Grand Rounds Recap 7.6.2022
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Baxterisms WITH Dr. Baxter
Consistency of thought and action. Does your work up, disposition, and conclusion make logical sense
Decide your level of concern and disposition then choose your treatment plan accordingly
The clinical pendulum
R1 everyone is sick
R2 everyone is fine
Task prioritization
R3 everyone is ACTUALLY sick
R4 right on target
Find the balance of letting R1s grow and resource utilization
Beware of the rapid disposition decision at the time of turn over
Patients at sign-out can be thought of for 3 levels
Clearly sick
Clearly well
I don't know yet
You are only allowed one “yeah but…” per patient. Said another way you are only allowed to explain away one goofy thing per patient
If you have thought about it for more than 30 seconds you have reached a decision you just haven't realized it yet
Thinking
System 1 and System 2 thinking
System 1 instinct,, pattern recognition
System 2 slower intentional logic and conscious thought
Time can be your friend
Some times reassessment is the most helpful test
Practice patterns WITH Dr. Lafollette
Identify Input sources and biases and where your decisions are coming from
Traditional texts / slow updaters (textbook, uptodate)
Summative resources (FOAMed, Reviews)
Personal Anecdotes
Education (Second hand anecdote, interpreted literature)
How do you search for the right data in the moment to come to a decision
Example of pattern variation: Hyponatremia admission - what’s your absolute number?
Mild >130
Moderate 120-130
Severe <120
The UK and NHS has guidelines that say greater than 120 could go home. Many suggestions say 125-120 is dependent on the mechanism of hyponatremia
All acute, severe and symptomatic hyponatremia should be considered for admission as RR 1.47 for all cause mortality
Example of evaluating the unknown: Sodium Nitrate Toxicity
Induces Methemoglobinemia
Becoming more popular in Euthanasia communities online for Suicide attempts
Oxygen sat ~85%, vasodilatory shock
Methylene blue 1mg/kg over 5 minutes repeat at 1h if having symptoms
Example of being skeptical: Mobitz Type 2 Block
Patient presented with a fall and a head laceration. Had a reassuring evaluation. EKG abnormal but no prior available. Story from family and PCP was a mechanical fall like all other mechanical falls. Patient was discharged and then returned in a complete heart block.
2:1 Block takes intentional suspicion and evaluation as hidden p can look like a U wave on the EKG
How do you have a deliberate practice to integrate your case experience with your continually evolving evidence base:
Epic Lists for patient follow ups
Personal Case review
M&M
Shift Debriefs
Literature surveillance
Summative Feeds
Teaching
Spaced repetition
Quick Hits WITH (EKG, Penetrating Neck Trauma, Research) with Drs. Lang, Sabedra, and Zalesky)
EKG: QT interval
EKG: QT interval
-Beginning of Q or R wave to end of T wave
-What is it? Entirety of ventricular cardiac cycle
-Measuring QT interval:
-Intersection of T wave maximum slope with the isoelectric line
-Bazett Formula: QTc=QT/sqrt(RR)
-MD Calc: Corrected QT Interval calculator
-Causes of prolonged QT
-Hypocalcemia
-Hypomagnesemia
-Hypokalemia
-Hypothermia
-MI
-Medications/Drugs
-Genetics/congenital
-Raised ICP
-Risk of prolonged QT
-Torsades de pointes: shock, magnesium, overdrive pacing
-Short QT syndrome: channelopathy
-Males: QT < 330
-Females: QT < 340
-higher risks of afib, arrhythmias
Treatment: ICD
Penetrating Neck Trauma:
Anatomy
-Zone 1: clavicle/sternum to cricoid cartilage; highest mortality
-trachea, carotid artery, esophagus
-Zone 2: cricoid cartilage to mandible; “requires” surgical exploration
-Zone 3: superior angle of the mandible to skull base
GSW low vs high velocity
-High velocity weapons can fire at speeds over 2000 to 3000 ft/s
-More direct, predictable course through bone and soft tissue
-Cavitation
-Entry and exit wounds can appear innocuous
-Military weapons and hunting rifles
-Low-velocity weapons
-More erratic, unpredictable path
-0.22 caliber guns, other handguns, air guns
Focus on immediate life-threats: exsanguination, asphyxiation from airway obstruction
Massive hemorrhage
-Direct pressure
-Wound packing
-Balloon tamponade
-Exploration
Airway:
-RSI with double set up
-Awake look
-Fiberoptic guided oral intubation
-BVM can be problematic
C-spine immobilization
-Eastern Association for the Surgery of Trauma (EAST): only necessary when a neurologic deficit is present or a proper physical examination cannot be performed and the mechanism is suspicious for possible spinal cord or column injury
Hard and soft signs of penetrating neck injury
-Hard signs for vascular injury
-Severe or uncontrolled hemorrhage
-Large, expanding, or pulsatile hematoma
-Thrills or bruits
-Shock unresponsive to IV fluid resuscitation
-Absent or diminished radial pulse
-Neurologic deficit (eg, hemiplegia) consistent with cerebral ischemia
-Hard signs for aerodigestive injury
-Air bubbling from a wound
-Massive hemoptysis or hematemesis
-Respiratory distress
Physical exam
-Voice
-Tracheal position
-Thrills/bruits
-Crepitus
-Focal neuro deficit/Horner’s syndrome
Zone vs No-zone
Zone:
-relatively high rates of negative surgical exploration
-multidetector CTA (MDCT-A)
No Zone
-based on patient stability and the presence of soft versus hard sign of injury, regardless of injury location
-unstable patients → OR
-stable but symptomatic → MDCT-A
-NPV: 98-100%
-findings can be compromised by suboptimal contrast timing and by artifacts from metallic foreign bodies such as dental fillings, bullet fragments, and spinal hardware in up to 1% of studies
Pharyngoesophageal Injury: mortality rates as high as 20% with delays in diagnosis
-Delays >24 hours further increase the mortality rate
-MDCT alone is inadequate
-Direct esophageal studies nearly 100% sensitivity
-Broad-spectrum antibiotics in all patients with possible PEI
For the test…
-Injury to platysma suggests a deeper injury
-Know the hard signs
-Most commonly injured artery is the carotid
-Zones, particularly zone 2, which “requires” surgical exploration
Research Lit Blitz
The Effect of Macrolides on Mortality in Bacteremic Pneumococcal Pneumonia: A Retrospective, Nationwide Cohort Study, Israel, 2009–2017
Population: Israeli cohort from 2009-2017 with pneumonia on imaging and Blood cultures positive of Pneumococcus. Patients ~67yo, admitted for an average of 6 days, 20% mortality, and 18% admitted to the ICU.
Intervention: Exposure to macrolides
Comparison: Mortality after 72 hours of admission
Outcome: patients treated with macrolides in addition to beta-lactams had a decreased mortality compared to beta-lactams alone or quinolones OR 0.55 or decreased odds of mortality 45%
Neuro Imaging WITH Dr. Knight
Basilar Artery Thrombosis
CT/CTA negative by original doctor and transferred for seizures
Be concerned for dizzy “plus” an additional finding
Gauze preference, posturing(“seizure when touched is likely stimulus induced posturing”)
Holo-hemispheric contrast lost
Patient came from OSH and was found acutely unresponsive. Had CTA completed showing contrast intracranially and extracranially on one side of the body
Angio showed intact circle of willis
Eventually further investigation showed the PICC line was intra-arterial and the contrast timing on the initial imaging was missed timed as the contrast was given in an arterial port.
GSW to the head
2 ballistic injuries to the right hemisphere with no involvement of the left hemisphere.
Initial CT with significant injury
CTA with intact circle of willis and Empty Delta sign
Patient had a Sinus Venous Thrombosis
These are time sensitive diagnosis that are important to consider in the ED
Cerebellar Infarct
Need non-con and vessel imaging
Neurosurgical emergency for Sub-occipital craniectomy
Worsening swelling will cause herniation
Care of the incarcerated patient WITH Dr. Srivastava (Medical Director of the Hamilton County justice center)
The Connected system
NAPHCARE
Private Organization contracted for the care of incarcerated persons at the Hamilton county justice center
Medical Director
Mental health director
Psychiatrist
Midlevel Providers
Counselors, RNS LPNs support staff
The connected system
Hamilton County Justice Center
Sheriff McGuffey, Major Daniel E EMS
Captain Scott Kerr
NAPHCARE
Medical
Mental Health
UCMC
Indigent Care Levy
Emergency Department
Inpatient care
Outpatient care
Post acute care (UCMC and Naphcare)
National Commission on correctional health care
Medications
Onsite pharmacy
Formulary
Non-formulary
UCMC IDC
Psychiatric
Injections
Medication assisted treatment
Methadone
Pregnancy
Buprenorphine
Community continuation
Induction
Vivitrol
Sublocade
Available Diagnostics
X-Ray
Fetal Heart tones
EKG
Labs
Some stat labs are sent to UCMC
UDS
UA
Interventions
IVs
PICC care
Ostomy care
Wound Care
Suture/Stapling of sounds
Splinting and casting
Patient Services
MD Sick call
Chronic Care
OB/GYN
Nursing sick call
Diabetic care
Detox support and monitoring
Nursing H&P
Dental care (annual and acute care)
Sentinel Events
Formal Case review
Follow up with Coroners office for autopsy
Policy and procedure review
UCMC Partnership
Formal pathways in the ED, Hoxworth, Infectious disease clinic, Ortho clinic, plastics
