Grand Rounds Recap 12.19.18

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M&M - Mindfulness - CPC - PECARN head ct

Morbidity and Mortality Conference WITH DR. BAEZ

Case 1: Acute Cholecystitis

Background:

  • 3.9% of visits for abdominal pain

  • Third leading cause of readmissions for abdominal pain

Diagnostic Accuracy of History, Physical, and Lab Findings

  • Positive Murphy’s sign has the highest LR

  • LFT abnormalities are uncommon in acute cholecystitis

  • Epigastric pain is just as common as RUQ pain in cholecystitis

RUQ Ultrasound

  • Overall, CT misses radiolucent gallstones in 40-50% of the time

  • Ultrasound is a safe, low cost, efficient low cost modality for evaluation

  • Ultrasound has a sensitivity of upwards of 80-90%

Barriers to ED RUQ US

  • “I’m not as good as an ultrasonographer”

  • “Study is likely to be limited by body habitus”

    • You never know until you try

    • Utilize the curvilinear probe for scanning as well as the left lateral decubitus to optimize image quality

  • “My patient just ate”

  • “I can’t find the CBD”

    • In patients with normal labs and no other ultrasonographic findings of cholecystitis, finding CBD was clinically relevant in <2% of patients

    • However, gallbladder distension is an early sign of obstruction and cholecystitis (>10cm long, >4cm wide)

Case 2: Spinal Epidural Abscess

Epidemiology of Spinal Epidural Abscess

  • 12.5 per 10K visits

  • Up to 75% missed on initial presentation

  • 45% will have residual weakness if there is diagnostic delay, compared to only 13% in those who were diagnosed on initial presentation

  • Source

The utility of ESR/CRP in this diagnosis

  • ESR is a sensitive early marker of spinal epidural abscess, so consider use

  • After implementation of utilizing a screening ESR/CRP for patients with fever, risk factors, static neuro deficits, or radicular pain, diagnostic delay went from 83% of patients to 10% of patients in one prospective study

  • CRP was elevated in 87% of those with epidural abscess, and 50% of those abscess free

  • ESR was elevated in 100% of those with epidural abscess, and 33% of those abscess free

  • Utilizing ESR + Risk factors was 100% sensitive and 67% specific

Case 3: Aortic Aneurysm

ED Management of Thoracic Aneurysm

  • >5.5 cm, repair is indicated

  • 4-5.5 cm, sometimes electively repaired

  • <4 cm, medical management is the mainstay of treatment

  • Blood pressure control with beta blockers can reduce the need for surgery in 31% of patients

  • Statins have a 13% reduction in mortality in patients with aortic aneurysms

  • Counsel patients on smoking cessation!

ED Management of Abdominal Aortic Aneurysm

Case 4: Medical Hold vs Psychiatric Holds (Statements of Belief)

Medical Hold

  • An institutional policy that allows for detention of a patient to allow for assessment of capacity

    • If a patient has capacity and demonstrates understanding of the implications of leaving, they can leave against medical advice

    • If they do not, they may be detained for ongoing treatment

  • There has never been a ruling against a physician who has detained a patient for assessment of capacity

  • Does NOT require 24 hour assessment by a psychiatrist

Psychiatric Hold (Statement of Belief)

  • Can be signed for patients who are suicidal, homicidal, or gravely disabled because of a patient’s psychiatric illness

  • The patient is mandated to be transferred to a psychiatric facility or evaluated by a psychiatrist within 24 hours

Case 5: Diagnostic Testing in Post-Arrest Patients

EKG

Toxicology Labs

  • Out of 1000 patients, 9% had a toxicologic component to their arrest in one retrospective study, so consider sending toxicology labs (ASA, acetaminophen, UDS)

Chest X-ray

  • CPR related consequences can be identified on CXR

    • 65% had rib fractures

    • 13% had sternal fractures

    • 10% had pneumothorax

Ultrasound

Head CT

Chest and Abdominal CT

Case 6: Temporal Bone Fractures

Anatomy of the temporal bone

  • The internal carotid, facial nerve, external auditory canal and sigmoid sinus all run contiguous to the temporal bone

  • It requires up to 1875 pounds of force at 25 mph to fracture the temporal bone, so other injuries are frequently present

  • This fracture caries a 12% mortality due to associated injury

Diagnosis

Indication for Operation

  • Otic capsule sparing injuries usually has only CSF leak, and conductive hearing loss, but are not typically emergently surgically repaired

    • Take note of hearing loss, as this is a indication for non-emergent cochlear implant

  • Otic capsule violating lesions have facial paralysis too, which is an indication for surgery

  • Evidence of herniation is a hard indication for surgery

  • Carotid laceration is a hard indication for surgery

    • IR can balloon occlude the ICA in cases of carotid laceration

  • There is no indication for prophylactic antibiotics

Mindfulness in Emergency Medicine  WITH DR. BERNARDONI

What is mindfulness?

  • Paying attention on purpose to what is occurring in one’s immediate experience without judgement

    • Attention- Actively focusing on what is occurring at hand

    • On purpose- Purposely picking something to focus on rather than allowing external stimuli decide what you pay attention to

    • Immediate experience- Not getting distracted by what is to come

    • Without judgement- Noting our emotions and sensations without judging them

Biochemical changes

  • When mind is wandering, multiple areas of the brain are engaged

  • During intentional mindfulness, intentional focus puts demand on your frontal cortex

    • The longer and more frequently you sustain that focus, the stronger the frontal cortex and hippocampus become, and the stronger your focus becomes

    • You have decreased grey matter in your amygdala, leading to less response in emotionally charged situation

    • This helps you sustain attention over time

Why should you care?

How do I get started?

  • Breathing techniques

    • Breath in for four seconds, hold for four seconds, breath out for four seconds, hold for four seconds

    • Consider this before a code or before a stressful procedure

  • Mindful moments in the ED

    • Anytime you get hand sanitizer or wash your hands, take a deep breath, focus on washing your hands, then take another deep breaths

    • Take 2 deep breaths when logging into your computer

    • Take 1 deep breath before answering a phone, and then shift focus to listening

  • Mindful listening

    • You can process words at 200 words per minute, but talk at 120 words per minute

    • Focus on listening, not on what you are going to say during conversations

  • Mindful Meditation

    • A home-based way to practice mindfulness

    • Find a comfortable location, position, activity, limit distractions,

    • Focus on your thoughts:

      • See your thought, observe it, let it be, and return to your anchor (deep breathing)

Clinical Pathologic Conference WITH DR. MAKINEN V. CURRY

Severe Hyperthermia/Pyrexia

  • Hyperthermia: increase in body temperature without increase in hypothalamic set point. Any temperature >105 degrees is typically hyperthermia.

  • Pyrexia: increase in body temperature due to an increase in the hypothalamic set point

Hyperthermia Differential Diagnosis

  • Serotonin Syndrome

    • Acute in onset, and typically presents with clonus

    • Treatment is supportive care +/- cyproheptadine

  • Neuroleptic Malignant Syndrome

    • Typically subacute in onset, and presents with rigidity

    • Treatment is benzodiazepines and supportive care

  • Anticholinergic Syndrome

    • Typically presents with dry skin, mydriatic pupils

    • Treatment is benzodiazepines and physostigmine use (with caution and in discussion with tox)

  • Heat stroke

    • Skin is typically dry, environmental exposure in the history, and there is no rigidity

    • Treatment is supportive

  • Delirium tremens

    • Visual hallucinations are prominent

    • Treatment is benzodiazepines

  • Thyrotoxicosis

    • Goiter is prominent in physical exam

    • Treatment is PTU/methimazole, propanolol, steroids, and iodine

  • Malignant Hyperthermia

    • Due to succinylcholine and inhaled anesthetics

    • Present with rigidity

    • Treatment is with dantrolene and 100% FiO2


PECARN head CT rules WITH DR. Frederick

See Dr. Frederick’s original post here

Background

  • A clinical decision rule to help decide on CT scan vs. no CT scan in pediatric patients with blunt traumatic brain injury

  • Original trial was a prospective study that included 42,000 children <18 years old. The primary goal was to assess if the tool could adequately screen patients for clinically important TBI (death from TBI, neurosurgical intervention, intubation more than 24 hours, or hospital admission >2 nights)

  • This has been externally validated with two different studies with a 100% sensitivity and 100% NPV

Clinical Use

  • First, patients must be separated into >2 years of age or <2 years of age

  • Clinically, separates patients into high risk, moderate risk, or low risk TBI

    • High Risk- Has palpable skull fracture, GCS < or = 14

      • CT scan recommended as there is a ~4-5 % risk of clinically important TBI

    • Moderate Risk- Has hematoma, LOC > or = 5 seconds, not acting normal per caregiver, or severe mechanism (MVC with ejection, death in same vehicle, rollover, pedestrian struck, fall from 3 ft if less than 2 years old or 5 feet if greater than 2 years old)

      • Clinician judgement on CT vs observation as there is a ~1% risk of clinically important TBI

    • Low Risk: no moderate risk or high risk features

      • No CT as there is a <0.05% risk of clinically important TBI