Grand Rounds Recap 4.17.19

Conflict resolution - qi/kt: Epistaxis - simulation: Peds EKGS

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Leadership curriculum: Conflict resolution WITH DRs. leenellett and mcdonough

Navigating Difficult Conversations

• Know yourself (consider a DiSC profile)

• Know the objectives of the person with whom you are having a discussion

• Bring or model your behavior after a role model

5 Strategies for Dealing with Conflict

• Flight Response (Avoidance, Silence, Sarcasm, Withdrawal) - This has the most potential for misunderstanding as your body language frequently does not mirror what you communicate verbally

• Accommodation- This can lead to resentment if employed too often

• Fight or Violence (Controlling, Name calling, Attacking)

• Compromise- Leaving the conflict with both parties agreeing on partially fulfilled needs

• Collaborate- Discuss the different issues with the persons and come up with a Win-Win

Rules of Conflict Resolution

• Reflect before you begin

• Seek first to understand

• Come up with a shared goal- What do you want from them? What do you want for the relationship?

How to Implement a Shared Goal

• Create trust

• Focus your attention on them

• Be open to discussion

• Their perception affects your reality

• Determine the goal before looking for solutions

Navigating a Difficult Situation

• Effectively listen

  • Use open rather than closed questions

  • Use a reflective response to reiterate the point they are trying to communicate

• Separate the person from problem

• Focus on “I” statements of fact rather than “you” statements of opinion

• Acknowledge others’ contributions

• Avoid Always and Never statements

• Focus on solutions that satisfy their needs, and be okay with a compromise or a new solution

What if None of That Works?

• Keep your eyes on your ultimate rather than your immediate goals

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epistaxis WITH DRs. li and iparraguirre

Background

• 450,000 patient visits per year in the ED for epistaxis, with the majority of patients being discharged home

• Uncomplicated vs. Complicated

  • Uncomplicated epistaxis is due to mucosal irritation, URI, sinusitis, allergic rhinitis, or trauma

  • Complicated epistaxis is due to anticoagulation, thrombocytopenia, drug abuse, or structural abnormalities

• Anatomy

  • 70-95% of nosebleeds are anterior at Kiesselbach’s plexus and tend to bleed from one nare

  • Posterior source bleeds are more difficult to visualize and tend to bleed from both nares

Hypertension and Epistaxis

• In a meta-analysis of 10 studies, no association was found between epistaxis and arterial hypertension. There is a lack of prospective cohort studies of well-matched groups.

• In a prospective study of 80 patients, no association was found between hypertension and epistaxis

Assessment

• Assess airway, breathing, and circulation to determine stable or unstable

• Have the patient blow their nose to get rid of the excess blood and unstable clot

• Administer an alpha agonist to constrict the vessels (Oxymetolazine vs. Lidocaine with Epinephrine vs Cocaine)

• Apply direct pressure for at least 15 minutes with a nasal clip or having the patient apply appropriate pressure

Diagnostics

• Diagnostics should be individualized based on history and physical exam

• CBC can detect thrombocytopenia or acute anemia from hemorrhage

• Coagulation studies are not routinely recommended

TXA

• Antifibrinolytic agent used to reduce blood loss that has shown to reduce all cause mortality when used in trauma patients

• Studies have not shown an increased risk of MI, stroke, DVT, or PE after administration

• In a meta-analysis of 6 randomized controlled trials of TXA (oral or topical TXA versus placebo) for epistaxis, there was a statistically significant decrease in re-bleed at 10 days when administering TXA

• In a randomized controlled trial of assessing IV TXA (500mg in 5ml) on cotton pledges vs 2% lidocaine with epinephrine, there was a statistically significant reduction in bleeding after 10 minutes of application (71% vs 31%) and discharge at 2 hours (95% vs 6%)

Cautery

• Useful if source of bleeding can be visualized

• Silver nitrate can be used for this, and utilize this by drawing a circle around the bleeding source

• Do not cauterize both sides of the septum as it can lead to irreversible septal ischemia or perforation

• This has a success rate of 79% of controlling hemorrhage in one study of 147 patients presenting to an Emergency Department

Anterior Packing

• One can pack with nasal packing and bayonet forceps, or use of commercial devices such as the Rapid Rhino or Rhino Rocket

• In a study of 52 ED patients comparing the Rapid Rhino vs. Merocel, they had equal efficacy in halting hemorrhage of anterior hemorrhage. However, Rapid Rhino was much easier to insert and had higher patient satisfaction.

• In a study of 40 ED patients, the Rapid Rhino was easier to insert and less painful for patients, but both had similar efficacy.

Posterior Packing

• There are commercial devices to halt posterior bleeds such as the Epistat

• If this is unavailable, you can place a foley 8cm into the nasal cavity (standard nasal cavity is 5.5 cm), partially inflate and seat against the posterior nasopharynx, then inflate with 5-7 cc of sterile saline initially with a final goal of 10-15cc of saline

• In a review of the literature, there were no documented cases of mortality from vagal stimulation of posterior packing, so ICU admission is not universally necessary in these patients.

Antibiotics

• For anterior packing, it is controversial whether antibiotics should be prescribed prophylactically to prevent Toxic Shock Syndrome

• In a review of the literature from 2015, it was found that there were no well designed studies to answer this question. All studies were retrospective, observational, or nonrandomized. Despite these limitations, there were no cases of Toxic Shock Syndrome or otitis media in patients in whom antibiotics were withheld in the 3 trials reviewed .

• Regardless of whether antibiotics are given, signs and symptoms of TSS should be included in discharge instructions.

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R4 simulation WITH DRs. colmer, harrison, mckee, and continenza

Left Main Coronary Acute Myocardial Infarction Simulation

Left Main Coronary Acute Myocardial Infarction

• These typically present with diffuse ST depressions in the anterolateral leads as well as aVR elevation

• Left Main AMI have a higher chance of need for CABG

• Despite a higher complication rate in patients receiving clopidogrel before CABG, it is an AHA level 1 recommendation to give clopidogrel as well as aspirin in undifferentiated acute myocardial infarction

Thrombolytics in Acute Myocardial Infraction

• Thrombolytics are a second line treatment of STEMI compared with PCI as they have a lower efficacy

• Thrombolytics are indicated if time to PCI is greater than 2 hours from medical contact

• The decision to give thrombolytics should be made within 30 minutes of patient evaluation

Pediatric EKGs

• Juvenile T-Wave patterns

  • T-Waves in V1-V3 can be inverted because the RV:LV ratio is higher in pediatric populations

  • 0-7 days, V1-V3 should be upright

  • 7 days- 8 years V1-V3 will be inverted, and sometimes in V4

  • T-Waves should NOT be peaked and upright, flattened, or have large, deep, symmetric inversions throughout

• Sinus Arrhythmia

  • Variation in P-P interval, without variation in the P-R interval

  • This is benign and a normal variant, not requiring intervention

• Congenital Long QT

  • Machines cannot calculate QT as accurately at higher rates, so manually calculate your QT in pediatric patients

  • This is the most commonly missed arrhythmia in pediatric patient

  • Normal in 0-6 months of age is <0.49 seconds

  • Normal in 6 months of age is <0.44 seconds

  • Treatment in pediatric patients is beta blockers or AICD. Beta blockers will prevent adrenergic surge and tachycardia, preventing fatal arrhythmia.

• Brugada Syndrome

  • Most commonly present in adolescent or early adulthood rather than very early ages

  • Also more common in patients that present with a fever and syncope concurrently

  • There are 3 different morphologies of Brugada

• Wolf Parkinson White (WPW)

  • In the case of PR shortening, search for a delta wave

  • A delta wave must be identified to diagnose WPW

  • Beware retrograde P-waves burying themselves within the T-wave complex

• AVRT

  • This is due to an accessory pathway connecting the atria to the ventricles

  • AV nodal blocking agents are contraindicated as it will force the electrical impulse down the accessory path

  • Procainamide is a first line treatment for this arrhythmia

• Supraventricular Tachycardia

  • Vagal maneuvers are first line treatment for stable SVT, and include ice to the face in infants vs. valsalva in older children

  • You must hold the ice on the infants face up to 20 seconds to stimulate a diving reflex

  • If these fail, adenosine can be given in 0.1 mg/kg for the first dose, 0.2mg/kg for the second dose with max being adult dosing

• Benign Early Repolarization

  • Up-sloping ST segment is reassuring

  • Your ST segment amplitude compared to your QRS height should be <25% in benign early repolarization

See an in depth review of normal pediatric EKG’s on TamingTheSRU here!