Grand Rounds Recap 1.30.19
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January Morbidity and Mortality WITH DR. SHAW
Case 1: Medication Errors
Why Should We Care:
Occurs 1.5 million times annually leading to $3.5 billion in cost (Leape et al)
Causes of Error:
Occur during all stages of medication delivery
Prescription Stage (provider orders)
Transcription Stage (pharmacy interprets order)
Dispensing Stage (pharmacy delivers medication)
Administration Stage (medication is given)
Monitoring Stage (post-administration)
Prescription and Administration stages are most common time for medication errors
Prevention:
Prescription Stage: look at medication alerts through the EMR (although alert fatigue is real and is a challenge to this), use quick-lists in EMR that already have proper doses pre-populated
Administration Stage: standardize the administration process (closed-loop communication, barcode scanning)
Case 2: Wake-Up Strokes
DWI v Flair Mismatch
Flair often lags behind DWI for acute stroke findings
May indicate a time where patients may benefit from intervention
Looked at patients who were >4.5h from last known normal time and had DWI/Flair mismatch
Randomized these patients into tPA vs no tPA
Found improved functional outcomes (mRS of 0 or 1) in tPA group
This would suggest that if a patient is a wake-up stroke and is >4.5h from LKN and does not have a LVO (would get neuro-intervention) but does have a DWI/Flair mismatch; you can consider tPA in these patients. Admittedly this is a single, but well done trial.
Case 3: Toxic Alcohols
Isopropyl Alcohol
Presents with significant intoxication and GI effects
Metabolizes to acetone and so does not cause anion gap (but does cause osmolar gap)
Treatment: supportive care
Ethylene Glycol
Metabolizes to glycolic acid and then oxalic acid; oxalic acid can precipitate calcium oxalate crystals in renal tubules
Has an elevated osmolar gap which then becomes an anion gap as it is metabolized
Treat with fomepizole to prevent metabolism, can consider dialysis
Thiamine, Magnesium, and Vitamin B6 can also be considered to decrease toxic metabolite formation
Methanol
Metabolizes to formic acid. This disrupts oxidative phosphorylation, especially in retinal and optic nerve cells leading to blindness
Has an elevated osmolar gap which then becomes an anion gap as it is metabolized
Treat with fomepizole to prevent metabolism, can consider dialysis. Sodium bicarbonate may help to reduce vision loss.
Folate can be considered as it may help formic acid metabolism
See this article for a more in depth review
Case 4: Emergency Care of the Psychiatric Patient
Medical Clearance:
ACEP guidelines state that no labs are mandatory, but should be guided by presentation
Labs are often not high yield in the absence of specific complaints
Diagnostic Overshadowing
Concept that we take medical complaints and attribute them to their psychiatric complaints (ex: anxiety, drowsiness, tachypnea)
Psychiatric disease is associated with 4-7x mortality rate and 10-25 years lower life expectancy, often due to medical causes
In cardiovascular disease, psychiatric patients receive cardiac catheterization less often despite having the same risk of disease (Druss et al)
Risk of PE in antipsychotics
OR of VTE in patients on antipsychotics is 2.39 (Zhang et al) compared to general population
Case 5: Strangulation and Hanging Injuries
Pathophysiology
Damage primarily comes from compression of venous system leading to cerebral anoxia
Pulmonary edema thought to be due to laryngeal obstruction, although could be neurogenic as well
Imaging
Literature is overall fairly poor
Image when GCS < 15, presence of focal neurologic signs, abnormal vitals, external signs of trauma
Disposition:
Literature again is poor
Consider 24h observation if there is loss of consciousness, petechiae of conjunctiva or face/neck, near hanging injuries, intoxication
Ultrasound QA WITH DR. Stolz
How to document findings outside of credentials?
Risk management recommends to document the findings in the chart, even if the practitioner is not “certified.”
Study of lawsuits involving ultrasound: 5 total cases. 4 involved failure to perform the ultrasound. The one case involving an ultrasound that was performed was a case of a missed DVT in a radiology performed ultrasound.
Recommend to document that you did the ultrasound looking for x, but incidentally found y. Because of this incidental finding, we did z. Caveat is that you should never intentionally do an ultrasound that you are not credentialed for.
Knee Arthrocentesis:
Image suprapatellar bursa (communicates with joint space). Use linear probe in longitudinal view to visualize quadriceps tendon, patella, and bursa space with femur underlying it. This can help visualize the bursa and if there is an effusion.
Can perform arthrocentesis by visualizing needle entering this space in an in-plane approach. (get a post or article of this technique)
Ultrasound guided knee arthrocentesis associated with decreased pain, increased patient satisfaction, more fluid obtained, improved success, and no difference in procedural duration (Wiler et al, Wu et al).
See this article for further description of the procedure with pictures.
Early Pregnancy Ultrasound:
Optimize image technique in the cases of a gestational sac without a yolk sac
Make sure the depth is appropriate
Move focal zone to where the target structure is
Adjust gain at different depths to optimize image quality
Empty bladder with transvaginal scans, full bladder with transabdominal scans
Motivation WITH DR. Murphy
Motivation is the reasons one has for acting or behaving in a particular way. Early man was motivated for survival. But as societies became more complex, rewards and punishments were used to motivate people. This was based on the premise that implementing rewards/punishments improved performance, and that people will respond rationally to these rewards/punishments. However, neither of these premises are always true.
Rewards and punishments work for algorithmic work (work that has a fixed set of procedures that lead to a defined outcome) but can actually be harmful to heuristic work (work in which one must experiment with possibilities to develop a novel solution). This is because there are two types of motivation. Extrinsic motivation involves engaging in behaviors in order to attain contingent outcomes beyond the activity itself (money, rewards, prestige). Intrinsic motivation involves engaging in an activity for its own sake, for the pleasure and satisfaction of the activity.
Those which are primarily motivated extrinsically exhibit what is termed Type X behavior while those that are primarily motivated intrinsically exhibit what is termed Type I behavior. This matters because those who exhibit Type I behavior actually outperform Type X’s in the long term and in general are happier. So how can we foster Type I behavior? We can foster Type I behavior by maximizing autonomy (having direction over your own life), mastery (the desire to continually improve at something that matters), and purpose (the desire to do things of service greater than ourselves).
We are lucky that in medicine we are largely self-directed, intellectually stimulated, and serve a greater purpose. However, it is important to self-reflect to find out what truly motivates you as exhibiting Type I behavior can improve your performance, increase your resilience, and improve your general well-being. We can also improve the engagement of others by fostering their autonomy, mastery, and purpose.
Much of this lecture was taken from Daniel Pink’s book Driven, for further reading check it out here.
Endocarditis WITH DRs. Modi and kircher
Epidemiology:
5-7 cases per 100,000 people; in hospital mortality of 20%
Pathophysiology:
repeat trauma damages endothelium of the valves, this leads to a thrombus. Microbes then seed the thrombus leading to vegetations that can subsequently embolize
Risk factors:
prosthetic valves, diseased heart (cardiomyopathy, valvular disease), IVDU, immunosuppression
Diagnosis:
History: ask about risk factors
Physical: fever (present in 85%), murmur (present in 50%), janeway lesions/osler nodes (present in 5-15%), neuro deficits
Labs: WBC (not sensitive or specific), ESR/CRP (95% sensitive, not specific), blood cultures (2 sets: 90% detection, 3 sets: 98% detection)
Imaging: TTE (61% sensitive, 94% specific), if negative followed by TEE
Duke Criteria: sensitivity of 72%, specificity of 74%
Treatment:
Empiric Antibiotics (vancomycin and ceftriaxone); 4-6 week therapy
Surgery: for refractory CHF, cardiogenic shock due to valvular dysfunction, large vegetations, failure of medical management, fungal endocarditis
Retrograde Urethrogram WITH Dr. Irankunda
The urethra is divided in the anterior and posterior portions, with the anterior urethra being 5 times longer than the posterior portion. Because of this, injuries to the anterior urethra are more common. The female urethra is much shorter and less externally located. Because of this, isolated urethral injuries are uncommon in females.
Mechanisms of Injury:
Anterior Urethra: blunt trauma to perineum, penetrating trauma, penile fractures, urethral foreign body, iatrogenic causes (catheters, endoscopic instrumentation), constriction bands
Posterior Urethra: penetrating injuries, high velocity injuries, iatrogenic
Indications for RUG:
trauma with suspicion for urethral injury (presence of blood at urethral meatus), concern for urethral obstruction/foreign body, suspected urethral fistula
For more information on the RUG see this post, for more information on pelvic trauma see this article.
