Grand Rounds Recap 11.2.22
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Morbidity and mortality WITH Dr. zalesky
Case 1: Diabetic Foot Infections
Swabs must be obtained in proper manner to be clinically useful
Wound Classification
PEDIS Score: predicts 6 month risk of amputation and mortality in diabetic foot ulcers
Perfusion
Extent
Depth
Infection
Sensation
Signs of infection: erythema, warmth, tenderness, induration, purulence
Uninfected: no signs of infection
Mild: ≥ 2 signs of infection & erythema ≤ 2 cm
Moderate: > 2cm erythema or deeper structures
Severe: SIRS criteria & local infection
Antibiotic coverage
Mild: Need to cover standard GP, GN
Cephalexin
Amoxicillin-clavulanate
Doxycycline or TMP-SMX for MRSA
What about pseudomonas?
“Empiric therapy directed at P. aeruginosa is usually unnecessary except for patients with risk factors for true infection with this organism”
Moderate-Severe
Ampicillin-sulbactam
Ertapenem
Vancomycin
Piperacillin-tazobactam
Pseudomonas
<10% of wounds
Often improved without coverage
IDSA: do not need empiric coverage from start except:
People who have been soaking their feet
Severe infection
Failure of treatment
Summary:
Diabetic foot infections have crucial information to be conveyed to predict long-term outcome
IDSA classification for severity can help guide management
Treatment should cover GP and GN organisms
Pseudomonas is likely less important than typically thought
Severe illness needs broad antibiotics, admission, and has high likelihood of amputation
Case 2: ED Population and Death by Suicide
45,979 Death by suicide in the US in 2020
40% of patients who die by suicide had contact with an ED
2x ED patients are likely to die by suicide in the next year
Suicide rates by 100,000 person years after ED visit
693 suicide attempt/self harm
384 suicidal ideation
23 control
Risk Factors
History of suicide attempts
Previous psychiatric diagnosis
Recent psychosocial stressor
Older age
Current lethal plan
Caucasian race
Modified SAD PERSONS Scale
Sex
Age
Depression/hopelessness
Previous suicide attempt
Excessive EtOH/SUD
Rational thinking loss
Single, widowed, divorced
Organized plan/attempt
No social support
Stated future intent
Universal screening tools are available: Columbia screener, patient safety screener, ED-SAFE, ICARE2
Summary: Death by suicide
The incidence of patients dying by suicide is increasing
The ED population is at higher risk than the general population
Those with an ED visit for SI or self harm at highest risk
Most ED screening tools have not been shown to be sensitive or specific
ACEP resources: https://www.acep.org/patient-care/iCar2e
Case 3: Respiratory Impact of Spinal Immobilization
FEV1: volume of air exhaled in first second → Decrease by 10%
FVC: total air that can be forced out during maximal effort → Decrease by 4%
20% of bed tilt did not improve FEV1 or FVC
Healthy patients do not usually decompensate from C-collar application but be cautious in patients with underlying respiratory pathology
Summary:
Spinal immobilization is not benign
C-collars and spine boards can decrease lung function in a clinically meaningful way in vulnerable populations
C-collars do not decrease oxygenation or ventilation in healthy trauma patients
Case 4: Substance Use Disorder and Trauma
Persons with SUD visits accounted for annual average of 7.3% of ED visits and 8.0% of hospitalizations
Head trauma and the intoxicated patient
9% of intoxicated patients with signs of injury above the clavicles had an ICH with 8% being deemed clinically important
SAH
IPH
SDH
Epidural
Worse sensitivity for tools used on intoxicated patients:
Canadian head CT tool: 73% sensitive
NEXUS head CT tool: 86% sensitive
Summary: Substance Use and Trauma
Persons with SUD represent a large portion of ED population
Patient with SUD present more frequently for traumatic injuries
Clinically significant head injuries often occur with intoxicated patients
Respect abnormal vital signs in intoxicated patients
Case 5: Thoracic Outlet Syndrome
Variants
Neurogenic: most common cause 90%
Venous: 10%
Arterial: <1%
Neurogenic
Can see color change and coldness due to overactive sympathetic nervous system whose fibers run on the circumference of the nerve roots
Initially managed with physical therapy
Medical therapy- interscalene injections of anesthetic agents, steroids, botox
Venous
Overhead sport athletes can develop this from repetitive shoulder hyperabduction and external rotation that can compress axillary-subclavian veins
Management: can involve systemic anticoagulation, extremity rest and elevation, catheter-directed thrombolysis
Arterial
Most common presentation: hand ischemia with pain, pallor, paresthesia, coldness
Symptoms due to arterial thromboembolization from mural thrombus from subclavian artery or subclavian aneurysm
Physical exam:
May reveal absence of distal upper extremity pulses
Delayed cap refill
Ischemia to distal fingers
May have tender supraclavicular prominence, palpable pulsation of supraclavicular artery, audible supraclavicular bruit when arm is placed in a position of arterial compression
Overhand exercise test: patient raise both arms overhead and rapidly flex and extend the fingers
Provocative test that suggest arterial insufficiency
Positive test: heaviness, fatigue, numbness, tingling, skin blanching, or discoloration within 20 seconds
Summary: Arterial Thoracic Outlet Syndrome
Thoracic outlet syndrome is a constellation of neurologic, venous, or arterial compression
Arterial is the most rare often presenting with pain and paresthesias of the hand
Cervical ribs or anomalous first ribs are common
Most provocative tests are not helpful but arterial exercise test and ULTT have been described
Examining the neck and subclavian area can also be helpful
Case 6: Multiple Sclerosis patient with expedited work-up
Always be weary of pending tests
Going the extra mile for your patients can make a difference
What you do matters
r4 case follow-up WITH Dr. Meigh
Central Vertigo:
Posterior circulation stroke/TIA
Vestibular migraine
Neoplasm
Demyelinating disease
Brainstem encephalitis
Peripheral
BPPV
Vestibular neuritis
Labyrinthitis
Meniere’s disease
Medication ototoxicity
Otitis media
Ramsay Hunt Syndrome
ATTEST Method: Definitions
Acute Vestibular Syndrome (AVS): acute, continuous dizziness lasting days, accompanied by nausea, vomiting, nystagmus, head motion intolerance, & gait unsteadiness
Benign causes: vestibular neuritis, labyrinthitis
Serious causes: posterior circulation stroke, multiple sclerosis
Spontaneous Episode Vestibular Syndrome (s-EVS): episodic dizziness that occurs spontaneously and is not triggered (lasts minutes to hours)
Benign causes: vestibular migraine, Meniere’s
Serious causes: TIA
Triggered Episodic Vestibular Syndrome (t-EVS): episodic dizziness brought on by a specific, obligate trigger (typically head turning or standing up), usually lasting <1 minute
Benign causes: BPPV
Serious causes: CPPV, orthostatic hypotension
HINTS exam= Head Impulse, Nystagmus, Test of Skew
Only use in patients with acute vestibular syndrome
Persistent vertigo
Nystagmus
Used to distinguish between peripheral and central causes of vertigo
Head Impulse
Positive test: corrective saccade = peripheral
Negative test: no saccade = suggest of central cause
Nystagmus
Central: bidirectional, rotary, torsional nystagmus
Peripheral: unidirectional (fast phase only even in one direction)
Test of Skew
Positive test: skew deviation = central
Negative test: no skew deviation = peripheral
Be aware of relying on age and risk factors
In largest prospective study in AVS, 25% of ischemic stroke were in patients < 50 years old
Most commonly vertebral artery dissection in younger population
50% of vertebral dissections occur without trauma
Young females at highest risk of being misdiagnosed
Imaging
Non-contrast Head CT
Estimated to be 21% sensitive
4% of posterior strokes hemorrhagic
Diffusion-weighted MRI
False negatives more common than thought in early posterior circulation stroke (<48 hours)- sensitive about 83% in one estimate
Specificity 97%
CTA
Particularly useful if concerned for vertebrobasilar artery dissection
May demonstrate arterial occlusion
Thrombolysis in pregnancy
Pregnancy is an exclusion criteria for RCTs on tPA; historically a relative contraindication
tPA does not cross the placenta- teratogenicity or fetal hemorrhage risk thought to be low
Most literature exists in case reports
Likely a risk-benefit discussion with the stroke team based on severity of deficits and bleeding risk
Dissection treatment: intracranial vs extracranial
Extracranial:
Thrombolysis is okay
Antiplatelet or anticoagulation therapy- several trials performed to determine which is superior; data appear inconclusive
Intracranial
Thrombolysis more controversial but still performed
Higher risk of SAH
Recommend starting antiplatelet therapy over anticoagulation (delay 24h if TNK given)
Social Emergency medicine grand rounds WITH dr. diaz and dr. jarrell
Language Justice: evolving framework based on the notion of respecting every individual’s fundamental language rights- to be able to communicate, understand, and be understood in the language in which they prefer and feel most articular and powerful
Limited English Proficiency: individuals who do not speak English as their primary language and who have a limited ability to read, speak, write, or understand English can be limited English proficient, or “LEP.”
These individuals may be entitled to language assistance with respect to a particular type or service, benefit, or encounter
More definitions
Interpretation: spoken language assistance
Interpreter: a person who interprets, especially one who translates speech orally
Translation: written language assistance
Translator: person who provides written language assistance by translating one language into another
Ad hoc interpreter: family member or friend of the patient providing spoken language assistance
Interpreters mediate languages orally while translator work with the written material
Why is this important?
Title VI of the Civil Rights Act of 1964
Title VI regulations, prohibiting discrimination based on national origin
Executive order 13166 issued in 2000- “Improving Access to Services for Persons with Limited English Proficiency”
Google Translate instructions in the ED
Google translate instructions in the ED are inconsistent between languages and should not be relied on for patient instructions
Phrasing matters
“Do you speak English?”
Instead, ask “Do you prefer English or another language?”
Tips on using a interpreter
Speak to the patient, not the interpreter
Speak in short sentences
Explain a physical exam before doing one
Explain next steps
Provide reassurance and discharge instructions
r1 clinical diagnostics: complications with immunotherapy WITH dr. rodriguez
Chemotherapy: the treat of a disease by the use of chemical substances by cytotoxic and other drugs
Immunotherapy: a form of treatment that uses the body’s own defenses to fight disease
Neutropenic fever
Who: patients on chemotherapy
Neutropenia: ANC <500 or expected to decline to <500 within 48 hours
Fever: single oral temperature > 38.3C or 101F OR at least 38C (100.4F) for at least 1 hour
What is immunotherapy?
Concept: A form of treatment that uses the body’s own defenses to fight disease
Immunosuppression: transplant rejection prophylaxis, autoimmune disorders
Activation: cancer treatment
Everyone on immunotherapy is NOT immunocompromised
Types of immunotherapy
Monoclonal antibodies
Checkpoint inhibitors
Cellular therapy (CAR-T)
Tumor infiltrating lymphocytes
Cancer treatment vaccines
Oncologic virus therapy
Immune related adverse events: term we would otherwise use for “adverse effects”
Most commonly presenting to the ED: diarrhea, colitis, dermatitis, pneumonitis, hypophysitis
Most feared complication: pneumonitis
Most common complication: diarrhea
Diagnostics depend on patient’s chief complaint and symptoms
Treatment: steroids (in consultation with specialist), supportive therapies
Example A: CAR-T
FDA approval for pediatric acute lymphoblastic leukemia (mostly B cell lymphomas) and adult advanced lymphoma that are resistant to standard therapies
Common Adverse Reactions
Cytokine release storm: fever, hypotension, hypoxia, multiorgan failure
Often confused for sepsis
Dx: CBC, CMP, mag, phos, CRP, LDH, ferritin, uric acid, fibrinogen, PT/PTT, INR, blood cx, urine cx, CXR
Management: IVF, O2, antipyretics, antihistamines
In life threatening cases can give tocilizumab
Neurotoxicity: fever, aphasia, AMS, motor weakness, seizures, cerebral edema
Can mimic stroke and meningitis
Dx: CBC, CMP, ferritin, fibrinogen, MRI or CT, LP, HIV, RPR
Management: supportive therapies + seizure prophylaxis
Example B: Immune Checkpoint Inhibitors
Common adverse events
Rash:
Maculopapular rash with pruritus
Eczematous
Blistering reaction (SJS/TEN)
Dx: Hx, physical exam CBC, BMP
Management: oral antihistamines or topical steroids
Diarrhea
Diarrhea
Abdominal pain
Hematochezia
Weight loss
Fever
Vomiting
Can lead to colitis, perforation, and death
Dx: CBC, BMP, TSH, LFTs, lipase, CT A/P
Management: monitor for dehydration, electrolyte imbalances, +/- give antibiotics
Pneumonitis
Flu-like symptoms
Dyspnea
Hypoxia
Crackles
Chest tightness
Dx: CBC, BMP, CXR, CT chest w/ contrast, COVID, blood cultures, UA
Management: O2, fluid resuscitation, high dose corticosteroids
Symptoms can present up to 2 years later
Take home points:
Immunotherapy does not mean immunocompromised
Patients can present with vague complaints
Look out for pneumonitis, colitis, neurotoxicity (depending on the agent)
Involve heme/onc early
R3 Taming the SRU with Dr. Stevens
Case: Necrotizing Pneumonia
Presentation
Ill appearing, toxic, rapid decline
Septic shock within 72 hours
Involves multiple lobes
Diagnostics
CT: patchy inflammation with lack of perfusion and microabscesses
Microabscesses may coalesce to form large cavities
Can progress to lobar gangrene
Management and Complications
Typically caused by Strep pneumoniae and Staph aureus
Less commonly: Klebsiella, Haemophilus, and Pseudomonas
Thoracic surgery consult for surgical debridement
Lung abscess
Indolent course
Single cavity with fibrous capsule
Anaerobes from mouth
Outpatient antibiotics
May need percutaneous drainage if failed medical therapy
Pulmonary Gangrene
Obliteration of pulmonary artery supply to segment or lobe associated with large cavities and necrotic parenchyma
Caused by Klebsiella and Pseudomonas aeruginosa but may also occur in Strep pneumoniae
Requires surgical debridement of sloughed lung parenchyma
