Grand Rounds Recap 10.4.23

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Morbidity and Mortality WITH dr. finney

Takotsubo Cardiomyopathy with COVID-19

  • Increasing incidence of Takotsubo Cardiomyopathy with the COVID-19 pandemic

  • Morbidity and mortality is similar to that of ACS

  • Diagnosis requires findings on U/S and EKG +/- troponin w/o significant obstructive CAD and the absence of other mimicking diagnoses

  • Treatment is supportive care and hemodynamic support, as it is typically temporary

Elevated ETCO2 in Out of Hospital CardiacArrest

  • ETCO2 provides noninvasive estimate of cardiac output and organ perfusion & can be used to monitor quality of CPR and predict ROSC

  • Higher values can be associated both with higher likelihood of ROSC and survival to hospital discharge with good neurologic outcome

  • Trends of ETCO2 may be of higher utility than isolated measurements, though all should be interpreted within the clinical context of the patient and potential confounders

Cutaneous Lupus Erythematosus

  • Isolated skin manifestation of lupus and can be rapidly progressive and disabling to patients

  • Treatment for localized rash begins with topical steroids

  • Systemic disease usually requires hydroxychloroquine +/- methotrexate

  • Flares or severe disease may require oral steroid bridge

Acute Ischemic Stroke due to Infective Endocarditis

  • Infective endocarditis has a high rate of ischemic stroke with severe morbidity and mortality

  • IV thrombolysis is not recommended in treatment due to increased risk for hemorrhagic transformation

  • There is limited data of mechanical thrombectomy for LVO, though overall seems to be feasible with similar safety outcomes to standard cardioembolic rates and may lead to neurologic improvement

Typical Atrial Flutter

  • More difficult to rate control atrial flutter with pharmacologic management

  • Successful catheter ablation in first time atrial flutter leads to low rate of recurrence

  • Patients with decreased EF secondary to tachycardia have higher rates of recovery of EF with catheter ablation

  • IV potassium and magnesium infusions have no correlation with successful cardioversion of atrial flutter

Closed Loop Small Bowel Obstruction with Necrosis

  • CT scan is the gold standard for diagnosis of SBO, though complications such as ischemia can be missed

  • Delayed time to surgery for ischemia portends a significantly increased mortality in patients with SBO

  • Patients with closed loop obstruction have a higher rate of ischemia compared to traditional SBO

  • Even in the setting of a negative CT, trust your history and physical exam

Quality improvement WITH Dr. Thompson

  • Human factors: how the cognition of individuals or teams intersects with environments in which they work

    • Cognition, biases, intellectual faults, workspace, technology that can work in our favor or work against us

  • Biases: confirmation, availability, anchoring, overconfidence

  • Human errors vs systems errors

  • Triggers for cognitive errors: interruptions and distractions, tasks required outside of normal sequence, unanticipated new tasks, interweaving multiple tasks

  • Stress management techniques: controlled breathing, positive self-talk, cognitive reframing, stress inoculation, mental rehearsal

  • Team dynamics in resuscitation: how we use language, graded assertiveness, pre-briefing, team structure

research grand rounds WITH dr. freirmuth

  •  Pragmatism can more closely resemble real world environments

  • Not all trials need (or should have) adaptive designs

  • When used appropriately, adaptive designs may:

    • Improve efficiency and reduce cost

    • Maximize the information obtained

    • Minimize risk to subjects and sponsor

  • Design decisions should be based on objective performance rather than habit

  • An adaptive design will not save a poorly planned trial or ineffective treatment

r1 clinical knowledge: posterior reversible encephalopathy syndrome/reversible cerebral vasoconstriction syndrome WITH dr. sookdeo

  • PRES occurs when the cerebral vasculature is compromised by either autonomic dysregulation or endothelial dysfunction, leading to vasogenic edema of different areas of the brain

    • These patients most commonly present with hypertension, dull gradual headaches or seizures

    • Initial imaging will likely be normal, if high suspicion, have a low threshold for involving neurology and aggressive blood pressure control

  • RCVS occurs when vasospasms of the cerebral vasculature restrict blood flow to certain areas of the brain, presenting as a thunderclap headache

    • Patients most commonly present with a sudden thunderclap headache +/- focal neuro deficit

    • Watch out for patients on chemotherapy and immunosuppressants

  • These can be difficult to distinguish as RCVS can be a complication of PRES when an area of the brain undergoes changes secondary to vasogenic edema —> vasospasm

    • Approach the two with similar thought and action in the ED

r4 case follow-up WITH dr diaz

Compartment syndrome:

  • Compartment syndrome can be difficult to diagnose just based on just clinical findings

  • The highest sensitivity can be achieved when clinical findings are coupled with compartment pressures

  • An arterial line transducer it can be utilized if no Stryker needle is available

  • Management includes immediate surgical consultation for compartment fasciotomies