Grand Rounds Recap 9/30/2015

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September Morbidity and Mortality Conference - Dr. Toth

Cases reviewed were from the month of August. We saw greater volume in 2015 than 2014 with longer ED hold times. We reviewed multiple cases including:

Acute Inflamatory Demyelinating Polyneuropathy

  • Pain is a common presentation, and cranial nerve palsies are not infrequent, but they usually follow weakness and numbness of the extremeties.
  • The diagnosis is in large part clinical, with progressive areflexia and sensory loss being the hallmarks. CSF studies showing albuminocytologic dissociation is confirmatory.
nms vs ss.png

Neuroleptic Malignant Syndrome

  • Results from dopamingeric blockade, typically after use of antipsychotics
  • Consider it in your psych patient who is altered, febrile, and in rhabdo

Gram Negative Sepsis in the immunocompromised

  • Consider which antibiotics are prioritized in the setting of a septic and ill patient
  • If a patient has been infected before, look to see the sensitivities to abx

 Necrotizing Fasciitis

  • Identification can be difficult, plain films sometimes help, and source control is the priority
  • Broad spectrum abx should include clindamycin for toxin sequestration
  • Consider it in a patient with severe hyponatremia, which is in and of itself a marker of mortality in necrotizing fasciitis
  • Roll and exam ill patients, particularly if their is any doubt as to the source of their infection

Nonconvulsive SE

  • Seizures can be heterogeneous in their presentation
  • Consider NCSE in an altered patient with no other good explanation for their behavior.
  • If they have a history of sz, prioritize cEEG and neuro consultation
  • A trial of benzos is almost never wrong if the diagnosis of SE is being considered

Urethral foreign body

  • If you don't take chest pain seriously, patients may resort to drastic measures to get your attention (get out of jail).

Cervical cord injury

  • Hypotension and bradycardia has a limited differential, and it may be a presentation of neurogenic shock.

Check out this great post over at EMLyceum for more information.

Frequent Flyer Head Bleed

  • Patient's who frequent the emergency department with chronic complaints often have long standing major medical comorbidities and will eventually present very, very ill and dying.
  • Examine patients as soon as they come in, and meet squads at the box

Hematemesis

  • Older patient and those with even a single bout of true hematemesis likely need same-day or next-day endoscopy.
  • Consider use of the Glasgow-Blatchford scoring system to identify patients who may be ok for outpatient followup and endoscopy.

Dr. Toth's overarching themes from reviewing August cases:

  • Patients with comorbid psychiatric disease may have medical problems which are inapparent 
  • Bad outcomes ≠ Bad care
  • Be vigilant
  • Watch your antibiotics like a hawk
  • You’ll miss the diagnoses you don’t consider
  • Boarding affects everything

Clinicopathologic Case Series with Drs. Dang and Knight

64 y/o F with T2DM, HTN, prior CVA and type II NSTEMI secondary to urosepsis year prior presented with altered mental status for three weeks...

  • Patient noted to have "inappropriate giggling" and confusion but otherwise normal examination with normal vital signs except for mild tachycardia. She has not been taking her medications including ASA, Atenolol, Atorvastatin and Metformin for months. NCHCT was unremarkable for acute pathology, metabolic workup including CBC, Renal Panel, VBG, Lactate, Coagulation profile, Thyroid studies, UA and CXR were not revealing. A diagnostic test was ordered...

Mnemonics for the differential on altered mental status

  • Dr. Knight explores the differential diagnosis for AMS, which is extraordinarily broad. 
  • You can simplify this as follow:
    • Acute: Vascular, Tox
    • Subacute: Mass, Infection, Tox
    • Chronic: Degenerative, Inflammatory, Some Infections
    • Dementia vs. Delerium

Dementia versus delirium 

  • But what about the inappropriate giggling?
  • Pseudobulbar affect
  • Emotional liability
  • Involuntary crying
  • Uncontrolled laughing
  • Can be mood-incongruent

Dr. Knight's diagnostic test of choice was... RPR for neurosyphilis. 

 

The diagnostic test ordered was...an EKG

  • Patient with Posterior ECG findings in V1, V2, V3
  • Posterior MI accounts for 15-20% of all STEMI and is the most commonly missed ECG MI pattern
  • Hallmarks are:
    • Horizontal ST depression
    • Tall, broad R waves
    • Upright T waves
    • R/S ratio >1 in lead V2
  • Posterior leads (V7, V8, V9) more sensitive than "flipping" standard ECG

Consultant of the Month: Cardiology and Cardiac Critical Care with Dr. TIm Smith

  • If a patient presents with greater than two any of the following unfavorable conditions with STEMI and ROSC, they may not be appropriate for cardiac catheterization
    • Unknown down time
    • PEA as initial rhythm
    • Greater than 30min to ROSC
    • Ongoing CPR
    • Increasing pressor requirement
    • pH less than 7.1
    • Lactate greater than 10
    • Age greater than 85
    • Active seizures
  • Lesions of 50-60% stenosis are more likely to cause acute MI rather than 90% as these are often highly calcified and unlikely to have plaque rupture. 
  • The evolution of cardiac critical care has improved outcomes. It began with rapid resuscitation with defibrillation, post MI care, focus on STEMI treatment. 
  • We now see a lot more shock and sepsis as well as additional critical care needs in the CVICU than we did in the past
  • Bronchoscopy and mechanical ventilation rates in the CVICU are up as well as sepsis, liver failure and NSTEMI. STEMI rates are decreasing. 
  • Mortality in ACS is improving with improved care
    • In the age of bed rest we had a 30% mortality
    • Defibrillation and hemodynamic monitoring improved to 13-15%
    • ACS pharmacology, PCI and lyrics has improved to 5-6.5%
  • Treatment of post-MI cardiogenic shock is the next frontier
    • 40% of patients with acute MI have cardiogenic shock
    • Previously this was as high at 80% before PCI and reperfusion. 
  • Mechanical circulatory support
    • IABP's have poor data to support their use, only get about 0.5L/min of CO augmentation. They are easy to place though with minimal improvement. The proof that they also improve coronary perfusion is lacking. 
    • Impella devices are likened to a percutaneous temporary LVAD. New devices can deliver up to 4L/min of CO augmentation. They are slightly more complicated to place due to their 13-14Fr catheter size. 
    • Tandem heart is very difficult to insert
    • ECMO can be technically difficult
“All who drink of this treatment recover within a short time, except in those who do not. Therefore, it fails only in incurable cases.”
— Galen

Chest X-Ray Interpretation with Dr. Sabedra

Check out Dr. Sabedra's excellent CXR interpretation module with some practice cases HERE!

R4 Capstone with Dr. CUrry

  • Up to 3% of ED patients return for a second visit within 72 hours after discharge
  • We can and should consider how to prevent patients from having to return
  • Inhaled corticosteroids (ICS) at discharge for asthma may prevent long term return rates
  • Initiation of low-dose ICS therapy is recommended by the Global Initiative for Asthma (GINA) as well as the National Heart Lung and Blood Institute at ED discharge
  • There was one paper (Rowe, et. al.) which showed a short term (21-day) decrease in return visits for high-dose ICS with a NNT = 9.
  • Subsequent research and a Cochrane review did not support that outcome.
  • Longer term, one study has shown a 45% reduction in return ED visits over 2 years when patients are started on an ICS after an index ED visit (Sin and Man).
  • PCP's only add ICS to asthma patients regimen 1/4 of the time after an ED visit (Cydulka, et. al.) 
  • ICS can be expensive for patients without insurance
  • Bottom Line: Consider starting ICS therapy on any patient who presents to the ED with an acute asthma exacerbation to prevent relapse in the future