Grand Rounds Recap 7.26.23

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Morbidity and Mortality WITH Dr. Kletsel

Pustular psoriasis

  • Psoriasis is characterized by discrete plaques of erythema, scales, and fissures of the extremities ​

  • It is associated with significant morbidity & treatment consists of topical steroids, along with referral to establish with dermatology​

  • Use caution with systemic steroids as they can potentially worsen flares​

  • While rare, pustular psoriasis is the most severe form and commonly requires hospitalization due to associated mortality ​

Central line placement complications

  • Common CVC mechanical complications include arterial puncture, hematoma formation, and an iatrogenic PTX​

  • Catheter misplacement/migration can occur as well and iatrogenic hydrothorax is a rare, but serious sequela​

  • Bedside CXR is slow and not very sensitive at detecting CVC misplacement​

  • Consider utilizing bedside US after placing your line, including a bubble study to ensure proper positioning of the catheter​

Spinal Epidural Abscess and Hematoma

  • SEA is an infectious disease emergency​

  • Has been gradually increasing in prevalence and is associated with high morbidity ​

  • Classic triad of back pain, fever, & neuro deficits occur in minority of patients​

  • Must be considered in patients with risk factors- including those with other infections, immunocompromised state, or recent trauma​

  • MRI w/wo contrast is imaging modality of choice, yet ESR can serve as a screening tool​

Ludwig’s Angina

  • Ludwig’s angina is a rapidly progressing cellulitis of the floor of the mouth​

  • Commonly starts as a tooth infection, especially in those with baseline poor dentition and/or DM​

  • Expect tense/tender submandibular area on exam, as well as a raised floor of mouth ​

  • Consider early awake intubation, plus broad-spectrum antibiotics ​

  • Commonly need admission to the ICU for airway monitoring ​

Post-traumatic Cerebritis

  • Patients with prior TBI’s are more prone to infections​

  • Respiratory, surgical site and urinary sources are most common​

  • Also consider a CNS source in patients with frontal bone or basilar skull fractures

Pediatric Arrest

  • Pediatric cardiac arrests are much more rare compared to adults​

  • Regardless, we have to be prepared for anything that comes in through the door​

  • After a challenging case consider a clinical debrief with everyone involved​

  • This helps address any systems issues that may need to be fixed​

  • Also provides a space to ask questions and process the event​

R4 Case FOllow Up WITH Dr. Smith

Left Ventricular Thrombus

  • Left ventricular thrombus has an incidence of 4-39% after MI and 2-36% id dilated nonischemic cardiomyopathy. 

  • Diagnostic test of choice is TTE with cardiac MRI as gold standard if TTE negative with high clinical suspicion. 

  • Mainstay of treatment for LV thrombus is anticoagulation, with mean time to resolution of 103 days. About 14% of patients will have recurrence of LV thrombus.

Taming the SRU WITH Dr. Jackson

Aneurysmal Subarachnoid Hemorrhage

  • Aneurysmal SAH is a critical diagnosis that must not be missed

  • Non-contrast CT head is nearly 100% sensitive within 6 hours of onset of symptoms

  • Principles of management are airway if needed, SBP <160 (<140 preferred if tolerated), aggressive reversal of anticoagulation, and immediate neurosurgery consultation

  • Do what is right for your patients:

    • If worried about a patient, expedite their evaluation

    • If worried about a significant head bleed, follow your patient to scan (applies to other immediate life threatening diagnoses: AAA, aortic dissection, massive PE, etc.)

    • Have a collaborative discussion with nursing and other staff about expedited evaluation of your patient

Opioid Use Disorder WITH Drs. Freiermuth and Paulsen + Joseph Fiorelli RN, BSN

  • Deaths from opioid overdose continue to sharply rise nationally due to the presence of illicit synthetic opiates

  • Opiate use engages the dopamine reward system in the brain leading to the need to continue use

  • Substance use is a disease which has effective treatment options

  • Language matters, and being up to date on best terms is crucial to reduce stigma

  • Harm reduction interventions can decrease morbidity and mortality associated with substance use