Grand Rounds Recap 1.24.24

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Morbidity & Mortality WITH Dr. Yates

Case 1: Stroke and Stroke Mimics

  • Early diagnosis of stroke improves stroke outcomes, where misdiagnosis is associated with an upwards of 4-time higher likelihood of mortality​

  • Missed strokes most often occur with atypical symptoms, in younger aged patients, those with posterior strokes, and those with lower NIH scores​

  • It can be difficult to discern between stroke mimics and the symptoms associated with a stroke, particularly in the setting of seizures 

Case 2: Chest Pain

  • High utilizers are defined as having 4 or more emergency department visits in a year, and make up 25% of all ED visits​

  • High utilizers tend to have more chronic illness are more likely to be admitted, and have a higher likelihood of death​

  • Solutions to management of high utilizers revolve around case management, which has limited but positive evidence for decreasing ED costs, and improving clinical and social outcomes for patients

Case 3: Respiratory Arrest

  • Emergency physicians are more likely to face difficult airways due to the emergent nature of the intubations performed​

  • First pass success is associated with decreased adverse events of intubation​

  • Preparations and backup plans for difficult airways need to be made based on the risk assessed​, both physiologic and anatomic

Case 4: LVAD and Trauma

  • Understanding the different components of an LVAD can help you determine a specific malfunction in the setting of trauma.​

  • Patients with VADs are at higher risk of bleeding due to anticoagulation and antiplatelet use, acquired von Willebrand syndrome, and reduced pulse pressure.​

  • In an acute, life-threatening bleed, anticoagulation reversal requires a risk-benefit discussion, with PCCs favored over FFP, and we should always discuss with the LVAD/heart failure experts if possible given high risk of morbidity and mortality in both scenarios

Case 5 & 6: Headache

  • Bacterial meningitis has a high morbidity and mortality, so there needs to be a high clinical suspicion for patients presenting with a headache and either neck stiffness, fever, or altered mental status.​

  • Physical exam maneuvers have an unreliable and low sensitivity, therefore the only test to rule out meningitis is a lumbar puncture. Only a select group of patients require a CT head prior to LP.​

  • Expeditious treatment with empiric antibiotics and adjunctive medications based on patient risk factors leads to a decreased mortality ​

Case 7: Cardiac Arrest

  • Transesophageal echocardiography is an emerging and likely useful tool in ongoing management, determination of etiology for arrest, and prognostication during cardiac arrests​

  • Transesophageal echocardiography allows for less time between compression on pulse checks compared to the transthoracic method​

  • Training models involving didactics and simulations are effective for obtaining appropriate images for emergency physicians ​

Mini Lit Blitz WITH Drs. Wosiski-Kuhn and Stothers

BP cuff sizing:

  • Using a cuff too large results in lower SBP, using too small results in higher BP 

VTE risk with hormonal contraception and NSAIDS

  • Isolated use + and contraception leads to IRR of 7.2

  • 10 or greater days and high or moderate risk hormonal contraception amplifies risk to IRR of 44.8

Procal with concurrent viral illness in febrile illness

  • Sensitivity dropped but specificity is unchanged

Transfusion threshold for anemia in MI

  • Improved outcome with liberal transfusion protocol 

Nitrate administration in RV MI

  • No statistically significant risk for hypotension, bradycardia, AMS or syncope in patients given nitro in RV MI vs. other MI region

ACORN trial - Cefepime vs. Zosyn

  • No difference in AKI and death between the mortality, even when receiving vancomycin

  • Delirium and coma - statistically significant increase when given cefepime

Post-Rosc Care WITH Dr. Benoit

 Post-ROSC = 2nd Most Critical Patient; Intra-Arrest = 1st most critical patient

Blood Pressure

  • Goal MAP > 65 for adults, can use epi and norepi to maintain this goals after potential fluids administered

Respiratory Rate

  • Do not want to hyperventilate the patients

  • Goal is 10-12 breaths per minute and end tidal of 35-45 (but this may be falsely low in shock)

Pulse Ox

  • Goal is 94-98% and can increase via O2 concentration and PEEP, the goal is not 100% and this may cause harm

Heart Rate

  • Too fast ( > 150 bpm) and too slow (< 50 is bad) and we can use our additional medications like amiodarone/lidocaine for tachycardia and epinephrine, atropine, and pacing for bradycardia

Temperature

  • Unlike trauma, cold is good!

  • Ways to do this in the OOHCA are leaving the patient semi-exposed and ice packs until the artic sun can be used in the ED/ICU

Advanced Airway

  • This is the not the most important step

  • If you are alone in the community, and the BVM/supraglottic device is working, then leave it 

EKG

  • Should not be the first thing you do post-arrest as waiting increases your specificity 

  • If the patient has an initial shockable rhythm, we should be calling the cath lab no matter what the initial EKG shows 

Prognostication

  • The pupils do not indicate an ability for prognostication

  • Should not be done within the first 72 hours

QI/KT: NSTI WITH Drs. Schor and De Castro

  • Necrotizing skin and soft tissue infection (NSTI) is a severe, rapidly progressive bacterial infection characterized by widespread necrosis of the skin and underlying soft tissues

  • Physical exam findings include edema that extends beyond erythema, severe pain out of proportion, crepitus, skin bullae, necrosis, or ecchymosis. 

  • Do not delay diagnostic studies such as imaging if the clinical suspicion is high. Consult a surgical service and start antibiotics (vancomycin, zosyn, clindamycin) promptly.