Grand Rounds Recap 11.13.19

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ULTRASOUND GRAND ROUNDS: OCULAR ULTRASOUND WITH DR. AVILA

Technique

  • There is a theoretical risk of harm to the globe due to elevated thermal index - use the lowest settings to still obtain the images needed for diagnosis

  • 10 scans appears to be the threshold for competency

  • 2 views (axial and sagittal) is best but sometimes a sagittal image is not possible due to the superior and inferior orbital ridges

  • Use the linear transducer

  • Place a tegaderm over the patient’s eye (removed it medial to lateral)

    • A small ribbon of sterile lubricant on the eyebrow and eyelashes can make removal more comfortable

  • Brace your finger on the patient’s cheek or nose to avoid putting too much pressure on the eye

  • Use a generous amount of gel to optimize your images

  • Place the probe over the upper eyelid to get the best quality image

Retinal Detachment

  • Ultrasound can be used to accurately rule in and rule out retinal detachment in the ED

    • Sensitivity 94%, specificity 96%

    • +LR 25, -LR 0.06

  • Retinal detachment can be differentiated from vitreous detachment by being tethered to the optic nerve

  • The “line” is often much thicker than in vitreous detachment

  • Remember that retinal detachment results in vision loss

Vitreous Detachment

  • Vitreous detachment can be differentiated from retinal detachment by not being tethered to the optic nerve

    • Sensitivity 42.5%, specificity 96%

  • Vitreous detachment will not present with vision loss

Vitreous Hemorrhage

  • “Washing machine” sign with eye movement

    • Sensitivity 81.9%, specificity 82.3%

  • Not all mobile vitreous opacities are pathologic

    • With normal gain setting, 1% of patients will have incidental vitreous opacities

    • Up to 29% will have vitreous opacities if the gain is turned up

    • Asteroid Hyalosis

      • 1-2 % of older patients

      • These are calcified lipid particles

      • They are difficult to differentiate from vitreous hemorrhage

      • In general, they are more echogenic than vitreous hemorrhage and do not layer in the posterior portion of the eye

Enlarged Optic Nerve Sheath Diameter (ONSD)

  • Measure 3 mm posterior to the attachment of the optic nerve to the retina

  • >5 mm is abnormal

    • Sensitivity 96%, specificity 92% for detection of elevated ICP

  • Measure from outer shadow to outer shadow

  • Aim the transducer medially and measure the optic nerve at its widest diameter

Miscellaneous Ocular Ultrasound

  • Lens dislocation

    • Sensitivity 96.8%, specificity 99.4%

  • Globe rupture

    • US does not need to be performed with obvious globe rupture

    • You will usually just see massive soft tissue swelling

  • Papilledema

    • Will appear as a small mound over the optic nerve, > 0.6-1 mm

  • Foreign Body

    • Metallic foreign bodies will appear as a reverberation ring down artifact

R1 CLINICAL DIAGNOSTICS: MSK ULTRASOUND WITH DR. BROADSTOCK

Please see Dr. Broadstock’s fantastic post here for more information!

Shoulder dislocation

  • Use the linear or curvilinear transducer

  • Position the transducer transversely on the posterior shoulder to identify the scapular spine and the humeral head, with the glenoid in between and the infraspinatus tendon running superficially

  • The humeral head will appear in the far field of the ultrasound image with an anterior shoulder dislocation, and in the near field of the image with a posterior shoulder dislocation

Patellar tendon disruption

  • Use the linear transducer

  • Position the probe inferior to the patella and image the tendon in both the longitudinal and transverse planes

  • Tendon disruption will appear as an anechoic area within the tendon itself

Necrotizing soft tissue infections

  • STAFF Exam

    • Subcutaneous thickening

    • Air

      • Hyperechoic structures within the soft tissue and “dirty” shadowing

      • This is a fairly late finding

    • Free fluid > 2mm tracking along fascial planes

      • This is the most sensitive ultrasound finding in necrotizing soft tissue infections

CPC WITH DRS. URBANOWICZ AND MINGES

 Uremic Pericarditis With Tamponade

  • Classic features of pericarditis

    • Sharp, pleuritic pain that is positional following a viral illness

    • EKG changes - diffuse ST elevation with PR depression, PR elevation in aVR

    • Clear lungs on auscultation with a pericardial friction rub

  • Differences in uremic pericarditis

    • Uremia causes an exudative pericardial effusion with or without constrictive features

    • More common in patients with chronic kidney disease or end stage renal disease

    • Uremic pericardial effusions will often present with earlier signs of tamponade

    • Uremic pericarditis often does not present with classic EKG findings

    • BUN elevation does not linearly correlate with the risk of uremic pericarditis, although patients with BUN values > 100 are at higher risk

    • Dialysis is the treatment of choice, but bedside echo should be performed prior to disposition to determine if a pericardial drain needs to be placed

The art of the consult WITH DR. HUMPHRIES

70% of medical errors can be traced back to miscommunication between healthcare providers

  • Delays in Consultation

    • Factors leading to delays in consultation

      • Lower triage level

      • Night time consultation

      • Emergent vs non-emergent consultation determined by the consultant

    • Consults are the greatest contributor to a prolonged LOS (greater than bloodwork, urinalysis, and imaging)

    • Novel solutions

      • Use of commercial messaging apps (such as WhatsApp) in Turkey improved ED LOS and decreased time from consultation to disposition

  • Difficulties with Consultation

    • Knowledge gaps

      • 90% of medical students have called a consult, and 70% were instructed on how to call a consult

        • Most students reported that their instruction came from a resident and did not receive any formal training on how to call a consultation

    • A standard approach to calling a consult - the 5 C’s of consultation

      • Contact

        • Introduce yourself and your role

      • Communication

        • Make sure to include an appropriate amount of information without being extraneous

      • Care Question

        • Prior to calling a consult, you should have a clinical question in mind for your consultant

      • Collaborate

        • Work with your consultant to determine what additional testing or imaging can be performed prior to the consultant’s arrival

      • Close the Loop

        • Make sure to thank the consultant for their time and expertise and have a clear plan for the next steps

  • Communication and Collaboration

    • Acknowledge the consultant’s expertise

    • Present patients concisely and consistently to improve your reliability and reputation with your consultants

    • Engage the consultant professionally but also be friendly

  • Crew Resource Management

    • This is well studied in the aviation industry

    • These principles can be applied to medical resuscitation

    • A study looking at this implemented in resuscitations showed that participants had better communication, better patient hand offs, and were more likely to speak up and ask questions

ACEP DEBRIEF

Condom Uterine Balloon Tamponade

  • Post-partum hemorrhage is the most common cause of maternal morbidity worldwide

  • Commercial uterine balloon tamponade kits cost ~ $400 USD

    • Alternative kit - condom, foley catheter, 3 way stop cock, syringe, and tie down

      • Significantly decreased cost (~ 5 USD) with both improved outcomes and good safety profile

The Use of Clinical Quality Reviews to Predict Medico-legal Risk in Emergency Medicine

  • Little evidence exists assessing the correlation between internal triggers for case review in the ED and medico-legal risk

  • Referred cases that do not meet an automatic trigger are associated with the highest medico-legal risk and patient compensation, with return admissions in 48 hours having the second highest risk

Differentiating STEMI from Acute Pericarditis

  • STEMI

    • ST depression except in V1 or aVR (which may be present in pericarditis)

    • ST elevation in III > II

    • Horizontal or convex upwards ST elevation

    • New Q waves

    • R-T sign (checkmark sign) - abrupt downward deflection following the R wave before the T wave

  • Pericarditis

    • Friction rub

    • PR depression in multiple leads

    • Spodick’s sign - gradual down-sloping of the T-P segment

The Role of Medical Economics and Resident Education

  • In the last 4 years, the number of emergency medicine residency slots has grown more than any other specialty, with the greatest growth seen in for profit hospitals

  • Pay transparency - ACEP has passed a resolution for hospitals to publicize physician pay to identify wage gaps among different demographics

CAR-T Therapy

  • Currently being used for treatment of B-cell leukemia and lymphoma

  • This therapy is targeted towards CD-19 antigens on B cells

  • The patient’s T cells are removed and "“programmed” to attack CD-19, then re-infused

  • Common problems associated with CAR-T

    • Cytokine release syndrome (CRS)

      • Appears similar to distributive shock

      • Treatment is similar to septic shock

    • Neurologic

      • Seizures, encephalopathy, and focal neurologic deficits

  • Treatment

    • Tocilizumab - anti IL-6 monoclonal antibody, which increases survival in CRS

    • Steroids - last ditch effort, give in consultation with a hematologist

Neonatal CPAP Using an Adult Nasal Cannula

  • The adult nasal cannula completely occludes the neonate’s nares

  • Cut one end of the NC and place it in a container of water and attach the other end to oxygen, which will create PEEP

A Subtle EKG Finding in Impending Inferior STEMI

  • Isolated T-wave inversion in aVL in a patient with active chest pain

  • If you see this, get a repeat EKG within 15 minutes

Jaw Dislocation

  • Traditional reduction is often difficult, requiring significant force and often procedural sedation

  • Extra-oral technique

    • Feel the bony process of the coronoid process and apply posterior pressure while applying anterior pressure to the mandibular ramus of the opposite side

  • You can also have the patient attempt self-reduction by rolling a 10 cc syringe in their molars

PEDIATRIC SEDATION WITH DR. GRAY

The Tools

  • Distraction is a powerful tool in pediatrics in combination with analgesia

  • Minimal Sedation - anxiolysis

    • Midazolam - commonly given orally or intranasally

    • Ketamine - pain dosing (0.1-0.3 mg/kg), often given intranasally

    • Nitrous - very fast on/off effect, often used for IV placement and lumbar puncture

  • Moderate sedation - airway reflexes are maintained and the patient responds to verbal commands and light touch

    • Using a single agent is safer than multiple agents

    • Be prepared to support the airway

    • Ketamine is the safest option

      • Longer recovery time

      • Vomiting is common on emergence

    • Propofol

      • More airway adverse events and respiratory depression than ketamine

      • Faster recovery time

      • Less vomiting

    • Ketofol

      • More airway adverse events that ketamine alone

      • Less vomiting

    • Opiates + Benzodiazepenes

      • Generally avoided in pediatrics

  • Deep sedation - patient responds only to repeated stimulation, airway reflexes may be lost

    • We try to avoid this level of sedation in the ED