Grand Rounds Recap 1.4.2023

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Morbidity and Mortality report WITH Dr. Broadstock

Acute Cholecystitis and Gangrenous Cholecystitis

  • 2013 Tokyo guidelines for diagnosis of AC:

    • Suspected diagnosis: 1 local sign of inflammation + 1 systemic sign of inflammation or imaging finding

    • Definitive diagnosis: 1 local sign of inflammation + 1 systemic sign of inflammation and imaging finding

  • Test Characteristics:

    • Ultrasound

      • Sensitivity: 86%

      • Specificity: 71%

    • CT

      • Sensitivity: 92-94%

      • Specificity: 51-79%

    • HIDA Scan

      • Sensitivity: 96%

      • Specificity: 90%

    • MRI

      • Sensitivity: 85%

      • Specificity: 81%

Influenza Myocarditis

  • In the year 2019, influenza data

    • 30M cases

    • 390k hospitalizations

    • 25k deaths

  • Influenza Myocarditis

    • Incidence 0.00002% (184 total cases published in the literature)

    • Mean age 33 +/- 17 years

    • Mean LVEF 29% +/- 14%

    • 35% mortality

    • 83% require mechanical support

    • Steroids, PLEX, IVIG may be beneficial

    • Patients should avoid exercise for 6 months to avoid arrhythmia

Corticosteroid-Induced Hyperglycemia

  • Renal glucose threshold: serum concentration of glucose at which the SGLT2 transporter is saturated at which point glycosuria occurs (increasing risk of UTI), occurs at 170-200 mg/dL

  • Driver et al noted that glucose at discharge conferred no difference in risk of ED revisit or hospitalization 

  • Administration of insulin carried 2-7% risk of iatrogenic hypoglycemia

  • Talk to patients about their understanding of management, ability to measure and treat hyperglycemia at home (most home glucometers upper threshold of detection is 500 mg/dL), and ability to follow-up as an outpatient

Listeria Rhombencephalitis

  • Listeria is a bacteria that breaks down plant matter, and is a known contaminant of food products such as dairy, raw meats, raw fruits and vegetables, ice cream, and smoked fish

  • Listeria meningitis typically affects the extremes of age, but listeria rhombencephalitis can affect patients of all ages

  • 5 to 15 day prodrome may be related to ascent from GI source via the vagus nerve, and predominantly causes clinical manifestations with cranial nerve palsies 

  • Workup should include MRI with contrast, blood cultures, CSF culture, and PCR

    • If blood cx positive but CSF negative, repeat LP should be considered 

  • Treatment is ampicillin and gentamicin, and providers should have a low threshold for empiric coverage 

Sepsis Induced Cardiomyopathy

  • Decreased SVR may impact visual estimation of LVEF

  • This is because the afterload reduction secondary to vasoplegia and capillary leak may cause a depressed LVEF to appear pseudonormal 

  • Anchoring Bias: consider running your list to try and frame things differently and consider alternate diagnoses, especially when confronted with a new conflicting piece of information

Massive Pulmonary Embolism

  • Right heart strain may not be apparent on CT given that this is a static image, consider early echo

  • These patients can decompensate very quickly

  • Consider PERT / interventional consult early, and thrombolysis can be utilized in the event of cardiac arrest 

 LAw Enforcement in the ED WITH Dr. Crawford

  • We see a lot of patients who are escorted or accompanied by law enforcement including:  crime suspects, arrestees, victims of crimes, individuals requiring medical clearance before jail admission, and inmates requiring treatment outside of correctional health facilities. 

  • Clinicians And Police Have Intersecting But Potentially Conflicting Responsibilities

  • We have a duty to protect patient privacy

  • Harada MY, Lara-Millán A, Chalwell LE. Policed Patients: How the Presence of Law Enforcement in the Emergency Department Impacts Medical Care. Ann Emerg Med. 2021 Dec;78(6):738-748. doi: 10.1016/j.annemergmed.2021.04.039. Epub 2021 Jul 29. PMID: 34332806.

    • Qualitative Study at 3 county EDs in Northern CA affiliated with residency programs

      • Large, urban, public hospitals, largely serve patients who are publicly insured or uninsured 

      • 20 EM physicians (BCEM or residents)

    • Positives surveyed experiences

      • Law enforcement could provide helpful health information 

      • Feeling of safety

      • Seeing Law enforcement as “part of the team”

    • Negative surveyed experiences

      • Interruptions by police during trauma evaluations 

      • Concerns for patient privacy and confidentiality 

      • Diminished patient trust 

      • Lack of training,  knowledge, policy 

      • The provider feeling intimidated by law enforcement 

      • Personal risk of confronting law enforcement 

  • HIPAA

    • HIPAA prohibits clinicians from releasing information about patients to the police with some narrow and defined exceptions by state and federal law 

    • A patient’s name, address and date of birth as well as many other qualifiers are considered PHI and are protected by HIPAA

    • Exceptions to HIPAA

      • Patient gives permission for release of PHI

      • Certain court orders

      • Avert Harm - large public health threat

      • Required by Law - child or adult abuse or neglect, injuries from gunshots or criminal activity

      • Identify a Person (suspect, fugitive, missing persons)

      • Victim of a Crime (necessary to determine whether someone other than the victim has committed a crime)

      • Prisoners - can disclose PHI if needed to care for patient while in custody 

  • Considerations prior to disclosure

    • Verify the identity and authority of person prior to disclosing information

    • Give minimum amount of information necessary  (office can help guide what information is needed for their lawful purpose)

    • If the situation does not fit within one of the exceptions allowing disclosures, the provider should explain the limits to the law enforcement official

    • Don’t lie, misrepresent or physically interfere 

    • Document the name and badge number of the person receiving information

  • Specific UC Health Policy (Policy# UCH-HIPAA-021-06)

    • The ability to disclose PHI to a law enforcement agent depends on the circumstances of the situation and the reason for the request

    • HIPAA permits disclosure of PHI without the authorization of a patient when federal or state law requires it

    • Limit the disclosure to the minimum amount necessary 

  • Police Access to Patients

    • In some cases, law enforcement presence may be necessary to facilitate treatment of a patient or protect health care providers

    • If a patient is under arrest, or if a search warrant or court order has been issued for law enforcement officers to be present, law enforcement officers may be entitled to be present in treatment areas 

  • Patients in custody or under arrest can always refuse care

    • Informed consent should always be obtained from the patient 

    • Law enforcement agencies should not be treated as a patient’s surrogate medical decision maker

  • Police Presence

    • HIPAA requires that providers implement appropriate safeguards to protect against unauthorized disclosure of confidential information; allowing unrestricted access may result in improper disclosures, therefore, health care providers should not allow general access to health care areas 

    • If a patient is not under custody, there is generally no reason for police to remain near patient

    • Like anyone walking on the street, patients who are not in custody can always refuse to speak with the police, and patients who are in custody can exercise their constitutional right to remain silent

  • Police Request for a Test

    • Patients generally have the right to consent or refuse health care

    • A court may order that an individual undergo certain tests or procedures to obtain evidence

    • The provider should comply with any court order unless doing so would jeopardize the patient, the provider, or others. In this situation, it is prudent to involve the legal team

    • Blood Alcohol Testing (UC Policy# UCH-HIPAA-021-06)

      • The officer must obtain consent to draw blood

      • The patient must agree to the test and consent must be signed by the requesting officer and the witness

      • Patients can refuse the blood draw

        • Implied consent for anyone is who dead or unconscious  

      • Emergency personnel should provide necessary medical treatment prior to any request from law enforcement

      • The ED will draw a blood sample for alcohol/chemical testing at the request of a law enforcement officer

      • The blood test must be related to a lawful arrest with probable cause that a crime was committed while the patient was under the influence of alcohol or intoxicated

      • The requesting officer must provide the blood tubes and witness the collection of the specimen

  • What can we do?

    • Officer near the patient:

      • “Please move away from the patient’s room. To protect patient privacy, we ask that all nonmedical staff standout of earshot from a patient’s room while we evaluate the patient. You may maintain a line of sight since this patient is in custody, but we cannot permit you to overhear sensitive private health information. Thank you for understanding.” 

    • Inquiring about specific information:

      • “Patient X has not consented to disclosing their protected health information. If you do not have a warrant for the information you are asking for, we can not share any information about this patient. If you have a subpoena or search warrant for this information, you can submit it to our hospital legal department or medical records department. Thank you.” 

    • Officer reports that they have a warrant for information:

      • “I understand you have a warrant to search this patient, access their health information, or take their property. As an ED medical provider, I am not authorized to review your claim on my patient’s behalf. I will refer you to someone who is authorized and equipped to review your claim. You will need to speak with: [my supervisor], or [the hospital legal department], or [the hospital department of medical records]” 

  • Frontline healthcare workers are rarely equipped to analyze the HIPAA implications of any given request for information or the legality of judicial warrants or court orders. 

Brainstem Stroke Syndromes WITH dr. arnold

Brainstem

  • Midbrain, pons, medulla

  • Function:

    • Influences level of consciousness, motor coordination, sleep-wake cycle, autonomic nervous system

  • Anatomy

    • Tracts communicating with the brain and spinal cords travel through the brainstem

    • CN exit the brain at the brainstem

      • 3-4 at midbrain

      • 5-8 at pons

      • 9-12 at medulla

  • Medial Tract

    • Medial Lemniscus

      • Proprioception, vibration, fine touch

      • Crosses in the caudal medulla 

    • Corticospinal tract

      • Motor

      • Crosses at junction of the spinal cord in brainstem 

    • Medial Tract = present with contralateral motor and vibration/propioception

  • Lateral tract

    • Spinothalamic tract

      • Contralateral Pain, temperature, crude touch, pressure

    • Cerebellar peduncle fibers/spinocerebellar tract

      • Ipsilateral information for proprioception and balance

    • Lateral Tract = present with ipsilater alataxia, ipsilateral horner's syndrome, contralateral pain/temperature

  • Stroke Syndromes:

    • Foville’s Syndrome (Anteromedial Pons)

      • Ipsilateral facial weakness (CN VII nucleus)

      • Ipsilateral lateral rectus palsy (CN VI nucleus)

      • Contralateral hemiparesis (corticospinal tract)

      • Contralateral loss of positional/vibrational sensation (medial lemniscus)

    • Marie-Foiux Syndrome (Anterolateral Pons)

      • Ipsilateral facial weakness (CN VII nucleus)

      • Ipsilateral loss of facial sensation (CN V nucleus)

      • Nystagmus, vertigo, ipsilateral hearing loss (CN VIII nucleus)

      • Ipsilateral Horner syndrome (sympathetic nerve fibers)

      • Ipsilateral ataxia (inferior cerebellar peduncle)

      • Contralateral loss of pain/temperature sensation (spinothalamic tract)

    • Locked-in Syndrome (Bilateral Ventral Pons)

      • Anarthria (corticobulbar tracts supplying CN V-XII)

      • Preservation of vertical eye movement (CN III)

      • Quadriplegia (corticospinal tracts)

    • Dejerine Syndrome (Medial Medulla)

      • Ipsilateral tongue weakness (CN XII nucleus)

      • Contralateral hemiparesis (corticospinal tract)

      • Contralateral loss of positional/vibration sensation (medial lemniscus)

    • Wallenberg Syndrome (Lateral Medulla)

      • Ipsilateral loss of facial temperature/pain sensation (CN V fibers)

      • Dysphagia, dysarthria, hoarseness (CN IX, X fibers)

      • Ipsilateral Horner syndrome (sympathetic nerve fibers)

      • Ipsilateral ataxia (inferior cerebellar peduncle)

      • Contralateral loss of pain/temperature sensation (spinothalamic tract)

  • Diagnostics

    • CT

      • Identifies hemorrhage

      • Negative (for ischemic changes) early in the course

    • CT Angiography

      • Locates large vascular occlusion

    • CT Perfusion Study

    • DW MRI

      • Identifies area of ischemia, penumbra, core infarct

      • High false negative rate for DW MRI in posterior circulation stroke in first 24 hours

        • 31% versus 2% outside of 24h

  • Management

    • Same time window, indications, contraindications as for anterior circulation ischemic strokes

      • No worsened outcomes, similar benefits

    • Posterior circulation strokes more likely to be outside window for thrombolysis

    • Sparse research on thrombectomy, especially for brainstem strokes specifically

  • Summary

    • Be on the lookout for “crossed” CN deficits

    • Neuroanatomy is your friend

      • CN symptoms → level of brainstem

      • Motor, vibration/positional sensation deficits → medial brainstem

      • Pain/temperature, coordination deficits → lateral brainstem

    • High false-negative rate for MRI with posterior circulation strokes

Air Care Grand Rounds WITH Drs. Goff, Winslow and Anthony Braun, RN

HEMS/Air Care Quality

  • GAMUT (Ground & Air Medical Quality in Transport) collects data

    • 350+ transport programs across the world

  • Measured variables

    • Medication errors, equipment failures, scene times, time to mobilization, pain reassessment, blood glucose checks for AMS, vent use, waveform capnography, DASHH-1A, verification of trach tube placements, RSI protocol compliance

  • Measured success

    • Mean mobilization time for all unscheduled transports

      • < 17 minutes

      • Comparison group 30-40 minutes

    • Bedside time for STEMI activations

      • ~ 9 minutes

        • Decreased in half from QI project in the mid-2000’s

      • Comparison group ~12 minutes

    • Pain assessments 98-100%

    • Management of hemorrhagic shock 100%

      • Comparison group ~93%

    • Treatment of pre-eclampsia 100%

      • Comparison group ~87%

  • Areas of Improvement

    • Blood glucose checks for AMS (GCS < 15 or focal deficits)

    • Blood pressure management for hemorrhagic stroke

    • Intracranial hemorrhage with SBP > 160 requires antihypertensives

      • Bring SBP < 160 or down 20%

    • Percent of intubated patients with documented confirmed ETT placement

      • Document direct visualization, equal breath sounds bilaterally, waveform capnography

    • RSI protocol compliance

      • Bougie first, ap-ox, end tidal (turn on after connecting to zoll)

    • DASHH-1A

      • ACMC monitors before RSI

      • If sats < 97%: BVM instead of NRB, increase PEEP, jaw thrust, two person bagging, DSI

      • Jaw thrust and good mask seal, bag during induction

      • Push dose pressors if SBP < 100, even in trauma after blood resuscitation 

      • Roc 1.5 mg/kg if you decide to use over succinylcholine

      • Intubation procedure note

        • On EMSCharts: Human resources, document warehouse, reference documentation, intubation procedure template; paste into page 8 (activity log)

Hamilton T1 Ventilator Cases 

  • Please spend time on shift becoming fluent in the operation of this excellent device! 

  • Record the “vital signs of the ventilator” in your documentation (EMScharts) which can be found on the left of the home screen or under the monitoring tab to describe the outputs (i.e. minute ventilation, peak inspiratory pressure, etc.) of your input settings (i.e. tidal volume, RR, PEEP). 

Ventilated patient without respiratory failure (isolated head trauma with healthy lungs or similar) 

  • Startup mode is APVcmv which is reasonable for this type of patient 

  • Only required inputs to begin case are gender and height in inches to determine ideal body weight for tidal volume calculations  

  • Note that Air Care Hamilton Ventilators default to 6 mL/kg IBW (the ventilator during grand rounds from respiratory therapy defaulted to 8 mL/kg) 

  • Please reference one of our many pocket or online resources to determine appropriate tidal volumes based upon ideal body weight – it is reasonable to utilize higher tidal volumes in a “healthy lung” case to achieve minute ventilation goals and manage other conditions such as respiratory compensation for a metabolic acidosis or targeted hyperventilation (EtCO2 30-35) in a patient with clinical evidence of brain herniation. 

Hypercarbic respiratory failure (Ventilatory failure) 

  • The general goal is to manage this condition with increased minute ventilation 

  • Recall that PEEP / CPAP is for oxygenation while BiPAP is for ventilation 

  • If patient has appropriate mental status and work of breathing, then begin with noninvasive BiPAP – set the PEEP / EPAP + pressure support (Pdelta) to achieve PIP / IPAP.  

  • May continue inhaled therapies including albuterol via Aerogen for both invasive and noninvasive ventilation 

  • If intubated titrate RR and tidal volumes to achieve minute ventilation goals while remaining mindful of risks including breath stacking and high peak pressures 

Hypoxic respiratory failure – ARDS 

  • Manage hypoxia with FiO2 and PEEP for driving pressure 

  • If mental status and work of breathing allow may consider noninvasive high flow nasal cannula; Hamilton ventilator inputs include FiO2 and Lpm (adults start 20-30 Lpm; peds 2 L/kg / min) 

  • Must humidify HFNC via Aeorgen! 

  • If intubated with hypoxic respiratory failure and ARDS then utilize low tidal volume / lung protective ventilation strategies with higher PEEP matched to FiO2 

  • If receiving facility can continue the therapy, consider initiation of Veletri via Aerogen for refractory hypoxia in ARDS 

Intubated Asthma 

  • Ventilatory failure due to obstruction 

  • Adjust I-time (<1.0) and RR to achieve I:E of 1:4 / 1:5 

  • Continue inhaled therapies via Aerogen 

CO poisoning 

  • Hypoxic respiratory failure  

  • Manage with FiO2 1.0 and PEEP to maximize PaO2 and displace CO from hemoglobin  

  • CPAP highly effective if mental status / clinical condition allows 

  • OSU has the only dive chamber available for emergency use in Ohio