Grand Rounds Recap 4.24.24
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Morbidity and Mortality WITH Dr. Kletsel
Case 1: Chest Pain
Consider the underlying etiology driving the elevated HR and try to correct it prior to administering a rate control agent.
During times of acute illness, blunting a patient’s underlying compensatory tachycardia may be dangerous.
We should be comfortable with the different types of advanced care documents that we may encounter in the field and in the ED.
We need to improve our conversations with patients, as well as amongst providers, pertaining to code status in the ED.
Case 2: Deep Vein Thrombosis
Isolated distal DVTs have about a 15% risk of propagation if left untreated.
Treatment of these isolated calf clots remains controversial, yet surveillance with weekly ultrasound can be considered in patients with a high risk of bleeding.
While AC can typically be initiated a few weeks following a hemorrhagic stroke for at-risk patients, cerebral amyloid appears to have a higher risk of re-bleeding and providers should be cautious prior to initiating anticoagulation in these patients.
Quick Hit Case A: Shoulder Injury
Posterior shoulder dislocations are rare and commonly missed on initial presentation.
We need to be proficient at reading normal A/P and lateral shoulder x-rays.
Look for joint space widening, a positive lightbulb sign, and/or improper alignment on a Y view to suggest a posterior dislocation.
Quick Hit Case B: Ankle Pain
When looking at an ankle radiograph, start by looking for a uniform ankle joint mortise that measures <4mm
Next, look for a fibular bone fracture and grade it based on the Danis-Weber classification system.
If you are concerned for a Danis-Weber B, perform stress views of the ankle to assess for instability.
Quick Hit Case C: Abdominal Pain
A definitive IUP requires a yolk sac within a gestational sac, in the same plane as the endometrial stripe, and surrounding with a endomyometrium measuring at least 8mm.
When there is clinical concern for an ectopic pregnancy, always assess for the presence of a moderate or significant amount of free fluid in the pelvis/RUQ- as these are highly specific for a ruptured ectopic.
Case 3: Chest Pain
Lactic acidosis is not always caused by tissue hypoperfusion.
Type B lactic acidosis involves impaired clearance of lactate by the liver/kidneys or certain medications/toxins that impair typical cellular aerobic respiration.
Metformin toxicity impairs the electron transport chain in the mitochondria and leads to production of excess lactate.
Patients typically present with vague symptoms, including GI distress and confusion, and dialysis remains the mainstay of treatment.
Case 4: Cardiac Arrest
Consider massive PE as the underlying etiology when a patient presents with undifferentiated cardiac arrest.
Predictors that suggest PE include a non-shockable rhythm, history of a prior clot, and lack of a cardiac history.
If suspicion if high, you consider administration of intra-arrest thrombolytics, yet there is conflicting data about the benefits.
Furthermore, there is no consensus about dosage and/or duration that CPR should be extended for.
R1 Diagnostics and Therapeutics: Neuromuscular Weakness WITH Dr. Onuzuruike
Thorough neurological exam along with cardiac and respiratory exam
With NM, try to locate source of weakness. There are various ways to do this, but elucidating the timing and pattern of distribution is key for finding source
Motor unit pathway gives us pathophysiology of disease, and if it comes with or without pain or sensory changes
Employ your knowledge of neurolocalization and anatomy to identify NM weakness and suspected etiologies
The neurological exam is key
Use bedside respiratory parameters, ETCO2 for monitoring of respiratory function and know the signs of impending failure; maximize treatment of other variables (ex. secretions)
EKG Quick Hits: Artifacts and Errors WITH Dr. Urbanowicz
There are many common artifacts in EKGS, but they can include: motion, interference, placement distortion, and machine dysfunction
Limb lead reversal is common, can incorrectly suggest inferior ischemia, and is most commonly reversal of right vs. left
Electromagnetic interference can be either intrinsic (simulation devices) or extrinsic (cell phones, machinery, etc)
How to troubleshoot artifact:
Check the cable location, on both patient and box
Replace the electrode stickers (shave if needed!)
Remove all cables and electronics from bed
Try a different machine
Try a new physical location
Social Emergency Medicine GR WITH Drs. Pulvino and kimmel
Socially conscious emergency medicine is good for patients and performance measures
Examples: Case management for ED frequent users, MOUD, street medicine
Social EM is cost effective
You can align your practice with Social EM without ruining your workflow. You can do this by:
Working SEM into your reading rotation
Check yourself before discharge, including if the plan is realistic and what barriers the patient may face
Know what resources you have within your hospital system and local community, and phone a friend when you don’t know (social work, pharmacy, EIP/SUD, etc)
Advocate for resources within your emergency medicine group, hospital system, and community(24/7 social work, substance use teams, voting, community advocacy)
You can bill for your work! New billing rules make it possible, and MDM templates can be found online
Incorporate SEM into your presentations, and collaborate with other departments and sub-departments (IM, palliative, ultrasound, research, etc)
Landmark Studies of EM: Critical Care WITH Drs. Richards, GIllespie, and Wosiski-Kuhn
Early goal directed therapy, while some of the initial principles have now been proven harmful or ineffective, still has a great impact on our care of the critically ill septic patient
Focused on early recognition and treatment of sepsis in the emergency department
Protocolized treatment pathways & treatment goals
Model for acute, time-sensitive conditions in the emergency department
Low tidal volumes based on patient’s ideal body weight with ARDS significantly decreases mortality in these patients
Non-invasive positive pressure ventilation benefits include reduced mortality, reduced intubation, decreased hospital length of stay, and lower composite risk of in-hospital complications including pneumonia, barotrauma, and sepsis
