Grand Rounds Recap 11.6.19

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QIKT: Strangulation and Asphyxiation WITH Dr. Berger and Dr. Irankunda

Definitions

  • Strangulation: excessive or pathologic constriction or compression of a bodily tube that interrupts its ability to act as a passage

  • Asphyxiation: a lack of oxygen or excess of carbon dioxide in the body that results in unconsciousness and often death and is usually caused by interruption of breathing or inadequate oxygen supply

Epidemiology

  • North America and South America have highest rates of hanging

  • Hanging most predominant method of suicide in most countries (2nd in US behind firearms)

  • Hanging more common in males as suicide attempt, strangulation more common in females as homicide

Injury Patterns

  • Symptoms: neck/throat pain, trouble swallowing, shortness of breath, vocal changes, dizzy, blurred vision, urinary incontience, pain with talking

  • Exam findings: linear abrasions around neck, petechial bruising, non-petechial bruising around neck, subconjunctival hemorrhage, soft tissue swelling

  • Injury Patterns: pulmonary edema/emphysema, hyoid fracture, thyroid fracture, cerebral edema, vascular injuries (ex. dissection), cervical spine injury (rarely in isolation, often found with other injuries)

    • Of note, a low GCS is a risk factor for development of ARDS

Diagnostics and Management

  • Airway:

    • Per one study, 58% of patients end up needing emergent airways, and nearly all were successful without complications

    • Neck injury disrupting the airway is very uncommon

    • Signs of non-emergent airway: Dysphonia/hoarsenss, stridor, dysphagia/odynophagia, SOB, anterior neck pain/swelling/crepitus, hemoptysis

      • CT is preferred evaluation of cartilaginous structures

      • Recommend endoscopic evaluation as CT does not tell you about cord dysfunction

      • This group of patients often end up with observation

  • Respiratory Considerations:

    • Patients at risk for post obstructive pulmonary edema (POPE), neurogenic pulmonary edema (NPE), acute respiratory distress syndrome (ARDS)

    • CXR indications: intubation, respiratory distress, new oxygen requirement, abnormal lung auscultation

    • Treatment can include positive pressure ventilation (ex. BiPAP), diuretics, increase PEEP if intubated, frequent suction

  • Vascular Considerations: high risk of stroke and poor neurologic outcomes

    • Guidelines for imaging: GCS<8, audible neck bruit, expanding neck hematoma, focal neurologic deficit (including TIAs, Horner’s syndrome, vertebrobasilar syndrome), arterial bleeding from nose, mouth, neck

      • OR consider adding on if high C spine fracture, cervical vertebral body or fracture through foramen transversarium, subluxation or ligamentous injury at any level, significant thoracic/cardiac blunt force trauma, LeFort II or III fractures, skull base fracture, diffuse axonal injury

      • CTA neck AND head (can miss top of carotids with just CTA neck)

  • Spine:

    • Patients should be placed in cervical immobilization

    • Cervical spine clearance should be performed by standard clinical and radiologic means

  • Brain:

    • All patients with GCS<15 should receive a head CT

    • Patients with lateralizing symptoms should have CTA head and neck

    • Findings consistent with anoxic brain injury should prompt consultation with neurocritical care

      • Consider TTM as treatment in these patients

Ventilator Management WITH Dr. Knight

Indication for mechanical ventilation are the same as intubation 1) failure to oxygenate 2) failure to ventilate 3) airway protection 4) clinical course.

  • Variables: the independent factors that we can set

    • Tidal Volume - connected to pressure through compliance

    • FiO2 - titrate down as fast as possible

    • RR - set rate and check gas in 30 min

    • PEEP - initial settings in ED usually between 5-10

    • Pressure - connected to tidal volume

    • Inspiratory flow/time

  • Modes: the right mode is the one that is best for the patient, as well as the one that you are familiar with

    • Assist Control (Volume) - watch plateau pressure for concern for barotrauma

    • Assist Control (Pressure) - often used in restrictive pattern, ex. ARDS

    • Spontaneous - used for airway protection patients, will correct acid/base issues themselves

    • APRV - inverse ratio, pressure controlled, intermittent mandatory ventilation with unrestricted spontaneous breathing

    • SIMV - combined spontaneous and AC (patient can take additional breaths above what you set); can be dyssynchronous

  • Trouble Shooting:

    • D - displacement

    • O - obstruction

    • P - PE, pneumothorax, pulmonary edema

    • E - equipment failure

    • S - stacked breaths

R4 Capstone: myths WITH Dr. Habib

Dr. Habib used his clinical capstone to challenge certain mythology that is commonly utilized in the ED.

PPI in GI bleed

  • Theory that low pH decreases clot formation; therefore raising pH could help with coagulation

  • 2010 Cochrane review: PPI prior to EGD in UGIB

    • No mortality benefit

    • No difference in re-bleeding

    • No difference in need for OR or transfusion requirements

  • Long term adverse effects associated with PPI use: C diff, hypomagnesemia, small bowel bacterial overgrowth

  • Bottom Line: Not a ton of evidence to support PPI use in GI bleeds, but GI colleagues will request use. There does seem to be some benefit in Asian populations.

Lucas Device

  • Earliest large patient study from 1978

  • Meta-analysis from 2018 looked at ROSC as outcome

    • mechanical CPR equal to manual CPR

    • overall no difference in pre-hospital setting

  • Cochrane review 2018: “we conclude that mechanical chest compressions are reasonable survival where manual compressions are not adequate”

  • SOS-KANTO study looked at Lucas device use in ED setting

    • No difference in outcomes between mechanical vs manual CPR

  • Although no evidence to suggest superiority with Lucas device, can be used to decrease risk of harm to transporters

Bariatric Surgery Complications WITH Dr. Zalesky

  • >179,00 procedures per year (as of 2013)

  • 26% of these patients present to the ED in 2 years (most common complaints are nausea, vomiting and dehydration)

  • 20% readmission rate

  • Patients have BMI > 40 or over 35 with co-morbidities

    • High risk for complications

Types of Procedures

  • Gastric Balloon, Gastric Banding, Gastric Sleeve, Roux-en-Y, Biliopancreatic Diversion

    • All cause decrease in functional size

    • Roux-en-Y, Biliopancreatic Diversion also cause decreased absorption

Early Complications

  • Gastric Balloon and Banding: hardware in patients

    • Complications include: perforation, band tightness/migration, balloon overinflation/migration

    • Can start evaluation with xray to see positioning of band

    • Cross sectional imaging with PO contrast will likely be best test

  • Gastric Sleeve, Roux-en-Y, biliopancreatic diversion

    • Complications include: staple line leaks, strictures, marginal ulcers, hemorrhage, internal hernia, small bowel obstruction

    • HR>120 consider leak

      • treat with ceftriaxone and metronidazole

    • If RUQ pain, consider cholecystitis

      • 1/3 of patients will develop cholecystitis, some have gallbladder prophylactically taken out

    • CT abd/pel with IV and PO contrast for further imaging

  • Roux-en-Y, biliopancreatic diversion ONLY

    • Early Dumping Syndrome: 10-30 min

      • hyperosmolar diarrhea

    • Late Dumping Syndrome: 1-3 hours

      • rapid sugar absorption, exaggerated insulin response with hypoglycemic symptoms

    • Treatment for both includes: less refined sugars, more complex carbs, small meals that are more frequent

Late Complications

  • Gastric balloon, gastric banding

    • Infection, vomiting, reflux, implant migration, implant rupture/damage

  • Gastric Sleeve:

    • Reflux, strictures

  • Roux-en-Y, biliopancreatic diversion

    • Nutritional deficiencies (D, B12, folate, iron, thiamine), late dumping syndrome, internal hernia, small bowel obstructions, marginal ulcer, cholelithiasis

Takeaways

  • Patients have multiple co-morbidities making them at high risk of complications

  • Xray for hardware, CT with IV and PO contrast for anatomy

  • Anastomotic/staple line leaks need antibiotics

  • Watch out for nutritional deficiencies long term

Taming the SRU: intubating Shock WITH Dr. Makinen

Middle aged gentleman involved in an MVC who presents hypotensive with depressed GCS. Remains persistently hypotensive despite multiple blood products. How do you manage this airway?

  • Intubating under shock

    • Don’t do if you don’t have to

    • Multiple IV access points

    • Have pressors available

    • Resuscitate: IVF or blood products

  • What causes peri-intubation hypotension?

    • Patient pathology

    • Pharmaceuticals

    • Positive pressure ventilation

    • pH

  • What induction agent should you use?

    • Propofol:

      • dangerous at standard dose

      • safe and efficacious at 10-20% standard dosing (0.1-0.2 mg/kg)

    • Etomidate

      • reasonable choice if full dose can be tolerated (0.3 mg/kg)

      • don’t know if reduced doses provide adequate sedation

      • avoid in septic shock

    • Ketamine

      • could consider half dosing (0.25-0.5 mg/kg) as it doesn’t dampen sympathomimetics

      • “K hole” may be tolerated for this patient population

    • Nothing: Last resort, but can be considered in the truly obtunded or peri-arrest patients

R4 Sim and Oral Boards WITH Drs. Nagle, Klaszky, Habib and Harty

High Altitude Illnesses

  1. Acute Mountain Sickness: Mildest form of altitude sickness caused by low oxygen levels at high altitudes

    • often related to length of stay and rate of ascent

    • symptoms include mild headache (often positional), nausea, vomiting

  2. High Altitude Cerebral Edema (HACE): Brain swells from fluid because of effects of high altitude travel

    • Symptoms include ataxia and encephalopathy

    • Don’t usually see focal neurologic deficits

  3. High Altitude Pulmonary Edema (HAPE): non-cardiogenic pulmonary edema caused by high altitude travel

    • Thought to be caused by transiently elevated pulmonary pressures, leading to VQ mismatch and capillary leaks

Treatment

  • Acetazolamide: 125mg q12 hour

  • Steroids: 4mg dexamethasone q6h

  • Nifedipine: 10mg q6h

  • Rapid descent

  • Portable Hyperbaric Chamber

Oral Boards Case: Malaria

17 yo M with HA with recent travel to Nigeria. Did not take malaria prophylaxis. Presents febrile, but otherwise well. Exam with hepatosplenomegaly. Labs notable for positive peripheral smear and AKI. Diagnosis = malaria.

  • Indications for admission to ICU: AKI, seizures, acidosis, Hgb less than 7, high parasite density, DIC, jaundice, ARDS, pulmonary edema

  • Treatment: IV Artesunate

Oral Boards Case: Decompression Illness

35 yo male presenting with chest pain and shortness of breath after diving off the coast of Florida. Presents hypoxic and tachycardic. EKG with ST elevations in V1-V5. Labs notable for elevated lactate to 6 and creatinine to 2. Diagnosis = arterial air embolism

  • Blood vessel blockage from air bubbles causing strokes, MI and other end organ dysfunction

  • Can be both venous and arterial (through PFO)

  • Treatment: Hyperbaric Chamber