Grand Rounds Recap 01.27.2021
/
morbiditiy and mortality WITH Dr. Hughes
Case 1 - Hypothermia
Hypothermic arrest: AHA vs ESC guidelines
Defibrillation:
AHA - May be reasonable to do more defibrillation
ESC - May be reasonable to do up to 3
Epinephrine dosing:
AHA - Double dosing intervals until normothermic
ESC - Hold until body temp is greater than 30C
VA-Ecmo - Gold Standard since the early 2000s
K typically determines who should get VA-ECMO
Asphyxia with the hypothermia has poor outcomes and is an immediate contra-indications
Clinicians who are not familiar with hypothermic arrest may underestimate the potential for their patient’s survival
ICE Score; weighted risk stratification tool, factors with favorable outcome
Factors used: asphyxiation, lower K, Female gender, rewarming rate (excluded from final score)
Used all case reports for VA-ECMO
Factors not associated: age, initial core temp, pH, cardiac rhythm, duration of CPR
HOPE Score - 286 patients with excluded case reports
Primary outcome: survival to hospital d/c
AUC: 0.895 vs 0.774 based on K alone
False positive rate dropped from 58% to 31%
Less people putting on ECMO that wouldn’t survive
Core temp 14-32C, Foley temp probe, no more than 3 rounds of epi/defib
Asystole is not an exclusion for ECMO in hypothermia
Case 2 - New Onset Diabetes and Visual changes
New Onset Diabetes
7.3M undiagnosed adults with diabetes in US
Diagnosed in the ED: If >200 glucose plus typical symptoms
Visual acuity in patients with DM could be indicator of inadequate metabolic control or even the first sign of DM
DM Retinopathy: vascular endothelial dysfunction
Most frequent complication of DM
Leading cause of blindness in the US
Independent associate: male, long duration of DM, insulin use
Hyperglycemia and refractive error
Fluid shifts cause lens shape to change causing refractive error
Myopia or hyperopia symptoms
Case 3 -Empiric Antibiotic Selection
Empiric antibiotic selection
Need to know the local antibiogram for different infectious processes
Look at previous culture data for a patient
Does previous culture impact future susceptibilities?
92% specificity for predicting future antibiotic resistance
Still 1 in 5 providers ordered antibiotics that were resistant
Case 4 - Protocols and TIA
Observation TIA protocol requires a non-con CT given chance of mass, bleed, etc with subtle residual symptoms
TIA guidelines do state that if symptoms completely resolve then you can skip the non-con CT
Barriers to protocol utilization:
Guideline related factors: too complex, access, applicability, focus on a single disease
Personal factors: knowledge and awareness
Attitudes: agreement, motivation, outcome expectancy
External factors: organizational constraints, lack of resources, collaboration, social and clinical norms
GFR for CTA: does CKD increase risk of developing an AKI compared to normal kidney function in patients getting empiric emergent CTA
No increase in AKI
CT vs MRI:
MRI is better due to increased sensitivity for lack of ionizing radiation
CT is lower cost and more rapid to obtain
MRA still has increased risk of AKI due to contrast use in selected studies
CTA is slightly superior for distal vascular imaging - better if considering endovascular therapy
MRA is preferred for TIA patients (aka - no symptoms)
Case 5 - Extreme Leukocytosis
Leukocytosis
Does extreme leukocytosis (>25) have prognostic significance compared to moderate leukocytosis (12-25)
Infectious etiology: 74% vs 48%
Hospitalized: 100% vs 0%
Death: 32% vs 12%
Prolonged hospital course: 7.5d vs 4d
Blood Cultures: Shapiro prediction rule- designed to decrease unnecessary blood cultures
1 Major or 2 or more minor criteria
Major: Suspect Endocarditis, Temp >39.4C, Indwelling vascular catheter
Minor: 38.3-39.3C, Age >65, Chills, vomiting, hypotension, WBC >18, Bands >5%, Platelets <150K, Creatinine >2
97% sensitivity vs 29% specificity
Clinical gestalt may outperform
Case 6 - AKI Etiology
BUN:Cr ratio for AKI
Classically taught:
>20:1 ratio is prerenal
<10:1 ratio is ATN
BUN is reabsorbed in the proximal tubule in a prerenal state and thus will increase the ratio
In ED patients: AOC is 0.5 for an elevated BUN:Cr ratio if this helps determine prerenal etiology
Urine Chemistry:
Urine sodium: low in Prerenal and high in intrinsic
Spec Grav: high in prerenal and low in intrinsic
No single test will help determine prerenal vs intrinsic
History will outperform the tests in these patients
Scleroderma Renal Crisis
20% of patients with diffuse scleroderma will have a renal crisis
Highest mortality associated with diffuse scleroderma
Abrupt onset of severe HTN leading to:
Renal failure, hypertensive encephalopathy, heart failure, MAHA
Activates the RAAS system
No diuretics or other ACE activators
ACE inhibitors are the treatment, esp captopril
High level of care is warranted
Case 7 - Lactate and Diagnostic Error
Profound lactic acidosis
Increased glycolysis: lactate is an end product
Increased catecholamines cause this too
Decreased pyruvate processing, thiamine is an important cofactor
Thiamine deficiency will elevate lactate
Chronic EtOH use will have high lactate
Electron transport chain disruption will cause elevated lactate as well
Type A: tissue hypoxia
Seizure, shock, mesenteric ischemia, anemia/CO
Type B: no tissue hypoxia
B1: Hepatic or renal failure, mostly cleared in the liver
B2: Toxins and drugs
B3: Inborn errors of metabolism
*in profound lactic acidosis be concerned about liver failure as it is where most is cleared
Diagnostic Error - a study looking a reasons for delayed diagnosis:
Process errors: Failure to order diagnostic (58%) - but this is never done in isolation
Contributing factors: Supervision, handoffs, workload
People: >1 clinician (66%)
Ethics of limited resource allocation - possible methods:
Likelihood of benefit: which patient is likely to survive
Biased against the elderly
Greatest need: who is acutely more ill
Biased against the young
Amount of resources needed: goal is for the greater number of patients served
Persons performing vital functions
Biased against essential workers forgotten (grocery store workers)
Random allocation: fair distribution by random chance
r4 capstone WITH dr. shaw
What the TV show Scrubs taught me about medicine
It has stood the test of time, from high school to residency
The nurse-doctor relationship is very complicated
Nursing serves as a safety net
Residents can become a threat to authority over time
Most of the literature is from the nursing field looking at how we interact
Nurses often think the relationship is less collaborative than the docs do
Nurses think its less communicative than the docs do
The hospital is a dangerous place
Overdiagnosis can lead to over treatment which creates a vicious circle
Bringing someone into the hospital is not without risk
Empathy can be hard to find
As soon as we are indoctrinated into the medical culture our empathy goes down
Every year our empathy drops and we degrade each others empathy over time
Though some studies suggest:
Medical trained people have increased empathy over time
When you hear hoofbeats…
Consider the zebras, don’t forget about them
Doing nothing can be the pinnacle of medical care
The Zentensivist Manifesto - using clinical minimalism in the ICU
Risk tolerance: biggest disconnect between ICU and ED
Not as much observation in the ED
Low risk syncope and chest pain - tolerate some risk and d/c them
Calming presence: in an intense resuscitation be a duck
Duck: churn the water underneath but calmness above the water
Pragmatic practice - minimize testing that will not change the plan
Abiding abnormality - don’t rush to rate control afib w/ RVR
Treating lightly but swiftly - be decisive when the situation calls for it
“The delivery of good medical care is do as much nothing as possible”
The House of God
You need others to succeed
Faculty and co-residents to help you get through the day
Mentors to help get you through residency
R1 clinical diagnosis: Nausea and Vomiting in Pregnancy WITH drs. Ferreri and mand
Check out Dr. Ferreri’s full post here
In summary “there is a lack of high-quality evidence to support any particular intervention”
Epidemiology:
Nausea is in 80% of pregnancies
50% will report vomiting or retching
1% will have hyperemesis gravidarum
Severity of illness:
Motherisk: Pregnancy-Unique Quantification of Emesis and Nausea (PUQE)
Can help us decide how bad her emesis is
Hyperemesis: persistent vomiting unrelated to underlying pathology
Measures of starvation:
Ketonuria
Weight loss of 5% of pre-pregnancy weight
Pathophysiology:
Human Chorionic Gonadotropin: this may make people more susceptible and may respond more robustly to this
Estrogen: In a cohort study of smokers, they had less estrogen and less nausea
Evolutionary adaptation: certain foods may prevent badness
Psychological predisposition - not seen in any studies
Risk Factors: especially in a multiparous patient
Why should we care?
There have been cases of Wernike’s and central pontine myolysis
Fetus may have smaller birth weight or prematurity
Treatment and Pharmacology
What are some dietary recs?
Avoid triggers that cause nausea or vomiting
Small frequent meals
Approach to evaluation?
UA and BMP to eval for AKI and ketones
Rehydration and electrolyte repletion
Increased risk of Wernicke's encephalopathy
Consider giving thiamine before any dextrose containing fluids
Pyridoxine: Vitamin B6, water soluble
MOA is unknown
Dose is 10-25mg po q6-8 hours
RCT in 1991: significant decrease in nausea and vomiting in the pyridoxine group
RCT from Thailand in <17 wks: significant decrease in nausea, no difference in vomiting
Safety: Study evaluated greater than usual doses and congenital malformations
No significant difference
Pyridoxine and Doxylamine: first generation antihistamine
MOA: Acts at the tuberomammillary nucleus, causes drowsiness
1 tablet = 10mg of doxylamine, can do on in the am and pm and up it to 2 in pm
RCT in 7-14 wks: improved nausea control
Safety:
Bendectin - pulled off the market due to association of birth defects
Meta-analysis: pooled risk of birth defects: 0.95 with CI of 0.88-1.04
After pulling Bendectin
Estimated to cost the US $73 million in costs due to increased admissions
Ondansetron:
MOA: Antagonist of 5-HT3 receptor - peripherally and centrally
RCT in <16wks:
Ondansetron vs B6/doxylamine: improvement in nausea/vomiting w/ ondansetron
Safety: may be an association at <10 weeks with VSDs and cleft palates
Meta-analysis: pooled OR, increased risk of VSD and cleft palate
Metoclopramide:
MOA: Dopamine antagonist
Dosing: 5-10mg q6-8 hours IV/IM/po
Ondansetron vs metoclopramide <16 wks: no difference in nausea, improve vomiting ondansetron
IV Ondansetron vs metoclopramide: no difference in n/v, worse side-effects in metoclopramide
Safety:
2 large cohort studies: JAMA and NEJM:
No difference in metoclopramide use in findings of congenital malformations or fetal death
Promethazine: compared to metoclopramide=increased dystonia and request to d/c use
Steroids:
RCT: prednisolone vs placebo in patients admitted: no statistically significant difference
Systematic review: 3 RCTs comparing steroids to other therapeutics
Trend towards improvement compared to the other groups (placebo, ondansetron, metoclopramide)
Safety: multiple studies suggesting an oral cleft if <10weeks
Risk Factors for complications: DM, poorly controlled HTN, CHF, infection, osteoporosis
Other:
Droperidol:
Droperidol and diphenhydramine - cohort study: shorter hospital stays and less re-hospitalization
No study on safety
Chlorpromazine: in refractory cases if there is a steroid contraindication, associated with worse maternal side-effects
Dimenhydrinate: ACOG recognizes this as a second line
r3 small groups WITH drs. connelly, Frederick, Leech, and Roblee
Visual Diagnosis with Dr. Leech
Herpes Zoster Ophthalmicus:
Treatment with Acyclovir and topical steroids to reduce inflammation
Oral antivirals w/i 72 hours of onset: 800mg 5x for 7 days
If iritis: can use cycloplegics
ANUG: acute onset of terrible breath, severe oral pain, blunting of interdental papilla, necrotic sloughing
Chlorhexidine oral rinses
Antibiotics: Augmentin + Metronidazole
Referral to dental for debridement
Topical anesthetics and analgesics
Geographic Tongue: benign migratory glossitis - local loss of filiform papillae
Polycyclic borders, looks like a map
Usually in atopic individuals
May only have mild discomfort or sensitivity to some foods
Lis Franc Fracture: injury of the foot in which one or more metatarsal bones are displaced
Management: reduction and ortho consult: can be non-op if very minimal displacement
Neonatal gonococcal conjunctivitis: can result in blindness
Rule of 5’s:
0-5d: gonococcus -IV ceftriaxone
5d-5wk: chlamydia po erythromycin
5wk-5yr: staph, strep
CRAO: sudden painless monocular vision loss
Cherry red spot: retinal edema leading to the fovea becoming red due to lack of edema
Management: 90-100min: can save the retina
No increase benefit with tPA vs intra arterial injection vs conservative management
Ocular massage
IOP reduction per ophthalmology
Lens dislocation: usually caused by trauma, can even be trivial
Surgery is required if anterior dislocation results in papillary block and acute angle closure glaucoma
Acute mastoiditis: kid with a history of ear infection
Protruding ear and tender on the mastoid bone
Rx: if uncomplicated - ENT involvement and IV Abx
If suspected intracranial complications: imaging is necessary with IV Abx
Diphtheria:
Clinical diagnosis - white/gray pseudomembrane, fever, sore throat, pain w/ swallowing
Treatment: prompt erythromycin or PCN (will prevent exotoxin spread)
Admit for airway watch
Testicular torsion: severe acute testicular pain
High riding testicle, absent cremasteric reflex
Get urology involved
Fournier’s Gangrene: early finding is pain out of proportion on exam
SJS: begins w/ nonspecific prodrome and then rash appears 1-3 days later
Bullae are Nikolsky +
Most commonly implicated medications: allopurinol, AEDs, sulfa
Watch for sepsis, ARDS, GI Hemorrhage
Rx: stop the offending agent
Erythema multiforme: target like lesions, separated into minor and major (mucosal involvement)
Will not progress to TEN
Rx: topical steroids, viscous lidocaine
Contact dermatitis: previously sensitized skin exposed to an allergen
Delayed type hypersensitivity reaction
Pruritus is a dominant feature
Can give a topical steroids however, limited involvement
If poison ivy on the face/genitals: need long dose and high potency steroids
Admit, Discharge, Transfer with Drs. Frederick and Connelly
Boxer’s Fracture: 10-20-30-40 rule for angulation (index, long, ring, pinky)
No malrotation is acceptable - if fingers cross with a fist, then needs OR
Look for fight bite - will need abx
Corneal/scleral laceration: full thickness is an open globe
Iris may herniate into the defect - cause pupil shape change
Needs operative repair
IV Abx = Fluoroquinolone, put on a shield, give antiemetics
Flexor tenosynovitis: tenderness along tendon sheath
Symmetric/fusiform swelling, finger held in flexion, pain w/ passive extension
Poorly specific but highly sensitive
Rx: IV abx plus monitoring, but likely needs OR
Ranula: disruption of the submandibular gland, causes a bluish bump from all the mucus
If there are external changes - talk to ENT for possible admission
If just in the mouth - they can spontaneously resolve - can f/u with ENT as outpatient
High Pressure Injury to the hand: typically in men on the non dominant hand
30% amputation rate, need to be in the OR within 10 hours
Paint is the worst case scenario, the body reacts poorly to it
Button Battery in the ear: ingested or nasal are worse than the ear
Can damage the ear canal,TM, cause hearing impairment and damage the facial nerve
Our ENT trusts us to remove it, but they want to see them either in the morning with tight follow-up or transfer for evaluation
Dry socket: 2-4 days after recent extraction
Risk Factors: smoking, straw use, sneezing, coughing, exercise
Most common in mandibular sites
Rx: dental block, soak gauze in clove oil and put into the socket, send to dentist
Jeopardy w/ Dr. Roblee
30% of posterior SC joint dislocations are life-threatening
Tracheal injury, great vessel lac, esoph compression, brachial plexopathy, PTX
Captain Morgan Hip Reduction: place patient’s knee under your knee on the bed with pelvic counter traction and use your knee as a fulcrum, plantar flex your ankle
12/13 in initial paper had success with this method
Lupus Pernio: violaceous plaques on head/neck/noise. Bx shows granulomatous tissue characteristic of sarcoid
Associated with lung sarcoid and other systemic involvement
Button battery: can give honey and carafate to help neutralize the pH
Lateral Canthotomy: anesthetize, crush, cut through the skin and cut again now through the ligaments
Erythema nodosum: nsaids, potassium iodide, steroids only if it is refractory
Posterior nosebleed - sphenopalatine artery
Acute angle closure glaucoma
Beta blockers
Alpha-2 agonist
Prostaglandins
Muscarinic agonist
Carbonic anhydrase inhibitors - acetazolamide
Mannitol-for very refractory cases
