Grand Rounds Recap 10.20.21
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Wellness Grand Rounds WITH REVIVE FITNESS
Eustress - essential to grow, develop, and achieve high levels of performance
Distress - potential source of physical, psychological problems, especially when chronic
When stress exceeds capacity, it is often the result of a cumulative effect and has physiologic effects on the body.
Think about inputs - intentional eating, drinking, meal prepping, appropriate portioning and storage (mason jars!).
Options on the go might include stir fry, meat skewers, thin crust/flatbread, salad bar
Be conscious of your water intake - drink at least 50% of your bodyweight, in pounds, measured in ounces of water each day. Drink small amounts throughout the day rather than chugging.
Aim to maintain a regular eating pattern regardless of your shift
Eat q 4 hours with 3 main meals and 2-3 snacks in a 24 hour period
If you snack at night, aim for protein-containing snacks
Don’t go to bed hungry
Planning your meals for day shifts
Eat a breakfast that gives you energy
Lunch to keep you alert/energized
Dinner to help you fall asleep and reduce hunger cravings
Reverse this for night shifts
Self-survey - Ask yourself these questions
How is your energy throughout the day?
How much sunshine do you get in a day?
How many hours do you sleep? What is your sleep quality?
How often do you defecate? Quality of that BM?
What are your stress levels?
How often do you move throughout the day?
Your food hygiene?
Tips for night shift workers
Maintain consistency in your sleep schedule, even while on night shift
Caffeine in moderation
Get moving if needed, take a break and go for a small walk
Take a power nap ~ 10-20 minutes
Consider a post shift snooze
For ideal sleep: reduce light and noise pollution, delay bedtime post-shift for a few hours, consider relaxing activities before bed and avoid alcohol immediately before as it can lead to fragmented sleep. Aim for ambient temperature modulation.
Implementing a fitness routine
Should be (1) sustainable aiming at balance between elite sport and fitness for life depending on personal goals (2) specific for your personal goals (3) repeatable with easy adherence
R1 Clinical Knowledge: Acute Vision Loss WITH DR. GRISOLI
The differential for acute monocular vision loss or decreased visual acuity can be broken down by anatomic location
Anterior chamber (generally painful): foreign body, ulcer, glaucoma, hyphema, lens dislocation, cataract
Posterior chamber (if painful, then often traumatic): vitreous hemorrhage, retinal detachment, retinal ischemia, macular degeneration, endophthalmitis
Optic nerve, tracts, and cortex: compression, neuritis, ischemia, CVA
Central retinal artery occlusion (CRAO): “Stroke of the eye”
Unilateral acute painless vision loss
On exam, patients will often have a relative afferent pupillary defect (90% of patients according to 2018 Vanderbilt study) and complete or partial vision loss on confrontational visual field assessment. Exam should also include a fundoscopic exam and/or a dilated exam with a panoptic, which may show a cherry red spot (macula)
Risk factors for CRAO include: sickle cell disease, carotid and cardioembolic disease, arteritis, hypercoagulability, vasculitis such as SLE, polyarteritis nodosa, sarcoidosis, GPA
Treatment:
Time is…eye.
Decrease IOP with Timolol q 30 minutes x 2, Acetazolamide 500 mg
Alternative therapies:
Ocular massage, consisting of repeated increased pressure applied to the globe in an in-and-out movement for 10-15 seconds followed by sudden release q 3-5 minutes
Anterior chamber paracentesis
Hyperbaric oxygen
Thrombolytics?
(European Assessment Group for Lysis in the Eye) EAGLE Study - multicenter RCT to evaluate treatment of CRAO with lytics.
Population: 18-75 with CRAO for 20 hours or less, visual acuity < 0.32 and no BRAO, cilioretinal artery supply, serious general disease
Intervention: Local intra arterial lysis therapy with 50 mg of rtPA into Ophthalmic Artery followed by Heparin
Control: bulbus massage, lowering intraocular pressure with topical beta-blocker and acetazolamide, acetylsalicylic acid, heparin, and-depending on the hematocrit-isovolemic hemodilution
Outcome: Unfortunately, study conclusions limited by very slow recruitment. Loca intra-arterial fibrinolysis (LIF) has promise, but currently insufficient evidence to support it.
Tenecteplase potentially safer and more effective alternative tPA given the results of the ENTEND trial.
Ophthalmology consult/transfer and admit patient for stroke and GCA work up (possible steroids) and risk factor modification
According to one study, 70% found to have clinically significant carotid disease, 36% found to have critical stenosis, 93% had a change in medication as a result of their work up.
Patients with CRAO had a comparable risk of subsequent stroke, myocardial infarction, and death as patients with high-risk transient ischemic attack (TIA).
Central retinal venous occlusion (CRVO)
Painless, monocular vision loss
Patients may or may not have APD on exam. On fundoscopic exam, providers may not “blood and thunder” appearance, which represents dilated and tortuous veins, intraretinal hemorrhages, and cotton wool spots. No findings on eye ultrasound.
Differential may also include AIDS retinopathy, syphilis retinopathy
Treatment:
No real treatment in the ED
Consult ophthalmology
Focus on preventing complications and progression
Macular edema often develops in first week, which may be their initial presentation.
Glaucoma can develop within 90 days.
Ophthalmology may offer anti-VEGF treatment to help prevent.
No need for system anticoagulation or antiplatelet agents
Attending Case Follow-Up: Abdominal Aortic Aneurysm WITH DR. MINGES
Case 1: Elderly patient with PMH of HTN, tobacco use presents with lower back pain and syncope at home and appears diaphoretic and has a tender, distended abdomen. VS: BP 70/55, HR of 65, RR 20, SpO2 98% on RA on presentation.
Diagnosis: Ruptured abdominal aortic aneurysm, confirmed by US 6 minutes after presentation
Case 2: Elderly patient with PMH of HTN, tobacco use presents with low back pain after doing yard work. Looks well. VS: BP 170/104, HR 74, RR 20, SpO2 98%.
Diagnosis: Ruptured abdominal aortic aneurysm, confirmed by US 15 minutes after presentation
Paradigm 1 - Making the diagnosis
If you are finding a AAA on a CT, you are doing it wrong.
CT angiography is important and can tell you important details that we are not able to obtain from US, but it is far too time-consuming to make the diagnosis. The time to US diagnosis in studies involving an ED population ranged from 5-30 minutes with the average CT diagnosis being over an hour.
False positives on US: enlarged abdominal lymph node, pancreatic pseudocyst
Tips for scanning: put your weight into it, use the windows you have, find the spine, look for the cookie monster mouth
Assess in both transverse and longitudinal views. Measure in transverse view.
Beware of cylinder tangent effect that can lead to a falsely low luminal measurement if the probe is not positioned at the vessel midline in the longitudinal plane.
Paradigm 2 - Treatment
“US might set the table, but you still have to clear the dishes”
Call your friends (Vascular Surgery)
Get the blood, consider activating MTP
Rapidly establish multiple points of IV access
Bring family to bedside. This is a highly morbid condition so give family the opportunity to see the patient before they go to the OR.
Paradigm 3 - Facilitating the best treatment efficiently
EVAR patients do better than open repairs. You will need a CT to facilitate EVAR, but you can expedite care of the patient by doing US first, making the diagnosis, and then calling the surgeon, ordering the CT, +/- arranging transport.
Other important aspects of management:
Permissive hypotension
Reverse anticoagulation
TXA?
When preparing for the high risk transfer: aim for speed, know your referring centers/options, grab blood, meds/drips, procedures like intubation.
Resuscitation Debriefs WITH DR. PAULSEN
Resuscitation debriefing can be an effective and valuable method, especially for adult learners
According to one study, 60% of participants did either no debrief or debriefed only once after resuscitation
Debriefs most often did not take place due to lack of time, perceived neglect of other patients, lack space to do so, lack of training in resuscitation debriefs.
In one study of those who did do 1-5 minute debriefs, 100% rated them as “good or excellent,” 90% said that they felt better afterwards
Two semi-structured options to guide debriefs:
PEARLS Healthcare Debrief Tool - “Debriefing without judgement”
Set the scene - ensure that goals are aligned, create a safe context for learning
Reaction - explore feelings
Description - clarify facts
Analysis - explore variety of performance domains
Application/summary - identify takeaways
STOP5 Tool
Summarize - allow for expressions, feelings
Things that went well
Opportunities to improve
Point to responsibilities - ensures accountability, can suggest operational issues that need to be discussed and reported back
5 minutes - set a timer
When to debrief
Trauma stat
Cardiac arrest
Airways
Provider discretion: infrequent, emotionally charged events like significant burns, pediatric patients
Setting the stage - what to say:
“Is everyone okay?”
“We're going to have a 5 minute debrief, team”
“The goal of this is to improve patient care. This is not punitive.”
“All are welcome, but no one is required to attend.”
