Grand Rounds Recap 8.24.22

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R2 CPC: Neurocysticercosis wITH Dr. Negron and Dr. Pulvino

Case presentation: Middle aged female who presents after a fall followed by shaking seizure-like activity that occurred for 5 minutes. Afterwards, the patient was sleepy and could not recall the event. Now the patient has a headache without any other complaints.

Diagnosis: Neurocysticercosis 

  • Taenia solium

  • Ingestion of infected and poorly cooked pork = Taeniasis (classic tapeworm)

  • Ingestion of T. solium eggs or proglottids

    • Human cysticercosis

    • Porcine cysticercosis

  • Endemic regions: Central and South America, sub-Saharan Africa, portions of Asia

  • Clinical presentation

    • Parenchymal neurocysticercosis (cysts in brain tissue)

      • Most common form (>60% of affected individuals)

      • Can be asymptomatic 

      • Most common symptom: seizures 

    • Extraparenchymal neurocysticercosis (cysts located in intraventricular and subarachnoid spaces)

      • Symptoms associated with elevated ICP including headache, nausea, vomiting, and visual disturbances

      • AMS

    • Extraneural

      • Ocular: impaired vision, diplopia, blindness

      • Can also be in subcutaneous tissue, muscle, cardiac tissue

  • Diagnosis

    • Important to obtain detailed patient history, exposure, risk factors

    • CT or MRI brain- may see cystic lesions, enhancing lesions and calcifications, different stages of cysts

    • Serologic testing should be performed as confirmation, especially when CT/MRI findings are suggestive but not diagnostic

      • Serologic test of choice: enzyme-linked immunoelectrotransfer blot (EITB)

    • Patients should also undergo screening for latent tuberculosis as well as screening for parasitic infection caused by S. stercoralis 

  • Management

    • Manage complications first:

      • Cerebral edema → dexamethasone

      • Elevated ICP → ventricular drain

      • Ocular cysts → surgical removal

    • Corticosteroids prior to antiparasitic

      • Albendazole monotherapy for 1-2 cysts

      • Albendazole + Praziquantel for >2 cysts

      • 10-14 day course of anti-parasitic, follow up MRI 6 months

    • AED recommended for 24 months from start of treatment: Keppra

R4 Clinical capstone WITH Dr. Goff

Learning Cases from R1-R4 year

Acute mitral valve prolapse secondary to papillary muscle rupture after MI

  • presents within the first week (similar to ventricular wall rupture)

  • results in hypoxic respiratory failure due to pulmonary edema

  • treat with afterload reduction and diuresis while awaiting mechanical support and operative repair

Ascending Cholangitis

  • Charcot's Triad: Abdominal pain, fever, jaundice

  • Treat with broad spectrum ABX (Zosyn) and ERCP

Bougie Intubation

  • This is a two person technique

  • May rescue a difficult airway with unique feedback mechanisms including tracheal "ticking" and "hold up"

  • Remember expected depth of ETT in adults is ~22 cm at the teeth

Igel Exchange to ETT

  • Ideal for patient with multiple failed intubations now rescued by Igel and other predictors of a difficult airway

  • If the endoscope is at the carina and the patient vomits and a fountain of emesis is issuing from the ETT, this is the one time where the solution is to advance the ETT

Steps for Endoscopic Intubation through a SGD

  • 12F salem sump will fit through a size 4 iGel decompression port

  • Insert ETT

  • Add bronch adaptor to allow for oxygenation and ventilation

  • Insert endoscope and advance to the carina

  • Remove endoscope and bronch adaptor and insert a second ETT one half size down

  • Advance initial ETT and pilot balloon through the iGel 

  • Remove second ETT, then remove the iGel, and attach to BVM/vent

Indications for eFAST

  • Hemodynamically unstable blunt or penetrating trauma seeking immediately reversible cause (PTX) or indication for direct to OR

  • Sensitivity / NPV is not high enough to exclude intra-abdominal injuries

Indications for DRE in trauma

  • High risk blunt (straddle injury) or penetrating trauma to the perineum, pelvis, abdomen

  • Pelvic fractures (prior to Foley as well)

  • Evidence of neurologic injury (assessment of rectal tone)

  • Gluteal flexing is a poor surrogate for DRE

NG feeding a hiatal hernia

  • Increased risk of aspiration versus sub diaphragmatic feeding but may be the right choice in the right patient 

Exam maneuvers for factitious disorders

  • These patients are symptomatic, the question is as to the locality of the disease

  • We should be facile in some maneuvers to augment decision making regarding disposition

  • Special tests include Hoover's sign and Give Away Weakness

Medical screening exam and cake

  • The MSE requires that we identify patients with emergent conditions (these are the boards questions, the "cake")

  • Our work includes many patients that fall outside of this mandate which offers unique and exciting challenges, like the frosting on the cake

  • It is expected however that too much frosting can make you feel sick sometimes

r1 clinical knowledge: Traumatic aortic injuries WITH Dr. Rodriguez

  •  Blunt aortic injury is the second most common cause of death from blunt trauma after head injury

  • 80% mortality for patients prior to reaching the hospital

  • Mechanisms: 

    • Penetrating

      • Stab injury

      • Firearm injury

    • Blunt

      • MVC >30 mph

      • Falls > 4m/13 feet

      • Crush injuries

  • Sites of Injury

    • Chest: 1-2% of blunt thoracic trauma causes aortic trauma

      • Aortic isthmus: 75-95%

      • Children are less likely to sustain injury to aorta due to more elasticity in their vessels

    • Abdomen: <0.1%

  • Aortic Injuries in the chest

    • History: chest pain, dyspnea. 25% have chest pain that radiates to their back

    • Physical Exam: broken ribs/flail chest, new murmur, unequal pulses, hemorrhagic shock, tachycardia, hypotension

  • Aortic injuries in the abdomen

    • 1 in 4 thoracic aortic injuries extend into the abdomen

    • History: MVC (75%), crush injury (25%), abdominal pain, compression of seat belt and spinal column 

  • Diagnosis: history, imaging modalities

    • FAST exam: does not include the aorta but may see secondary signs of aortic trauma including intra-abdominal hemorrhage

    • Chest X-ray: Sensitivity 41%

      • 7-30% normal, do not always see widened mediastinum

      • May see tracheal deviation, apical pleural cap, aortic knob obscuration, L main bronchus depression

    • CT angiography of chest

      • Reserved for hemodynamically stable patients

      • Abnormal aortic contour

      • Extravasation of contrast

      • Pseudoaneurysm

  • Treatment

    • Resuscitation: IVF, blood transfusions

    • Lower BP: Goal 100-120 SBP

      • Beta Blocker: 1st line esmolol

      • Nitroprusside can have reflex tachycardia and worsen injury

      • Nicardipine is an option

    • Definitive: surgery

  • Take-home points

    • Deceleration injuries are the most common cause of blunt thoracic aortic injuries

    • It is important to quickly recognize aortic injury and get appropriate imaging. Start with CXR, can pursue CT of stable

    • The isthmus is the most common site of injury in the chest.

    • Definitive treatment includes surgical repair

Patient safety WITH Dr. hemphill

  • Understanding Error

    • Active vs Latent Error

    • Blunt end vs sharp end

    • “Blaming the falliable individuals at the sharp end is universal, natural, emotionally satisfying, and legally convenient. Unfortunately it has little or no remedial value.”

    • Fundamental attribution error, illusion of free will, similarity bias

  • Just Culture

    • An atmosphere of trust in which people are encouraged (even rewarded) for providing essential safety-related information. Individuals trust that they will not be held accountable for system failures, but are also clear about where the line must be drawn between acceptable and unacceptable behavior

    • Understand human error and why adverse events occur

  •  The Leaders Role in Creating High Safety and High Functioning Teams

  • “Dictator”

    • Complete control, input not welcome

    • Autocratic, intimidating, rude, hostile

    • Atmosphere that inhibits:

      • Flow of information

      • Action

  • Leadership Theories

    • Transformational Leadership: how leaders stimulate others to transcend their own self interest to reach higher order goals or visions. Motivate others through raising awareness of idealized goals

    • Situational Leadership: effective leadership depends on selecting the right leadership style contingent on the follower or group context, these people shift leadership styles to the situation or group

    • Servant Leadership: drives from serving the needs of others. Listen, empathize, accepting stewardship, develop other potential

  • Leaders Create High Functioning Teams

    • Interpersonal Skill (NASA Study 1990)- greeting the team, using manners, eye contact, good body language, etc. NASA study found that Captains with interpersonal warmth and concern, termed expressivity, their crews made fewer errors when compared to crews lead by Captains with less interpersonal acumen

    • Invite Participation- “please speak up”

    • Strategic open-ended questions

    • Set acknowledgement expectation

      • Closed loop communication- any communication from the sender must be acknowledged- gesture, nod, or verbal- this is a staple behavior on high functioning teams

    • Briefings

      • Must be done by leader, done early after team forms, must be short (can be 30 seconds), must be structured, must allow the team to ask questions. Covers expectations for work and for communication

    • Debriefings

      • Initiated by team leader, short (usually a few minutes), guided by a checklist, reviews team performance/safety environment, goal is improvement

      • Great after high-risk, low-frequency events

  • Team Briefing Checklist

    • Greet team

    • Goals

    • Rules- speak up, acknowledge communications

    • Roles

    • Expected threats

    • Any questions

  • 3 “W”s 

    • What I see

    • What I’m concerned about

    • What I want