Grand Rounds Recap 2.19.20
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Morbidity and Mortality WITH Dr. Golden
Steroid Induced Leukocytosis
For patients who were on long term steroids, there was a trend toward peak WBC usually in the second week. The mean peak was around 17-18.
There tended to be a downtrend during the third week on steroids, but it still takes quite some time (several weeks to months) to return back to baseline
There should be no changes in metamyelocytes or bands with steroid use
It is important to note each individual person’s trend in WBC to evaluate potential etiologies as it varies per individual
Missed CT Scan
Develop your strategy of reviewing therapeutic and diagnostic interventions before dispositioning patients, including those you plant to admit
Perform a thorough neurologic examination in patients with a complaint that is potentially neurologic in etiology
NIPPV in COPD
Cochrane review in 2017 showed that BiPAP lowered mortality compared to usual care as well as decreased need for intubation
In 2019, GOLD guidelines updates their indications for NIPPV:
Respiratory acidosis: PaCO2 > 45 and ABG pH < 7.35)
Severe dyspnea with respiratory muscle fatigue and/or increased work of breathing
Persistent hypoxemia despite supplemental oxygen therapy
No weaning required for NIPPV
Additional updates include:
Nebulized budesonide provides similar benefits to IV methylprednisolone
High-intensity ICS/LABA for 10 days at onset of URI can reduce severe exacerbations. Instruct patients to take two puffs instead one
HFNC for six weeks after exacerbation improves health-related quality of life
Tertiary Examinations
1.3-14.3% of injuries get missed on primary and secondary surveys; 1/3 of these missed injuries end up needing surgical management
Now in the setting of CT scans, the most common injuries missed are those to the limbs
Patients at a higher risk of having missed injuries are those with an injury severity score >16 and GCS<15
Evaluation of Chest Tube Placement
Depth: First mark on a pneumocath chest tube is 5 cm from last fenestration. Each additional mark is 2.5 cm. The leading edge of the curve in a pigtail to the third black mark is 11cm.
Tidaling: In a spontaneously breathing patient, the bead should be rising when the patient inspires and falls when the patient expires. The opposite is true in an intubated patient due to positive pressure.
Air Leak: An air leak can be present for multiple reasons whether there is something wrong with the system or their is residual pneumothorax. To troubleshoot, clamp tube at patient’s skin. If the air leak stops, the air leak is internal. If persists, it is external. Continue to march the clamp down to figure out where leak is coming from
Chest x-ray: Evaluate for depth on xray, the course and shape of the catheter as well as any additional complications
AMA Discharges and Oral Antibiotics for Osteomyelitis
Only 21.4-24.4% patients were given at discharge. In addition, only 25.7-31.3% patients had follow up arranged.
Be vigilant in providing appropriate antibiotics and follow up instructions for patients leaving AMA
Study in NEJM found that oral antibiotics may be non-inferior to IV antibiotics for bone and joint infections. So if necessary, consider gram negative coverage (ciprofloxacin) and gram positive coverage (bactrim or doxycycline) for patients being discharged with concern for osteomyelitis.
Premature Closure
Fight the urge for premature closure and anchoring, especially when all the pieces of the history and exam aren’t fitting
Re-evaluate your patient’s complaints when they are not responding as you would expect with appropriate therapies
Have a low threshold to obtain additional diagnostic testing in elderly patients
Iatrogenic Opiate Overdose
Adverse events related to opiate use are common. About 50% of incidents require intervention and about 50% require intervention necessary to sustain life.
Factors contributing to adverse events include age, alcohol intoxication, altered mental status, COPD, dementia, hepatic impairment, obesity, renal impairment, sleep apnea
Be judicious in narcotic and sedative medication dosing in patients with significant underlying comorbidities or challenging anatomy that could make airway management difficult
Organ Donation
Not our jobs as physicians to initiate the conversation with families, but we can be aware of patients who qualify and remind nursing staff to contact LifeCenter
Appropriate organ donor referrals include:
Brain injured
Ventilator dependent
GCS <5 and/or two or more missing brainstem reflexes
R1 Clinical knowledge: eating Disorders WITH Dr. Mullen
Bulimia Nervosa
Recurrent episodes of binge eating (Note: this is different from binge eating disorder) with recurrent compensatory behaviors to prevent weight gain
This behavior occurs one time per week for 3 months
Severity:
Mild: 1-3 episodes per week
Moderate: 4-7 episodes per week
Severe: 8-13 episodes per week
Extreme: 14+ episodes per week
Presentation can be vague, but can include tachycardia, hypotension, parotid gland swelling, dental erosions, Russel’s sign (abrasion to dorsal aspect of knuckles due to induced vomiting)
Complications include Mallory-Weiss syndrome, Boerhaave syndrome, diarrhea, ileus due to hypokalemia, rectal prolapse, pancreatitis as well as electrolyte and cardiovascular complications (see below)
Electrolyte: Hypokalemia, hypochloremia, hyponatremia, hypomagnesemia, hypophosphatemia, metabolic alkalosis
Cardiovascular: Short term complications include hypotension, sinus tachycardia, orthostasis, edema; Long term complications include MI, PVD, atherosclerosis, conduction disorders
Anorexia Nervosa
Low body weight (BMI < 18.5) secondary to energy intake restriction with intense fear of gaining weight or behavior interfering with weight gain. Often have a distortion of body weight and shape perception
Lifetime prevalence in the US is 0.6% with the disease more common among women than men. Median age of onset is 18.
Severity:
Mild: BMI <17
Moderate: BMI 16 - 16.99
Severe: BMI 15 to 15.99
Extreme: BMI <15
Presentation can be a variable chief complaint, but often patients may present hypotensive, bradycardic, hypothermic
Complications include:
Cardiovascular: 1) structural - decreased cardiac mass, mitral valve prolapse, pericardial effusion; 2) functional - ECG changes, hypotension, decreased HR variability
Gynecologic and Reproductive: Secondary Amenorrhea (>3 months) which can persist in 10-30% despite weight gain, infertility, poor pregnancy outcomes
Neurologic: Wernicke’s encephalopathy which can lead to Korsokoff, diffuse cerebral atrophy
Other complications: Electrolyte abnormalities (similar to bulimia above), anemia, lagophthalmus (inability to close eyelids completely leading to dry eyes and photophobia), dry skin, fine hair, acne, hyperpigmentation
Refeeding Syndrome
Occurs as a result of reinstitution of nutrition to people who are starved or are severely malnourished
First seen in WWI prisoners
Most fatalities due to refeeding syndrome are due to cardiac complications. Starvation leads to atrophy of the heart which makes it more vulnerable to fluid overload which can lead to heart failure. (Thiamine deficiency can also lead to heart failure.)
Other complications include musculoskeletal (weakness, myalgias, tetany, hyperphosphatemia leading to rhabdo), GI (steatosis leading to abnormal LFTs, intestinal and pancreatic atrophy leading to diarrhea), neurologic (tremors, seizures, Wernicke’s)
Those at risk for refeeding syndrome include:
Patient has one or more of the following: BMI < 16, unintentional weight loss of >15% in the previous 3-6 months, little or no nutritional intake for >10 days, low levels of K, Phos or Mg before refeeding
Patient has two or more of the following: BMI <18.5, unintentional weight loss of >10% in the previous 3-6 months, little or no nutritional intake for >5 days, history of alcohol misuse or drugs, including insulin, chemotherapy, antacids or diuretics
Discharge vs Hospitalization?
Discharge: >85% ideal body weight or BMI > 16-17 with outpatient follow up
Hospitalization: bradycardia (<50), hypotension (<80/60), cardiac dysrhythmia, weight < 70% ideal body weight or BMI<15, marked dehydration, marked edema, serum phosphorous <2
Workup in the ED
Includes labs, bedside echo, EKG, repleting electrolytes and getting the patient the right resources
Taming the SRU WITH Dr. iparraguirre
Case: 31 year old male lights himself on gasoline and presents to the emergency department with 70-80% TBSA burns
Management of the Critically Ill Burn Patient
In the United States each year, approximately 2 million people are burned, 80,000 of these are hospitalized and 6,500 die from their injuries. A severe burn is defined as a burn that is complicated by major trauma or inhalation injury, chemical burn, high-voltage electrical burn, and for adults, and burn encompassing >20% of the TBSA excluding superficial burns.
Pathophysiology
The Burn Shock (ebb) phase: Period of hours to days after injury in which there is a relative hypodynamic state and diffuse capillary leakage. Managed with individualized fluid resuscitation.
The Hypermetabolic (flow) phase): Period of high cardiac output, low peripher vascular tone, fever and muscle catabolism. Managed with individualized nurtrional support and wound care
Initial evaluation
Treat like a trauma resuscitation: ABCDE’s (from ATLS)
Airway:
failure to oxygenate or ventilate, anticipated deteriorating clinical course and failrure to protect or maintain airway
evaluate for inhalation injury: carbonaceous sputum, singed facial or nasal hairs, facial burns, OP edema, stridor, vocal changes
Consider intubation if burn exceeds 50% TBSA including face and/or neck
Breathing:
All severe burns should recieve 100% oxygen
CO and cyanide toxicity must be suspected
If there is respiratory compromise secondary to chest wall eschar formation consider escharotomy
Circulation:
Burn shock is a combo of hypovolemic and distributive shock
Obtain 2 large bore IVs
Place Foley to monitor resuscitation
Several formulas available for fluid resuscitation (Parkland, Brooke, ISR Rule of 10s). Use only as initial guide, but not perfect.
Resuscitation endpoints: Look at systolic pressures (SBP 90-120), urine output (0.5 mL/kg/hr), base deficit <2, lactate <2)
Hypothermia:
Burn >10% TBSA have increased risk of hypothermia
Cover wounds
Bair hugger, warm fluids, etc
Management
Ancillary Testing: CBC, BMP, VBG/ABG, lactate, carboxyhemoglobin, imaging driven by mechanism of injury and if patient is intubated
Pain control: superficial and partial thickness burns can be extremely painful
Tdap: adminster with every severe burn
Prophylactic antibiotics: Burn patients at risk for severe infections, but systematic review found no benefit for prophylactic systemic antibiotics
Prognosis
Mortality increases with age, %TBSA and presence of inhalation injury
Revised Baux score is an accurate tool used to predict mortality = Age + %TBSA + 17(if inhalation injury present)
R4 Case Follow Up WITH dr. Scanlon
This case starts with a 20 year old female presenting for a psychiatric evaluation. Was previously a straight A student and has had a rapid progression of unusual behavior. Started with insomnia but led to hypersexuality, incontience and hyperreligiostiy. Was seen at previous hospital and treated with antipsychotics and anxiolytics and discharged with diagnosis of bipolar disorder. She represented to the ED for a second opinion. Upon further history, patient was found to have brief periods of lucidity where she would remember what had transpired and be embarrassed. There was also no family history of psychiatric disease, but multiple members with autoimmune diseases. She was also recently diagnosed with a “pelvic mass”. The providers had appropriate concern for NMDA encephalitis and the patient was admitted to neurology.
Autoimmune Encephalitis
Must have appropriate concern. Red flags to consider atypical age, autonomic dysfunction, seizures, dyskinesias, stupor or catatonia.
NMDA-Receptor Encephalitis:
2-4x more common in women
Often preceded by headache and viral syndrome
Associated with teratomas and herpes simplex virus
Diagnosed via CSF, serum markers and MRI (important to consider MRI prior to LP)
Treatment includes IVIG, PLEX and/or high dose glucocorticoids
Resection of teratoma is often curative
Hashimoto’s Encephalitis:
Also known as “steroid-responsive encephalopathy associated with autoimmune thyroiditis”
More common in women
Antithyroid antibiotics necessary for diagnosis
In addition to neuropsychiatric symptoms, seizures are common
CSF studies may reveal pleocytosis
Corticosteroids are first-line therapy
In conclusion, patient was treated for autoimmune encephalitis with IVIG and high dose steroids. No definitive diagnosis, but family reports patient has had significant improvement with treatment.
CPC: laurence vs Lagasse WITH dr. Laurence and Dr. Lagasse
Case: 46 year old female with 8 days of vaginal bleeding. Not sexually active, never been pregnant before. Has had multiple episodes of near syncope recently. Has been worked up for difficulty walking and had an MRI that showed mild to moderate atrophy which is advance for age. Labs found to have a pancytopenia.
Differential for pancytopenia
Bone marrow infiltration/replacement
Malignant: leukemia, myelodysplastic syndrome, multiple myeloma, metastatic cancer
Non-malignant: Myelofibrosis, TB, fungal infections
Bone Marrow Failure
Immune destruction: aplastic anemia, medications, HLH
Nutritional: B12, folate, malnutrition, anorexia, alcoholics
Marrow suppression: viral infections
Infective hematopoiesis: nutritional, MDS
Destruction/sequestration/redistribution
consumption: DIC
Splenomegaly: broad differential
Test of choice: Ethanol of 556
Alcohol Use Disorder
14.4 million (5.8%) adults age 18+ have alcohol use disorder
In 2010, alcohol misuse costs the US $249 billion
3rd leading cause of preventable death; 5th leading cause of preventable death globally
Defined by DSM 5 with 11 behavioral and psychological symptoms and a patient would be positive if you meet 2/11 in a 12 month period
Severity graded (mild, moderate, severe) based on # of symptoms
AUD effects on the brain
Promotes inflammatory processes, increases DNA damage, creates oxidative stress
Thiamine deficiency which can lead to Wernicke’s encephalopathy
Of note, there is no high quality data regarding duration, dosage or efficiency of thiamine repletion for those with AUD, but NIH/NICE guidelines recommend ongoing oral thiamine 100mg TID
Change in serum osmolarity which can lead to acute demyelination
Associated with decreased brain weight, white matter and number of cortical neurons
Typically a graded progression in volume loss according to severity of AUD
With ethanol cessation, brain volume gain observed, but return to “normal” unknown
AUD and hematologic complications
Suppresses hematopoiesis, creates abnormal RBCs that are destroyed
Megaloblastic anemia
Interferes with WBC production and function
Adversely affects platelet function and components of blood clotting system
r1 Clinical diagnostics: Pneumonia scores WITH Dr. Goff and Dr. Murphy-crews
Please see Dr. Goff’s post on pneumonia scores HERE (hyperlink) for more detail.
Case 1
Patient is a 64yoM with hx of HTN, DM, COPD, alcohol abuse presenting with fever, productive cough and shortness of breath. He has been using his inhalers for COPD at home but reports this feels worse than his typical exacerbations. T 38.2 BP 156/88 HR 106 RR 28 Sp02 92% RA. He is awake, alert and non-toxic appearing with diffuse wheezing and RLL crackles on exam.
Diagnosis is COPD with pneumonia. All labs normal.
CURB-65 is 0 making him appropriate for outpatient treatment
PSI is 64, but needs CBC, BMP, and theoretically ABG which is not typically ordered on all patients
Case 2
Patients is an otherwise healthy 24yoF, who reports she recently had one week of a viral sounding illness that seemed to get better but now comes in with a worsening productive cough, fever, and severe malaise. T 39.2 HR 144 RR 28 BP 84/38 Sp02 88% RA. She is awake, alert, but ill-appearing and has crackles on exam.
Patient is septic secondary to post-flu pneumonia
CURB-65 and PSI both suggest outpatient treatment, but most providers would admit this patient to higher level of care indicating some of the pitfalls of these scoring systems
SMART-COP score gives a 1/3 risk for intensive respiratory or vasopressor support and suggests consideration of ICU admission
Case 3
Patient is a 83yoM who resides in a nursing home for the past two years due to a disabling stroke. He is brought in for “altered mental status” when a nurse (it’s his first day working with this patient) noted that he was up for breakfast this morning and seemed more confused than he was told in report. PT is awake but only mumbles and not following commands (he reportedly assists with ADLs and is verbal w expressive aphasia per last DC summary). He appears chronically unwell and is tachypneic. T 35.8 HR 126 RR 32 BP 116/52 Sp02 88%RA.
PSI and CURB-65 both indicate admission; SMART-COP gives 2/3 risk of needing ICU or vasopressor support
With or without these scores, most providers would be admitting this patient and many to higher level of care.
Case 4
Patient is 46yoM who had a severe stroke and is PEG dependent after numerous aspiration issues. He is non-ambulatory at baseline. He has not been hospitalized in the last year and has not had an episode of PNA since his PEG was placed in 2018. Aside from his stroke he has only HTN and a stage 2 sacral decubitus ulcer. He presents today with productive cough and “low grade” fever. The nurse says this is the first time caring for him, but he seems at his baseline and definitely wasn’t allowed to PO like before. T 37.8 HR94 RR 18 BP 148/86 93%RA.
Challenging patient who has rather mild symptoms, but is unwell at baseline
PSI and CURB-65 both suggest outpatient follow
DRIP score indicates broad spectrum antibiotics, which could be more difficult in the outpatient setting.
