS all along with that vitals you posted. In the land of Airborne and SOF, I've noted that every single barrel-chested freedom fighter presented with bradycardia! Well, that's just their baseline of course. So when these types (just like our Team Sergeant pt here) presented with HR of 90, that's tachy for sure. Granted he's in pain, but still.

Toughness or stubborness (take your pick) can be problematic in the steely-eyed community. I remember treating this salty CWO4 SF who kept apologizing for showing up in the ER. He had long term steroid therapy for a previous condition, and ended up with pilonidal cyst that got to the point of both inner cheeks dripping with pus! It was the worst case I ever saw, thanks to 5 weeks wait from getting help.

You brought up a very good point Frostfire. As a Team Medical Sergeant I made it a point to really know the baseline vitals and medical Hx of the team members. A HR of 90 in the Team Daddy that had a baseline resting HR of 50 would be cause for concern to be sure. Couple that with the low-grade fever and neutrophilia with immature bands - voila! A Dx of sepsis is at the top of the list.

I did not initially consider this as part of the DDx :( but focusing on the back pain and RO simple causes that were field treatable it was clear that TS needed Medevac ASAP.

One other point, in my day (now I sound like an ol' geezer :eek:) we did not have field portable kits for doing a WBC. If I did and saw the neutrophilia with bands that would be reason for immediate Medevac. Now to the question of starting TS on antibiotics - probably contraindicated IMO. I don't know what the 18Ds carry these days, but I think the choice of antibiotic would be better left to the attending at a primary care facility.

Maybe some of you Docs and AD 18Ds could discuss this point (pros and cons) a bit more. I would be interested to read what you all think.

Start with fever....as mentioned, have to know a baseline to determine if the temp is elevated. Also about 75% of all fevers are inflammatory, not infection Ina hospital so how that correlated with the field I'm not sure.
An elevated WBC is too non specific and certainly not a sensitive indicator of a big problem. One of the studies I read years ago took SF warriors and checked their cortisol levels after stress, they were rarely if ever demonstrating adrenal insufficiency when significantly wounded and in an ICu..... Not the norm at all so WBC and neutrophil counts are an indicator of the immune functional and response so you SF guys mess all of that up!!!
I would go by other signs and sx's to figure out an infectious/inflammatory response.
ss

I double checked this with one of our EM faculty, and he agreed that an empiric antibiotic, even if its not perfect, should be administered immediately. Studies show that even if the ABX isn't the perfect choice, early administration in serious cases like this makes a real difference in outcomes. He also mentioned that while something like Rocephin might not cover all the possible bugs, it would cover most of the ones that would produce a rapid sepsis in a patient such as this. (again, not arguing its the perfect drug... just something I'm pretty sure 18D's still have around.)

IE was raised in the thread as it related to dental treatment. Therefore, I thought I would add to the reason that ender18D didn't focus on that possibility for the acute symptoms that this patient is experiencing based on his history.

Infective endocarditis (IE) is extremely rare in the postoperative dental patient population. In certain conditions, it is a valid concern. If at risk, the military dental clinic would have supplied Ab premedication to the TS before treatment began to prevent it. They would have also verified patient cooperation with Ab regimen before beginning treatment. Postoperative Ab therapy is not indicated to prevent IE.

When I first got out of school, the fear of postop IE dictated that we gave antibiotic prohylaxis pre and postop to patient in all sorts of widespread patient populations from MVP with or W/O regurgitation, all forms of congenitial heart defects, history of rheumatic fever, past IE episode, history of cardiac stints, valve surgeries, prosthetics, A-fib, etc. Basically, it was "if in doubt, give them antiobiotics before and after treatment. This thinking has changed as the actual scientific data has been developed.

Currently, IE is at the highest risk in patients with a history of:
1- prosthetic cardiac valve; risk 1:124,000
2- prior documented incidence of IE, risk 1:95,000
3- Heart transplant patients who develop cardiac valvulopathy
4- past rheumatic heart disease; risk 1:142,000

*** our patient in this thread has none of these in his history

The only other patient populations that are at high enough risk to warrant true concern for IE are certain congenital heart defects in the following specific groups:
1- Unrepaired cyanotic CHD, including palliative shunts and conduits
2- completely repaired CHD with prosthetic material during the first 6 months after surgery
3- repaired CHD with residual defects at the site of the prosthetic patch (inhibits endothelialization)

Since our barrel chested, freedom fighter does not fit into these parameters, it is VERY unlikely that the diagnosis is Infective endocarditis caused during a dental procedure or by his poor postoperative patient cooperation with antibiotics. Still hanging on to the likelyhood of our TS friend having IE??? What are the chances? Well, if he did in fact have mitral valve prolapse and experienced a very messy surgical procedure without the appropriate premed... his chances were still only 1:1.1 MILLION of getting IE postop to a dental visit. It is not even clear he had a heart murmor or any other even minor risk factor for IE from what I glanced at during the thread.


FWIW, Infective endocarditis would not only have been a Zebra, it would have been the ultra rare spotted, long neck blue throated zebra that is only found in far regions of Neverlandia. :D

BTW- there should are some simple, basic questions and tests that could help identify problems in his oral cavity and S/S of recurrent infection other than simply running a fever if the patient was septic from a dental condition/visit/treatment.

Great thread ender18D.

This is awesome and great info for me!

The funny thing is that they have run some variant of this scenario over and over again (at least 4 times I can think of), both on our written and practical exams... I've even seen board questions on it, often adding in no more information than I gave. Its to the point where as medical students the minute we hear "dental work" in a history we start thinking bacteremia... LOL

I will file this in my back pocket. That said, I would argue that even setting aside the dental history, there is a pretty short list of causes of this clinical picture, all of them are bad, and you can really only do much for one of them (infection, ABX) right now. I don't think the rarity of the particular cause I suggested here really changes the main diagnosis and treatment of this guy, although I'm open to debate on it.

My experience with boards and board type questions(not to mention briefbacks) is that a significant percentage of questions and scenarios include the near impossible improbables to the obtuse.

None-the-less, I understand the TS did in fact not fit into the parameters for IE and that it was only a blue-throated herring. ;)

Thanks! :)

I didn't say some academic won't put that on a board exam. They like to pull out wild Dx for common symptoms for standardized tests... HaHa

We had all sorts of "what ifs" drilled into us as well during school.... they are good to know when you've run through a very thorough process of ruling out the more likely causes. :cool: Just trying to give some scale to the problem so that our members knew how unlikely IE is from dental procedures. :cool: