Grand Rounds Recap 4.5.23
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M&M with Dr. Mullen
Diagnostic Errors
Diagnostic errors are often influenced by cognitive biases
Anchoring bias
Diagnostic momentum
Confirmation bias
Search satisfaction
Cognitive biases are not a reflection of knowledge
Obstructive Nephrolithiasis
Obstructive nephrolithiasis with UTI is a urologic emergency
Management of obstructive nephrolithiasis with UTI includes antibiotics (ceftriaxone or antipseudomonal coverage for patients with sepsis) and most often decompression strategies (i.e. stent, percutaneous nephrostomy) by urology or IR
Hypokalemia
evaluate for EKG changes
assess for underlying cause and factors that may influence ability to replete (i.e. medications)
consider using observation protocol or close outpatient follow-up with repeat lab for minor abnormalities
Transitions of Care
Transitions of care in the emergency department can be challenging and are not without risk of data loss or miscommunication
Reviewing Data at Signout
write your MDM at the time of signout
Use of the imaging report tab (under summary tab in epic) can easily condense imaging reports and make them easier to review
as the oncoming provider, reviewing all results rather than just those that were pending at the time of signout
Handoff checklists can be utilized
5 step process has been developed by ACEP
Record (offgoing provider fills out a paper form to identify key issues and pending tests)
Review (both teams sit at a computer and review the data)
Round (both teams go to the bedside)
Relay to the Team (communicate with nursing and other members of the team)
Receive Feedback (oncoming team completes the aforementioned record to update the outcome and give feedback to the offgoing team)
Signout checklist exists on TamingTheSRU
Status/acuity
Brief HPI
Pending
If/Then
Concerns
Questions
Re-cap
Minimize interruptions
Upper GI Bleed
can decompensate quickly
Specifically, variceal bleeding carries higher risk of morbidity and mortality
Consider a higher level of care for variceal bleeds as well as early consultation with GI for possible endoscopic intervention
PPI may decrease the size of post-endoscopic variceal band ligation ulcers
Prophylactic antibiotics provide mortality benefit (NNT 4) and are continued for 7 days. Ceftriaxone is often used
Octreotide can help by reducing risk of bleeding and blood product requirement, but does not necessarily confer mortality benefit
Ultrasonographic Findings in Cardiac Tamponade
Plethoric IVC is sensitive but not specific
RV collapse during diastole
Mitral inflow variation with respiration (this is the echo equivalent of pulsus paradoxus)
Physiology: there is increased preload during inspiration
Pulse wave doppler shows you these differences across the mitral valve during respiration
>25% variation across the mitral valve is concerning for tamponade
Hypertensive emergency
defined as >/= 180/120 with evidence of end organ dysfunction
ESRD patients are at risk for hypertensive crisis
Management strategies include diuresis, afterload reduction, NIPPV, and dialysis
Indications for emergent dialysis include acidosis, electrolyte derangements, ingestions, volume overload, and uremia
Recognize and expedite care for patients who need emergent dialysis
Atrial fibrillation with rapid ventricular response
Practice patterns vary regarding combination therapy with beta blockers and calcium channel blockers for atrial fibrillation with RVR
No great data on outcomes with this combination
Recognize potential bradycardia and hypotension that can result
R1 Clinical Diagnostics: Hyperthermia with Dr. Vaishnav
Hyperthermia: abnormally high body temperature due to thermoregulatory failure
Severe hyperthermia: temp greater than 40.5C
Fever: abnormally high body temp due to cytokine activation
Differential Diagnosis:
Infectious: sepsis, meningitis, encephalitis, brain abscess, tetanus, malaria
Neurologic: hypothalamic stroke, ICH, status epilepticus
Environmental: heat illness due to high temperature/humidity
Endocrine: thyroid storm, pheochromocytoma, DKA
Oncologic: lymphoma, leukemia
Drug/Toxin: malignant hyperthermia, NMS, serotonin syndrome, withdrawal syndromes (i.e. EtOH), sympathomimetic poisoning, anticholinergic poisoning
Heat load=heat dissipation
Methods of heat dissipation:
Evaporation
Radiation
Convection
Conduction
At high temperatures:
Increase in O2 consumption and metabolic rate
Blood shunted from splanchnic circulation to skin and muscles
MOSF and DIC
Production of heat-shock proteins
Hepatocytes, vascular endothelium, and neural tissue most sensitive
Oxidative phosphorylation uncouples
Risk Factors:
CV disease, DM
Neurologic or psychiatric disorders
Obesity, pregnancy, poor physical condition
Lack of air conditioning, social isolation
Extremes of age, physical disability
Use of recreational drugs (i.e. EtOH, amphetamines, or cocaine)
Prescription drugs (i.e. beta blockers decrease ability to dissipate heat through increase CO, diuretics predispose to dehydration, or anticholinergic agents can affect thermoregulation)
Clinical Presentation:
Temperature elevation, usually 40.5C with CNS dysfunction
Symptoms: weakness, nausea, dizziness
Vital signs: tachycardia, tachypnea, hypotension
Physical Exam: flushing, rales, ecchymosis, petechiae, AMS (agitation, somnolence, coma, seizures), ataxia, oliguria
Workup:
Labs: BMP, CBC, LFTs, INR, PT/OTT, VBG, lactate, CK, PO4, troponin, tox screen, blood cultures
Imaging: CXR, CT Head, consider EKG, LP
Management:
Airway: intubate and mechanically ventilate if unable to protect airway
Breathing: supplemental O2 if needed
Circulation: fluids and vasopressors
Get the patient naked, spray water on them, have fans blowing on moist skin
Ice packs, cooling blankets
Tarp assisted cooling oscillation (TACO), water ice therapy (WIT), pleural or peritoneal lavage, cool IV fluids
Management of shivering/agitation
ativan, propofol, fentanyl, rocuronium
Complications:
respiratory failure, arrhythmia and cardiac dysfunction, hypotension, seizures, cerebral edema, rhabdomyolysis, kidney injury, hepatic injury, DIC
Neuroleptic Malignant Syndrome:
Incidence: 0.02-3%
Seen in all ages but most cases occur in young adults, male>female
Mortality decreasing, now 10-20%
Most commonly associated with first generation antipsychotics (haloperidol, fluphenazine) but can occur in second generation antipsychotics (olanzapine, risperidone), or even in some antiemetics (promethazine, metoclopramide, prochlorperazine)
This can also be seen in withdrawal of L-dopa or other dopamine agonists
Pathogenesis: alterations in the autonomic and somatic nervous system caused by decreases in the function of central dopamine systems; muscle rigidity of NMS is secondary to loss of dopamine in the basal ganglia disrupting thalamocortical circuits; disrupted modulation of the sympathetic nervous system, manifesting in increased muscle tone and metabolism, inability to dissipate heat, labile BP and HR
Presentation: AMS, rigidity, hyperthermia, autonomic instability
Lab/Imaging Findings: elevated CK, leukocytosis, transaminitis, AKI, rhabdomyolysis, metabolic acidosis, EEG can show generalized slow wave activity
Management: discontinue offending agent, cardiorespiratory support, volume resuscitation as needed, cooling, benzodiazepines for agitation and muscle rigidity, dantrolene for moderate to severe rigidity with elevated CK, bromocriptine or amantadine for moderate to severe symptoms
Airway Grand Rounds with Dr. Adan
Laryngectomy
Larynx is surgically resected. Mouth and nasopharynx connect to the esophagus, and the trachea is sewn to the anterior neck stoma
Laryngectomy tubes are shorter, most often uncuffed, and some are fenestrated (to allow better airflow across a speaking valve if present). These are more often worn for comfort rather than for stoma patency
TEP speaking valve (voice prosthesis) aka Blom-Singer may be present and can clue you in to the fact that this is a laryngectomy
These patients cannot be oxygenated or intubated from above
Complications
Obstruction
mucous plugging: saline and deep suctioning
Granulation tissue
Strictures and stenosis (subacute)
Call for help (RT, ENT)
Apply oxygen over the stoma
Remove cover or tube
Pass suction catheter
Can bag using pediatric BVM or size 3 iGel placed horizontally over the stoma to create a seal
Can pass scope with ETT (i.e. 6.0 cuffed ETT) preloaded and intubate through the stoma if PPV needed
Infection (i.e. bacterial tracheitis)
Bleeding (skin irritation and bleeding at the stoma site)
Fistula (TEF or tracheocutaneous fistula), can perform fiberoptic scope to evaluate
Pulmonary (i.e. pneumonia)
MacSize-ICU study
Showed that the Macintosh 3 blade was statistically significantly better than Mac 4 for all comers regarding first pass success rate in direct laryngoscopy in a retrospective multicenter observational study in intensive care units in France. This showed no difference in Cormack-Lehane score.
2022 Pre-AeRATE Trial:
use of HFNC for preoxygenation and apneic oxygenation showed no difference in lowest SpO2 during first intubation attempt when compared with usual care. This did show that HFNC prolongs safe apnea time (~10 min) compared to NRB+NC (~7min), and decreased the risk of SpO2 falling below 90% compared to NRB+NC (RR 0.68).
DEI Visiting Lecturer: “What Kids and Kidneys can teach us about Racism in Cincinnati” with Dr. Ray Bignall
Race and racism works in tandem with other systems of inequality, such as residential segregation, housing and shelter, food insecurity, income inequality, education, environmental justice, policing, and health inequities
Systems of Inequality:
Segregation: the myth of “de facto” segregation exists, whereas in truth this segregation was legally enforced and federally directed. This impacted the ability to purchase homes in “red-lined” areas, and has had long standing impacts on generational wealth for their descendants
Housing: the byproduct of the new deal era housing policies often replaced neighborhoods with segregated housing projects. “Not in my backyard” movement has stifled attempts to expands low-income housing to address the housing crisis, and still, African Americans are 17.7% less likely to be offered rental property
Income: structural barriers also exist to prevent wealth-building in Black communities. Examples include wage inequality, 3x higher unemployment rate, banking and lending discrimination, racial disparities in home ownership, and little intergenerational wealth (as mentioned above)
Policing: differences in how people of different races interface with police
Defining Racism:
“I define racism as a system of structuring opportunity and assigning value based on the social interpretation of how one looks (which is what we call “race”), that unfairly disadvantages some individuals and communities, unfairly advantages other individual and communities, and saps the strength of the whole society through the waste of human resources.” - Dr. Camara Jones
Racism is disparity by design. This concept can be related to other marginalized groups such as women, immigrants, LGBTQ people, people with disabilities, people living in poverty, and other groups who experience social disadvantages.
How Racism Creeps into Medicine
Plantation physicians used spirometers to prove the “weak” lungs of “full blacks” or “mulattoes” compared to whites
Thomas Jefferson’s ‘Notes on the State of Virginia’ remarked that this data was valuable to prove that Black bodies were “fit for the field and little else”
This notion was reinforced as early as the 20st century medical literature (JAMA 1922)
To this day, race-based estimates of lung capacity have their basis in this history, and remains accepted practice, although recently there has been a push to re-evaluate this process
Using an example from pediatric nephrology:
20% of US households experience food insecurity
One study found that among children with ESRD, 64% were food insecure
higher healthcare utilization, increased infection rates, and lower health related quality of life
Nutrition and CKD/ESRD are inextricably linked and impact growth and transplant readiness
Food insecurity also ties back into historical redlining by the unavailability of nutritious foods and the existence of food deserts
Historically redlined neighborhoods that are overpoliced are also seen as less desirable for investment and are less likely to attract supermarkets and fresh food vendors
Housing insecurity is a major risk factor for food insecurity
Housing status can also impact dialysis options (peritoneal dialysis, which is preferred, becomes a much less accessible option)
How can we as physicians help to mitigate the health impacts of systemic racism?
Advocate for safe and affordable housing for all children, especially those living with CKD
Improve access to and education regarding healthy, nutritious, and kidney-friendly foods
Support institutional and societal policies that limit the influence of income on access to excellent kidney care
Improve patient education and health literacy to address adherence and psychosocial barriers to transplant listing
Advocate for safe and healthy environments for children and families to live that optimize kidney health
We need to be very intentional about our understanding of race and health outcomes. Are we seeing these disparities because of genetic or ancestral factors, or do these disparities exist due to systemic racism and its downstream impacts
Further, although some health conditions are related to ancestral factors, this can be difficult to determine. Many patients are mixed race, and unless genomic analysis is done, you cannot determine which genes may have been inherited from a particular ancestor
Ex. ApoL1 and its influence on risk for kidney disease among patients with African descent
Additionally, patients may appear to be of a certain race but identify differently, or may have ancestry that they are unaware of
Medical Mistrust among African Americans
Myths and conspiracy theories about the healthcare industry’s approach to Black communities are reinforced by personal experience
How can health professionals work to dismantle systems of inequality and injustice?
Acknowledge with our minoritized colleagues (and patients) the racism we see in the world around us.
Champion workforce diversity and inclusion through intentional recruitment, mentorship, and partnership
Screen for social determinants of health in encounters
Educate yourself by engaging with new voices
Encourage implicit (and explicit) bias training
Listen first, and don’t be afraid to ask questions
Develop sincere empathy for those who are crying to be heard and helped
Be an “active bystander” when confronting racist or intolerant language/behavior
Build trust through dynamic, “back bench” community partnership
Institutional statements must be backed by action and accountability
“Justice will not be served until those who are unaffected are as outraged as those who are”
-Benjamin Franklin
