Grand Rounds Recap 6.21.23

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Morbidity and mortality WITH dr. zalesky

Meningitis

  • Meningitis is an extremely difficult diagnosis with almost no clinical findings that can aid in the diagnosis outside of suspicion and a LP​

  • Seizures can be a presenting sign of infections, often without fevers or leukocytosis ​

  • Of patients with seizures who underwent LP, 22% had an infection (with about half of these patients without any other clinical signs of infection) 

  • Hydrocephalus is a rare complication of bacterial meningitis, which often portends a poor outcome ​

  • There is scant evidence for platelet thresholds for LP, but the agreed-upon level is 50k

Procedural Safety

  • Retained guidewires are considered a never event​

  • Based on a study on guidewire retention, there is no obvious identifiable risk factor ​

  • Checklists and a “wire count” are best practice

Acute Aortic Syndromes 

  • Acute aortic syndromes are made up of dissections, aneurysms, penetrating atherosclerotic ulcers, and intramural hematomas​

  • PAU, when symptomatic, can carry a mortality of up to 30%​

  • Intramural hematomas will progress to aortic dissections 16-40% of the time ​

  • AAA >8cm have up to a 50% rupture rate at 1 year​

  • Any concern for aortic pathology associated with new pain should be treated with a high level of concern

Hemophilia 

  • Factor Replacement should be given at the suspicion of bleeding before any diagnostics are completed 

  • When in doubt, administer factor immediately 

  • Replacement should be administered before transport when at all possible ​

  • Hemlibra acts prophylactically and dramatically reduces bleeding events for patients with Hemophilia A​

  • Give full-factor replacement for any critical bleeds

    • Factor VIII: full replacement dose 50 units/kg

    • Factor IX: full replacement dose 100 units/kg

    • If you do not have factor, can try cryo, DDAVP, FFP, aPCC, and aVII

Electrical Storm 

  • Three episodes or more of sustained ventricular arrhythmia over the course of 24 hours 

  • Management 

    • Early aggressive antiarrhythmics ​

      • Amiodarone: first line 

      • Procainamide: best at stopping VT, however lots of contraindications 

      • Lidocaine: best agent for monomorphic scar-related VT 

      • Magnesium: first line for torsades 

    • Early beta blockade is important 

      • Initial esmolol bolus followed by gtt 

    • Early and aggressive anxiolysis & sedation

      • Dexmedetomidine recommended 

      • Patient will likely ultimately require intubation and sedation with propofol 

  • Don’t neglect the ICD and EP assistance​ as you may be able to utilize overdrive pacing 

  • Hemodynamic support is a bridge to treatment

Euglycemic DKA 

  • SGLT2 Inhibitors “–glifozin”: block the resorption of glucose leading to glucose loss in the urine while also increasing ketosis

  • SGLT2i are becoming more commonly used in T1DM, T2DM, HFpEF, and HFrEF​

  • Patients are prone to ketosis and ketoacidosis, especially if a trigger is present​

  • Patients on SGLT2i require an extra moment of consideration for euglycemic DKA ​

  • Respect significant derangements in bicarb levels or VBG abnormalities

Wellness: Behind the curtain WITH dr. Martella

  • Anxiety, depression, and suicide rates in resident physicians is high; this ultimately lead to ACGME mandating that wellness is a core requirement of residency programs 

  • Wellness is the active pursuit of activities, choices, and lifestyles that lead to a state of holistic health 

  • Domains of wellness: 

    • Physical 

    • Mental 

    • Spiritual 

    • Emotional 

    • Social 

    • Environmental 

  • Many residencies have been implementing strategies to maintain residency wellness. While these programs differ, many have shown improvement in perceived wellness among residents.