Grand Rounds Recap 11.20.19
/M&M - Taming the SRU: Massive PE - R4 Capstone: Global Health - Pharmacy Update: Tox - R4 Case Follow Up: Hypertension
MORBIDITY AND MORTALITY CONFERENCE WITH DR. GOLDEN
Previous Positive Cultures in Sepsis
Surviving sepsis guidelines recommend utilizing previous cultures if available when selecting broad spectrum antibiotics
Previous cultures in the past 12 months have similar antibiotic resistance patterns with a specificity of 92%
Urine cultures within the past 4-8 weeks have similar resistance patterns in 57% of cases
Shock Index During RSI
Post-intubation hypotension is associated with a 35% in-hospital mortality
Shock index (SI) = HR/SBP
A shock index of 0.8 is predictive of post-intubation hypotension
A shock index of 0.9 is predictive of peri-intubation cardiac arrest
Remember - resuscitate before you intubate and have vasopressors readily available
Cognitive Errors in the Emergency Department
Cognitive biases are associated with 37-77% diagnostic inaccuracies in the ED
Ways to combat our biases
Note any outliers in a patient’s history or exam, and stratify patients as either straightforward, complicated, or complex
Take a cognitive pause for complicated or complex patients and talk through your differential
Ask yourself if the patient is presenting too early in their course to diagnose their condition and make sure you discuss this with the patient
Time to Source Control in Sepsis
Surviving sepsis guidelines recommend source control within 12 hours of the patient’s presentation
Several studies examined whether early source control improved outcomes
One study in Germany showed that surgical source control within 6 hours reduced mortality by 16%
Another study in Spain showed that source control improved mortality, but time to source control did not affect mortality
The only study performed in the ED showed that source control improved mortality, but there was no mortality benefit if source control was obtained earlier in the patient’s course
Necrotizing soft tissue infections are an important exception
12 hours remains the cutoff for surgical source control
Transitions of Care
Vital signs are often omitted in ED sign outs
Hypotension is omitted 42% of the time
Hypoxia is omitted 74% of the time
Exam errors are handed off 13% of the time
Laboratory errors are handed off 4% of the time
Ways to improve sign out safety
Location - avoid handing off care close to nursing stations to minimize interruptions
Signal a moment of transition - hand off your phone/pager to oncoming provider at the time of sign out
Minimize interruptions - divert EKGs and phone calls during sign out if possible
MRI in Subarachnoid Hemorrhage
MRI has been shown to have 100% sensitivity for detection of SAH within 6 days of symptom onset compared to 67% with non-contrast head CT
MRI is a reasonable additional tool for the evaluation of SAH if CTA/LP is unable to be obtained or equivocal
Emergency Severity Index (ESI) for Triage in the Emergency Department
About 50% of patients presenting to the ED are classified as ESI level 3
These patients have a baseline in-hospital mortality rate of 2.5%
Remember to have a high clinical suspicion for serious pathology in all ESI level 3 patients regardless of their location within the ED
TAMING THE SRU: massive PE WITH DR. LANE
Massive Pulmonary Embolism with Cardiac Arrest
Right ventricular diameter on transthoracic echocardiography
Multiple causes of cardiac arrest can result in RV dilation (pulmonary hypertension, asthma/COPD, MI, valve failure), not just pulmonary embolism
Prolonged cardiac arrest leads to pooling of blood on the venous side of the circulation and there is pressure equilibration between the arterial and venous circulation, and ultimately RV dilation regardless of the cause of cardiac arrest
Transesophageal echocardiography in cardiac arrest
Study showed that 9 out of 14 patients with PEA arrest who had RV dilation had a pulmonary embolism, while the other 5 patients ultimately did not have a PE as a cause of their arrest
Transthoracic echocardiography in cardiac arrest
Adds 6 seconds to pulse check times
Prepare before the pulse check by positioning your probe and obtain a video clip to minimize interruptions in CPR
Thrombolysis
Lytics should not be used empirically in cardiac arrest
Lytics are reasonable if there is a high clinical suspicion and echocardiographic findings are consistent with PE without imaging
Full dose thrombolytics have been shown to improve morbidity and mortality in hemodynamically unstable patients with pulmonary embolism (massive PE)
Thrombolytics are administered as a bolus followed by an infusion; do not administer heparin until after the infusion has been completed
Recent evidence has shown that catheter directed thrombolysis does not appear to offer a clear advantage compared with standard anticoagulation, but catheter directed thrombolysis was associated with the lowest probability of dying and bleeding
R4 CAPSTONE: Global Health WITH DR. OWENS
Global Health in Your Backyard
Angiostrongylus Cantonensis
Also known as the rat lung worm, this roundworm lives in slugs/snails and rodents and is transmitted to humans orally, usually after ingesting a raw snail or anything contaminated by snail slime (such as salads)
This parasite is endemic in southeast Asia, the Pacific Islands, and the Caribbean
Patients will present with classic signs of meningitis
Lumbar puncture will show CSF eosinophilia
Larva can bee seen on MRI of the brain
As the larva die, the body manifests an immune response resulting in meningitic symptoms
The highest number of cases in the US have occurred in Hawaii
There have been several documented cases in the US in Florida, Texas, Tennessee, and Louisiana
There is no treatment for this worm; it is mainly treated supportively with NSAIDs and steroids until the worms eventually die
Bottom line: don’t eat raw snails and make sure to wash your vegetables
Pharm jEOPARDY!: COMMON ANTIDOTES WITH Madeline Foertsch, PharmD and Jessica Winter, PharmD
The Gut
Multidose activated charcoal theoretically works via entero-hepatic recirculation
Whole bowel irrigation is recommended for iron, lithium, sustained release formulates, and for drug packet ingestion
The dose for activated charcoal is 1 g/kg
Charcoal should be given within 1 hour of ingestion
Ipecac is no longer recommended for home use in pediatric overdoses
Heart
Atropine is often ineffective for calcium channel and beta blocker overdoses
Digibind is indicated in digoxin toxicity if the patient develops ventricular arrhythmias, symptomatic bradycardia, or renal failure with hyperkalemia
Hyperkalemia and hypocalcemia are the most common electrolyte abnormalities seen in digoxin toxicity
Milrinone blocks phosphodiesterase 3 enzyme and is a second line agent in calcium channel blocker overdoses with refractory hypotension
Outdoors
Lactrodectus mactans antivenin is the antidote for a black widow spider bite
Coral snakes, cottonmouths, rattlesnakes, and copperhead snakes are the four poisonous species of snake in North America
Anavip is the name of the antivenin which is approved for rattlesnake bites in the United States
The dose of atropine in an organophosphate poisoning is much higher than standard doseing; start with 1-6 mg every 3-5 minutes followed by an infusion
Pralidoxime improves the nicotinic effects of orgaonphosphate poisonings
Toxicology Potpourri
Toxins that can be treated with hemodyalysis include salycilates, dabigatran, lithium, valproic acid, and toxic alcohols (such as methanol and ethylene glycol)
Isopropyl alcohol does not cause an elevated anion gap
Naloxone pulmonary edema is believed to be caused by an intrinsic sympathetic surge
Two medications that can be given for wide QRS secondary to an overdose are sodium bicarbonate and 3% hypertonic saline
Intralipid acts as a lipid sink for lipid soluble medication overdoses
Hyperglycemia
Glucagon is given at a dose of 0.05-0.15 mg/kg and activates adenylate cyclase
Calcium channel blockers cause hyperglycemia by blocking calcium gated ion channels within the pancreas which inhibits the release of insulin
High insulin euglycemic therapy dosing: 1 unit/kg bolus followed by an infusion of 0.5 - 10 units/kg/hr
Metformin can cause severe lactic acidosis
Octreotide is used for sulfonylurea overdoses
R4 CASE FOLLOW UP: Hypertension WITH DR. HAM
Chronic Hypertension in the ED
Why should we care?
46% of adults in the US have chronic hypertension, and 53% of patients who are already diagnosed with chronic hypertension have inadequate control of their blood pressure
Chronic hypertension drastically increases your risk for cardiac disease, cerebrovascular disease, and chronic kidney disease
Reduction of the systolic blood pressure by 10 mmHg decreases the patient’s risk of stroke by 38%
Can we make the diagnosis in the ED?
Patients who present with end organ damage based on laboratory studies or hypertensive emergency in the ED likely have chronic hypertension
If the patient’s blood pressure remains elevated (greater than 160/110) 60-80 minutes after the initial ED blood pressure, the patient can be diagnosed with chronic hypertension with 95% specificity and 90% sensitivity
What can we do about it?
Re-initiate and confirm the doses of previous prescriptions in those with known chronic hypertension
Start new medications for those with limited access to primary care
Options for non-African American populations
Thiazides (HCTZ)
Calcium channel blockers (amlodipine)
ACE-Inhibitors or ARBs (lisinopril or valsartan)
Options for African American populations
Thiazides (HCTZ)
Calcium channel blockers (amlodipine)
Options for patients with chronic kidney disease
ACE-Inhibitors or ARBs (lisinopril or valsartan)
Refer these patients for primary care follow up
