Grand Rounds Recap 4.10.19

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Wellness curriculum: physician depression WITH DR. mcdonough

Epidemiology

  • Rates are of depression amongst physicians 12.8% in males, 19.5% females, on par with the general population

  • Relative risk of physician suicide are 1.1-3.4 in males and 2.5-5.7 females, much higher than the general population

  • The rate of depression amongst medical students is 27.2% while in medical school, and the rate of suicidal ideation is 11.1%

  • The rate of depression amongst residents is 28.8% while in residency, and suicide is the leading cause of death in male residents

Complications of the Disease of Depression

  • Death

  • MI (in males)

  • Immune suppression

  • Job dissatisfaction

  • Relationship difficulties

  • Irritability and anger

  • Isolation and withdrawal

  • Personality changes

  • Mood Swings

Depression and Anxiety

  • Depression Definition: Five or more of the following symptoms - depressed mood, loss of joy, weight loss or gain, increased sleep, psychomotor agitation or retardation, fatigue, feelings of worthlessness or guilt, diminished ability to concentrate, recurrent thoughts of death, suicidal ideation, and suicide attempts. These cannot be due to concurrent substance abuse mania, hypomania, or psychosis.

  • 50% of people with depression will have concurrent anxiety

  • Symptoms of anxiety

    • Restlessness

    • Uncontrollable feelings of worry

    • Impending sense of danger

    • Irritability

    • Concentration difficulties

    • Sleep difficulties

    • Increased HR and RR

    • Rumination

Treatments

  • Psycho-therapy- first line

  • Antidepressants- first line

  • Mindfulness useful as augmentation of the above

  • Lifestyle modifications (all have evidence to support them)

    • Diet

    • Exercise

    • Actively engagement of your sleep-wake cycle

    • Socialization, Pets

    • Minimize EtOH/Smoking/Drugs

The Elephant in the Room

  • There is social stigma associated with admitting to depression as a physician

  • Finding a trusted provider that is not a colleague can be difficult

  • There are concerns about confidentiality as a physician

  • Physicians fear recrimination by colleagues, employer, and licensing boards

Defeat the Stigma

  • Talk openly about stress and burnout with your colleagues

  • We are diagnosticians - accept depression as a disease with morbidity and mortality and treat accordingly

  • Recognize the signs in others in order to help your colleagues

Thromboelastography (TEG)  WITH DR. wolochatiuk

Background

Interpretation

  • R-time (reaction time)

    • This represents the clot initiation time, or time until coagulation cascade has been activated to cross-link fibrin

    • Prolonged R-time is an indication for FFP

  • Alpha angle

    • The tangent line from the beginning of K-time to the 20mm point of K-time, decreased in hypofibrinoginemia, representing the propagation of a clot

    • Decreased alpha angle is an indication for cryoprecipitate

  • Max Amplitude

    • The widest part of the TEG plot, representing the maximum strength of the clot, functioning as a measure of platelet function

    • Decreased MA is an indication for platelet transfusion if platelet deficiency or consumption or DDAVP if concern for abnormal platelet function

  • Lysis30

    • Percentage of lysis of the clot at 30 minutes past the MA

    • Increased lysis is an indication for TXA

Rule of 55

  • R time > 55, give FFP

  • Alpha Angle < 55, give cryoprecipitate

  • Max Amplitude < 55, give platelets

TEG vs. Conventional Coags

Limitations to the TEG

  • Machine requires daily calibration, trained personnel, and standardized techniques

  • It takes time for the values to be generated on the TEG

  • In-vivo dynamics are not measured, it measure in-vitro dynamics

  • Algorithms have arbitrary cut-off values, as there is need for further research

For more on this, visit Dr. Wolochatiuk’s TamingTheSRU post here!

r3 small groups: ophthalmology WITH DRs. owens, harty, scanlon and ventura

Lateral Canthotomy with Dr. Ventura

Possible Indications

  • Proptosis with:

  • Intraocular pressure >40

  • Visual deficit (inability to count fingers)

  • APD in an altered patient

Procedure

  • Inject lidocaine with epinephrine into the lateral canthus

  • Use hemostats to crush the canthus to limit bleeding

  • Cut the lateral canthus with sterile iris scissors, taking care to protect the globe

  • Cut the inferior canthal ligament, recheck pressures, and then cut the superior canthal ligament with iris scissors

  • Check out the EM:RAP VIdeo for a demo

Ocular Ultrasound with Dr. Harty

Indications

  • In trauma, you can see eye movement, pupillary function, foreign body, and lens dislocation

  • If a patient has decreased vision, ultrasound can help in diagnosing Central Retinal Artery Occlusion, vitreous hemorrhage, retinal detachment

Technique

  • First consider and rule out open globe by CT before continuing

  • Apply a tegaderm to the closed eye

  • Switch to the linear probe on the specific ocular setting

  • Hold in a longitudinal plane and fan left and right

  • Hold in a sagittal plane and fan left and right

  • Hold against the cheek directed cephalad and you can see pupillary constriction and dilation

Optic Nerve Sheath Diameter

  • Measure your optic nerve diameter 3mm deep from the retina

  • If >5mm, this can be a sign of increased ICP, and will typically occur before papilledema is detected

Congenital heart disease in the pediatric patient WITH DR. krack

Physiology

  • Prior to birth, blood is shunted through the foramen ovale instead of the lungs

  • As the placenta is removed and PVR decreases, the foramen ovale will functionally close immediately and PDA will close over days

  • Ductal Dependent Systemic Blood Flow Lesions

    • These are left sided obstructive lesions that prevent blood flow to the systemic circulation

    • Will present as gray baby

    • Will typically present <1 month old

  • Ductal Dependent Pulmonary Blood Flow Lesions

    • These are lesions that affect the pulmonary vasculature

    • Will present cyanotic

    • Will typically present <1 month old

    • Causes are the four T’s (Truncus Arteriosis, Tricuspid Atresia, Tetrology of Fallot, and Total Anomalous Pulmonary Venous Return)

  • Shunting Lesions

    • Causes include VSD and PDA

    • The more shunting you have, the earlier they will present, but typically present later in life (6-8 months old)

Special Approach to Physical Exam

  • Take blood pressures in all four extremities. The right arm is the pre-ductal BP, and the lower extremities are post-ductal.

    • >20mmHg difference is abnormal

  • Take pre-post ductal and post-ductal SpO2

    • <94% is abnormal for post-ductal SpO2

  • Hyperoxia test

    • Put on 100% FiO2 for 10 minutes

    • If O2 saturation improves as expected, less likely a cardiac cause

    • Do with caution, as some cardiac patients do not tolerate hyperoxia well

Diagnostic Tests

  • EKG

    • LVH is always abnormal

    • RVH is normal, but should resolve within 1 month of age

  • CXR has good PPV, but very bad NPV

  • POCUS- Questions to Answer

    • Is the global cardiac function poor?

    • Are there four chambers of the heart?

    • Is the ventricular septum intact?

Treatment of Patients with Cardiogenic Shock

  • If a patient is gray, in shock, and under 1 month old, you should treat with prostaglandin as they have a PDA dependent lesion until proven otherwise

  • Do not anchor on congenital heart disease, and treat initially as undifferentiated shock. Sepsis is the number one reason of shock in neonates (treat with antibiotics, glucose, and hydrocortisone)

  • Prostaglandin E1

    • This is a continuous effusion

    • Starting dose is 0.05 mcg/kg/minute

    • Titrate to lowest effective dose to resolve shock

    • Takes effect in minutes

    • Beware of apnea

Treatment of Patients with Known Congenital Heart Disease Presenting with Acute Heart Failure

  • Your goal saturation is >85%

  • Treat with furosemide for volume overload

  • Consider milrinone for development of shock

Hypoplastic Left Heart Syndrome

  • These are surgically repaired via the Norwood Procedure

    • In Norwood 1, the pulmonary arteries are ligated. The proximal pulmonary artery is connected to the hypoplastic aortic arch and the coarcted aorta is repaired. An aortopulmonary shunt is then connected to the distal pulmonary artery for pulmonary blood flow

      • These patients do not tolerate hyperoxia as it will increase PVR. They are typically very early in their surgical course, so rarely present to the ED

    • In Norwood 2, once the pulmonary vascular resistance has fallen, a bidirectional SVC and pulmonary shunt is created.

      • These patients are helped more by supplemental oxygenation, unlike Norwood 1 patients they may be at home therefore may present to the ED.

    • In Norwood 3, a Fontan procedure is done where the SVC and IVC are connected to the pulmonary arteries. All of the pulmonary blood flow is via passive flow from the IVC and SVC, and the RV pumps blood to the systemic circulation.

Platelet Disorders WITH Dr. pulvino

Background

  • Platelets are necessary for both clot function and integrity

  • Thrombocytopenia is defined as <150k, <100k is moderate, <50k is severe

  • Causes are due to lack of production, destruction, iatrogenic fluid administration, or sequestration (splenomegaly)

Diagnosis

  • History should focus on family history, meds, drugs, diet

  • Physical exam focusing on purpura, ecchymosis, lymphademopathy, epistaxis/mucosal bleeding, and organomegaly

  • Laboratory Testing

    • In all patients: CBC, peripheral smear, and consider HIV and HCV testing (commonly associated with thrombocytopenia)

    • In some patients: PTT, PT/INR, d-dimer, fibrinogen if considering DIC

Platelet Transfusion

  • Rarely indicated in platelet disorders

  • Contraindicated in TTP and HIT unless patient has life-threatening hemorrhage

Immune Thrombocytopneic Purpura

  • Definition: Isolated thrombocytopenia <100k without leukopenia or other causes

  • This is a diagnosis of exclusion

  • Causes

    • Thought to be due to IgG autoantibody against platelet glycoproteins

    • Can be primary due to acquired autoimmune platelet destruction

    • Can be secondary to HIV, HCV, lupus, or CLL

  • Patients typically present asymptomatically, but if they do have bleeding, it is typically minor

  • Workup should include laboratory testing to rule out DIC, TTP

  • Treatment

    • If platelet count is >30k and is asymptomatic, they can be observed without treatment

    • If patient has severe bleeding, transfuse to platelet count >30k

    • Admit for significant bleeding or platelet count <10k

Thrombotic Thrombocytopenic Purpura

  • This is due to deficiency of ADAMST13 protein activity, which helps with platelet adhesion

  • Presentation

    • Patients will present with signs of end organ damage due to propagation of clots

    • Patients rarely present with the pentad of fever, thrombocytopenia, renal failure, neurologic deficit, or microangiopathic hemolytic anemia

    • Patients typically present with GI symptoms including nausea, vomiting, and abdominal pain

  • Treatment

    • PLASMIC SCORE

  • Used to differentiate severity of TTP and need for plasmapharesis (PLEX)

    • 0-5 low risk- no need for PLEX

    • 5-6 intermediate risk- consult Heme/Onc to consider PLEX

    • 7 high- these patients should all receive PLEX

Find out more about Thrombotic Thrombocytopenic Purpura in this AoBP post on TamingTheSRU!

 ethics in the emergency department WITH DR. mckee

Background

  • Historically, there have been multiple ethics infractions by the medical community including the Tuskegee syphilis experiments, and the sterilization of the developmental disabilities within the United States

  • There continue to be ethical challenges in medicine, including physician-assisted suicide during Hurricane Katrina and the case of the coding patient with a do-not resuscitate tattoo

Why does this apply to Emergency Physicians?

  • We do this every day

    • We collect informed consent vs. implied consent vs. assault

    • AMA discharges

    • Psychiatric Holds

    • Maternal vs. Fetal rights

    • Duty to inform

    • Triage of patients

The Four Principles of Ethics

  • Autonomy- Patients are rational beings capable of performing informed and voluntary decisions

  • Beneficence- Be a benefit to the patient

  • Nonmaleficense- Do not intentionally harm the patient

  • Justice- There should be fairness in our decisions, with equal distribution of burden and benefit, and equal distribution of scarce resources

Surrogate Decision Makers

What Should We Do with Unreliable or Absent Surrogates??

  • Contact Risk Management

  • Some hospitals have patient advocates that can serve as a surrogate decision maker in the absence of one

  • A two physician consent can help mitigate risk if there is no surrogate available

  • Involve the Ethics Committee Early

Triage

  • We typically believe that triage is maximizing beneficence and minimizing nonmalificence (utilitarianism)

  • This is a moving target balanced against justice, attempting to fairly distribute finite resources, treating patients as those who deserve equal rights and opportunities (egalitarianism)

  • Human factors affect these choices, so reflect on your insights and biases