Grand Rounds Recap 10.21.20
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Research in Residency with Dr. Freiermuth
What is research? Systematic investigation to reach a conclusion
Discover something new
Develop and evaluate clinical guidelines to practice evidence based medicine
Avoid mistakes
Improve care for patients and colleagues
Basic Steps in the Process
Identify gap
Develop question
Do your background homework
Design study
Collect data
Analyze data
Disseminate findings
PICO – the outline for devising a research question
P for population (who)
I for intervention (what)
C for comparator (alternative)
O for outcome (measurement)
Have an idea? What do I do with it?
Explore whether the question has already been answered
Literature search
Speak with colleagues
Determine if the answer is important to others
Involve a methodologist/biostatistician
Listen and incorporate feedback
TamingtheSRU Bleeding Fistula with Dr. Leech
Case:
EMS telemetry call for an ‘ruptured fistula’ and a tourniquet up. Patient is still bleeding and she is going in and out of consciousness.
Middle age female presents with fistula complication. She has vomit and blood all over her clothes. She is slow to respond to questions and pale appearing.
Vitals:
HR - 50
BP - 74/41
RR - 17
SpO2 - 100% on NRB
Primary Survey:
Airway - vomiting
Breathing - clear and equal
Circulation - thready tachycardic radial pulse in left arm
Hemorrhage - no active bleeding at fistula site
Access:
IO not flowing. Left arm PIV unsuccessful. Trauma line placed. Transfusion began
Disposition:
Transplant manages this fistula and patient was dispositioned to the operating room.
Normal AV Fistula Exam
Skin
No erythema
No focal masses or swelling
Minimal to no scabbing or evidence of inflammation
If an aneurysm exists, skin should not have depigmentation, thinning, or ulceration
Palpation
Soft and compressible
Non-painful
Soft, continuous, diffuse, thrill
Abnormal AV Fistula Exam
Non-healing eschar
Spontaneous bleeding from access site
Rapid expansion in size of aneurysm
Painful to palpation
Thin/red skin
Indications for Surgical Consult
Rapidly increasing aneurysm size
Ulceration or spontaneous bleeding of skin
How to Stop Bleeding
Direct focal pressure
Thrombogenic agents
GelFoam
Topical thrombin
Vasoconstrictive agents
Lidocaine with epinephrine
Severe Bleeding
Correct coagulopathy
Protamine
Heparin often used during dialysis to prevent clots in circuit
DDAVP
Can decrease bleeding in uremic patients
Consider IV TXA though minimal evidence
Last resort techniques
Proximal occlusion
Tourniquet
Figure of 8 stitch
Back to the Case:
Patient was found to have large aneurysmal fistula with multiple connections in the OR. Patient had significant dissection and removal of aneurysmal tissue. Stabilized after multiple units of PRBC and FFP.
Treating Pain in Pregnancy with Dr. Finney
Please see our accompanying TamingtheSRU article by Dr. Finney
Up to 57% of pregnant patients report at least once to an emergency department for pain. When providing medications to pregnant patients, we have to consider safety for mom and baby. Data is limited due to the challenges of studying pregnant patients. The US is moving away from the A-X category system to label medication safety and moving towards written guidelines.
Acetaminophen
Children exposed to acetaminophen had an increased risk of ADHD-like behavior, diagnosis of hyperkinetic disorder, or prescription for ADHD medications.
NSAIDs
Conflicting data between showing risk of spontaneous miscarriage. Avoid use in the third trimester.
Opioids
Increased association with neural tube and cardiac defects. Long term opioids in the 3rd trimester with additional maternal risk factors lead to highest risk of neonatal abstinence syndrome (NAS), whereas short-term, low-dose opioids even in the third trimester showed low absolute risk for NAS.
Ketamine
Very limited data. Would not recommend for routine use.
CPC - DRESs syndrome with Dr. Comiskey and Dr. Harty
Case:
Young male with a rash and fever. Rash began 10 days ago and was treated for poison ivy with steroids. Rash worsened and became more diffuse, red, and itchy. Patient also took ibuprofen for pain associated with poison ivy.
Vitals: BP 130/73, HR 81, SpO2 97% RA
Skin exam showed a diffuse erythematous papular rash with overlying dry skin
Labs:
WBC 12.7
Differential revealed 21.6% eosinophils
CRP to 17.7
DRESS = Drug Reaction with Eosinophila and Systemic Symptoms
Rare drug hypersensitivity reaction that presents with rash, fever, eosinophilia, and organ injury (often liver or kidney).
Approach to Dangerous Rashes Based on Morphology
Petechial/Purpuric
Febrile or toxic appearing
Palpable
Meningococcemia
Disseminated gonococcal infection
Bacterial endocarditis
Rocky mountain spotted fever
Hench-Schonlein purpura
Non-palpable
Thrombotic thrombocytopenic purpura
Disseminated intravascular coagulation
Purpura fulminans
Afebrile and nontoxic
Palpable
Autoimmune vasculitis
Non-palpable
Idiopathic thrombocytopenia
Erythematous
Febrile or toxic appearing
+Nikolskys
Staphylococcal scalded skin syndrome
Toxic epidermal necrolysis (TEN)
-Nikolskys
Toxic shock syndrome
Kawasaki disease
Scarlet fever
Afebrile and nontoxic
+Nikolskys
Toxic epidermal necrolysis
-Nikolskys
Anaphylaxis
Scromboid
Alcohol flush
Medications (niacin, vancomycin)
Vesiculobullous
Febrile or toxic appearing
Diffuse distribution
Varicella
Smallpox
Disseminated gonococcal infection
DIC
Localized distribution
Necrotizing fasciitis
Hand foot mouth disease
Afebrile or nontoxic appearing
Diffuse
Bullous pemphigoid
Pemphigus vulgaris
Localized distribution
Herpes zoster
Contact dermatitis
Burn
Maculopapular
Febrile or toxic appearing
Central distribution
Measles
Lyme disease
Viral exanthem
Peripheral distribution
Steven Johnson Syndrome
Erythema Multiforme
Meningococcemia
Rocky mountain spotted fever
Lyme Disease
Syphilis
Afebrile or nontoxic
Central distribution
Drug reaction
Pityriasis
Peripheral distribution
Scabies
Eczema
Psoriasis
AirCare Grand Rounds with Drs. Skrobut and Gottula
Acute Ischemic Stroke
Air Care transports many acute ischemic strokes and hemorrhagic strokes. We are not just a fast helicopter, we also provide excellent medical management for these patients.
Alteplase
Benefit found in NINDS and ECASS III.
Pooled analysis of ATLANTIS, ECASS, and NINDS showed earlier treatment leads to better outcomes’
Wake up stroke patients with disabling deficit but no LVO seen can benefit from emergent MRI and TPA treatment if indicated
Thrombectomy
6/8 studies showed benefit
Studies are all from 2015 and onward, stroke care has rapidly changed in the past five years
ESCAPE, DEFUSE, DAWN showed benefit for thrombectomy after 6 hours from last known well time in select patients
Intracranial Hemorrhage Simulation
Case
87 year old female on Xarelto with concern for stroke at OSH. Found to have ICH left basal ganglia. and Air Care was called for transport.
Airway
Predicted clinical course, typically will worsen rather than improve
Be sure to check glucose
Coagulopathy
Warfarin
Vitamin K and PCC
Xarelto/Eliquis
Andexxa
PCC appropriate as well. Do not give both
Anti-platelet agents
Consider platelets, but may increase mortality
Consider DDAVP
Dabigatran
Idarucizumab
Can consider emergent dialysis or PCC
Heparin/LMWH
Protamine
TPA
Cryoprecipitate
TXA
Uremia/Von Willebrand
DDAVP
Hemophilia
A - rFVIII
B - rFIX
Thrombocytopenia
Platelets
Blood Pressure
Goal SBP <140-160
On AirCare with have labetalol and nicardipine
Do not forget about sedation and analgesia if intubated
Avoid hypotension
ICP
Hypertonic saline
HOB to 30 degrees
Hyperventilation to temporize
Avoid hyper and hypothermia
Seizure
Treat as you normally would
Benzos and AED
Rapid Neurosurgical Consult
