Grand Rounds Recap 7.29.20
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MORBIDITY AND MORTALITY with DR. MAND
Case 1: Alcohol Withdrawal Assessment & Disposition
ED assessment of alcohol withdrawal is most often done by CIWA protocol, which does not include HR or BP due lack of sensitive for a withdrawal state, although it can be specific. Diaphoresis, anxiety, tremulousness, and nausea are more diagnostic. Therefore, normocardia and normotension don’t exclude alcohol withdrawal.
It is safe to discharge patients in mild alcohol withdrawal for outpatient treatment. Consider discharge if: (1) CIWA is less than 8 at least 1-2 hours apart, keeping trend in mind; (2) no active medical or psychiatric illnesses; and (3) no high risk features as below
High risk features include: substance use in addition to alcohol, known psychiatric history, history of alcohol withdrawal seizures or delirium tremens, BAC >200 mg/dL on presentation, CIWA >15, decompensated medical or psychiatric illness, severe autonomic hyperactivity
Case 2: Secondary A-Fib with RVR
Most of the literature surrounding treatment of A-Fib is based on non-valvular primary A-Fib. However, patients presenting in the ED are often sick with secondary causes of A-Fib (prevalence 31-37%).
There is no great way to delineate primary versus secondary A-Fib. Decision aids exist but are not yet ready for prime-time, with a 7% miss rate and pending externally validation.
Treatment of underlying etiology has a 44.5% success rate at rate control compared 17.7% for those treated with primary rate or rhythm control, with an odds ratio of an adverse event (bradycardia, hypotension, mechanical ventilation, or death) in rate or rhythm control patients of 8.3 for those treated with primary rate or rhythm control
Case 3: Hospice Myths
Being in hospice does not imply a patient’s code status. DNR code status is not required to be on hospice, with up to 12.9% of patients being full code. Additionally, patients and families can decide to change code status and hospice care status at any time, so it is important to reassess goals of care with each ED visit.
Evaluate each patient’s capacity, particularly if he/she is revoking their hospice care status. Call the hospice nurse/case manager for every ED visit. If being admitted, consult the palliative care team prior to admission if able.
Case 4: Female GU Infections
There is no constellation of symptoms to reliably differentiate between urinary and genital tract infections. Female patients are often overdiagnosed with UTIs with genital infections missed up to 10% of the time.
The UA performs slightly better than symptom constellation but should be interpreted with caution. The presence of leukocyte esterase and nitrites has the highest specificity at 92%. However, with isolated leukocyte esterase or pyuria, the specificity drops significantly. Do not let an equivocal UA bias you when symptoms are not definitive.
Strongly consider a pelvic exam in the appropriate, symptomatic patient population.
Case 5: Gout vs. Septic Arthritis
Oftentimes it can be difficult to differentiate between infectious arthritis and inflammatory or crystal-induced arthritis. Physical exam findings and serum testing are not diagnostic. The only reliable diagnostic test to assess for septic arthritis is synovial fluid.
Strongly consider infectious arthritis in patients with: immunosuppression, diabetes, recent joint surgery, and advanced age.
It’s OK to perform an arthrocentesis through cellulitis if your suspicion is high enough, as the morbidity and mortality rates from septic arthritis are high. Literature on ‘joint seeding’ is sparse to non-existant’
Case 6: Sexual Assault Exam
Sexual assaults are emotionally charged and up to a quarter of victims can be amnestic to the event.
General body injury is more common than genital-anal injury.
There is an increased odds ratio of injury with the following patient characteristics: major psychiatric disorder (OR 1.49), substance use at time of assault (OR 1.45), presenting for exam within 24 hours (OR 1.70).
There is an increased odds ratio of injury with the following assault characteristics: stranger (OR 2.38), intimate partner (1.94), report of being hit or kicked (7.74), attempted strangulation (4.24).
AIRWAY GRAND ROUNDS with DR. CARLETON
Safe apnea time is cut significantly in obese patients. Pre-oxygenation and safe apnea time are both improved with 25 degree heads-up position in obese and non-obese patients.
Secretions must be considered when performing video-laryngoscopy. Consider preparation adjuncts, such as glycopyrrolate.
Unlike a hyperangulated blade, a standard geometry blade can be converted to direct-laryngoscopy if needed. However, if anatomical predictors of difficulty suggest the need for a hyperangulated blade, it’s worth attempting this despite concerns for secretions obscuring the camera.
Succinylcholine is dosed by total body weight, not ideal body weight. We commonly underestimate the patient’s weight, thus it is recommended to dose succinylcholine at 2 ml/kg.
Quantify minute ventilation during pre-oxygenation and attempt to match during apneic period and post-intubation. Desired minute ventilation can be calculated by [(current PaCO2 x current minute ventilation) / desired PaCO2]. ETCO2 is an excellent surrogate for PaCO2, typically within 5 mm Hg, unless in shock.
While we often use 90% as our cutoff to bag a patient after an intubation attempt, we should increase that threshold to 94%, as all patients reach critical hypoxia once this level is reached.
R1 CLINICAL TREATMENTS: INCREASED INTRAOCULAR PRESSURE with DRS. YATES & MODI
Causes of elevated IOP
Glaucoma, open and closed angle
Chemical injury, both acid and alkali burns, from shrinkage and contraction of the cornea
Retrobulbar hematoma from bleeding in a contained space, with orbital trauma and orbital surgery being risk factors
Topical treatment agents
Alpha agonists (Brimonidine, Apraclonidine) peak in 1-4 hours, reducing aqueous humor production
Beta blockers (Timolol, Betaxolol) peak in 1-2 hours, also reduce aqueous humor productions
Prostaglandins (Latanoprost, Bimatoprost, Travoprost) peak in 2 hours, increasing aqueous humor flow
Cholinergics (Pilocarpine) peak in 0.5-1 hour, constricting the pupil to increase humor flow
Systemic treatment agents
Carbonic anhydrase inhibitors (Acetazolamide) peak in 15 minutes (IV) or 2-4 hours (PO), inhibiting aqueous humor secretion
Hyperosmotic agents (Mannitol, Glycerol) peak in 30 minutes - 3 hours and decrease aqueous humor production
Evidence behind medical treatment
Timolol as well as latanoprost, bimatoprost, and travoprost are the most efficacious medications in lowering IOP when compared with other medications including alpha-2 agonists, such as brimonidine (van der valk Ophthalmology 2005)
See full discussion here: http://www.tamingthesru.com/blog/diagnostics/elevated-iop.
R2 CLINICAL PATHOLOGIC CONFERENCE with DRS. MEIGH & JARRELL
Case Presentation
The patient is a male in his 30’s who was diagnosed with HIV/AIDs (low CD4) only 5 days prior, presenting to the ED with altered mental status. He’s found to be tachycardic to 115 but otherwise with normal VS. Exam notable for mild ill appearance, horizontal nystagmus, cervical lymphadenopathy, disorientation to time, and some confabulation. Labs demonstrate anemia and thrombocytopenia, unchanged compared to his baseline, and a mild transaminitis. CXR and CT head were both negative. On repeat assessment, he started to complain of LLE pain and was noted to have proximal LLE weakness with gait difficulty. An LP was performed, showing only 2 nucleated cells. Then a test was ordered….
RPR confirming the diagnosis of Neurosyphilis
Neurosyphilis
An absolute lymphocyte count in the ED < 850 is very likely to represent a CD4 count < 200
While commonly taught as one of the findings of tertiary syphilis, neurosyphilis can actually happen at any time. Early (weeks-years) neurosyphilis can present without symptoms, with meningitis, ocular syphilis, otosyphilis, and altered mental status. Late (10-30 years) neurosyphilis presents with tabes dorsalis and general paresis.
Treatment is IV penicillin, monitoring for jarisch-herxheimer reaction.
R4 CAPSTONE: personal finances with DR. JENSEN
Dr. Jensen, ironically, has no financial disclosures.
Track your finances every 1-2 months
Get a checking account that doesn’t penalize you, such as Charles Schwab that has no monthly fees, no transfer fees, and no ATM fees
Place 3-6 months of expenses into a high yield savings account (i.e. >1% APY compared to 0.01% from a standard savings account), admittedly more difficult in the current economic environment. Online only options like Discovery, Synchrony, etc tend to have better APY.
Set up a Roth IRA saving up $6k/year or $12K/year for couples and auto-deduct if possible
Maximize bank bonuses, such as free money from opening a new checking account, but limit new accounts to 1 every 3 months if going this route, otherwise you can negatively effect your credit score. Hold onto your longest credit line, even if you only use it sparingly.
Play the credit card point game with a couple caveats: a) only do this if your spending is controlled, b) never spend more than usual to complete a sign up bonus, c) only apply for cards that you will use the points
