Grand Rounds Recap 11/4

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A Walk Down the Difficult Airway with Dr. Carleton

Case 1: Morbidly obese young female presents after overdose - tachycardic and unresponsive to sternal rub but maintaining saturations at 92% on a non-rebreather.

Difficulties in the morbidly obese and implications for airway management...

Use your rules for airway assessment

  • 2 fingers of mouth opening - remainder of 3-3-2 cannot be determined due to habitus
  • both MOANs for BVM and RODS for EGD predict difficulty with ventilation due to the restrictive physiology of her habitus

Her main limitation is anatomic, both restrictive disease from her habitus and rapid desaturation - going with an awake look do you go fiberoptic or VL?

  • Improve your apneic oxygenation in morbidly obese patients - sit them up

How to perfect the awake look - implies a means of sedation to optimize oxygenation, not a method of intubation

  • Systemic sedation (think ketamine)
  • Topical lidocaine (2% mucosal)

Oral fiberoptic intubation through a Williams airway tips (morbid obesity, pulmonary edema, lack of functional nares)

  • Moderate your subtotal intubation to maximize the flexability of your fiberoptics (think cheap seats)
  • Keep the scope straight - it will allow your rotation to be more precise and increase your potential rotation

Fiberoptic nasal intubation

  • Subtotal intubation with impunity to 10 cm, then advance to 15cm (should be right to the epiglottis)

What direction should the bevel of the ETT?

  • Tip towards the septum (bevel out) reduces your chance of both turbinate laceration and nasal branch of the sphenopalantine artery

Pharyngitis - Clinical Knowledge with Dr. Soria

Let's talk anatomy

Nasopharynx - Adenoidal lymphoid tissue sits on the roof of the nasopharynx, typically largest in 5-7 year old range, then they regress in late childhood and nearly absent in the adult.

  • Presence of prominent adenoids in the adult should lead you to suspect pathologies such as HIV, lymphoma, or malignancy

Oropharynx –  Tonsillar capsule sits on the superior pharyngeal muscle.   Just deep to the SP muscle sits the glossopharyngeal nerve (CN9). CN9 can transmit the pain and odynophagia of inflammation during pharyngitis and tonsillitis.

  • Open tubed structure of the pharynx is formed by the superior, middle, and inferior constrictor muscles which fuse in the posterior midline at the pharyngeal raphe. Abscesses that form posteriorly tend to be bounded on one side of the retropharynx and don’t cross the midline.

 Many important muscular/fascial layers and spaces between the pharyngeal wall and the vertebrae:

  • One is the “danger space” – it is posterior to the retropharyngeal space and anterior to the prevertebral space, between the alar and prevertebral divisions of the deep layer of the deep cervical fascia.  Extends from the skull base to the posterior mediastinum and diaphragm.
  • "Danger space” because infection here tends to spread rapidly secondary to loose areolar tissue that occupies this region. This can lead to mediastinitis, empyema, and sepsis. 
  •  On imaging it cannot be reliably differentiated from the retropharyngeal space.

Let's talk about what infects that anatomy

Viral: most common etiology – up to 60% of pharyngitis is due to virus.

  • Rhinovirus/coronavirus associated with URI symptoms
  • Adenovirus associated with conjunctivitis
  • Sore throat is usually not the primary symptoms
  • EBV - Pharyngotonsillitis predominates
    • Associated with nasopharyngeal undifferentiated carcinoma, Burkitt lymphoma, and PTLD
  •  CMV - Presents as an asymptomatic latent infection in many
    •  Clinically similar to EBV with less LAD and increased transaminases common
  • HIV – ARS (Acute Retroviral Syndrome)
    • Occurs days up to 6 months after infection and affects up to 93%
  • HSV: Increased incidence of primary HSV infection in college students has been documented
    • linically difficult to distinguish primary from other sources of acute pharyngitis including GABHS and testing is required.
    • In adults, oropharyngeal HSV-1 causes pharyngitis/tonsillitis more often than gingivostomatitis.
    • lcers are characteristically shallow and covered with exudates.
    • isease is more severe in immunocompromised individuals (HIV) BUT it can cause painful esophagitis even in the immunocompetent, typically rare, if present can help you come to a diagnosis, especially in the young adolescent or college student.
  • HPV
    • Typically asymptomatic, associated with strains 6 and 11 (covered by vaccine) – has been implicated in development of squamous cell carcinoma of oropharynx.

Bacteria

  • Streptococcus - Most common cause of bacterial pharyngitis
    • If rapid strep negative in adult then follow up throat culture is NOT necessary (due to low incidence)
  • N. Gonorrhea - treat for both gonorrhea and chlamydia
  • Syphilis - pharynx involvement is usually during the primary or secondary stages.

Candidal infections: suspect in chronically debilitated/immunosuppressed (including chronic inhaled steroid use and DM).

  •  C.  albicans is the most common isolated organism (Thrush). Opportunistic infection common in HIV

 Distinguishing pharyngitis from an acute infection with abscess formation

  • Examples are peritonsillar, para/retro-pharyngeal abscesses - all of which will require more aggressive and possibly surgical management.
  • History will help suggest deep space involvement: neck pain, decreased range of motion, trismus and voice changes all help raise suggestion of complications.

Thinking about How We Think: A Primer on Cognitive Bias: R4 CAPSTONE WITH DR. OSTRO

  • Cognitive bias, also referred to as Cognitive Dispositions to Respond, are pitfalls in diagnostic reasoning that undermine objectivity and rational thinking. There are >150 described in the literature.
  • Cognitive biases are pervasive, and they can be helpful when applied appropriately. When they are inappropriate they lead to misdiagnosis and potentially adverse patient outcomes, at which point they are labeled cognitive errors. 
  • 50% of closed claims brought against emergency physicians are secondary to misdiagnosis. 
  • Patients at highest risk for falling victim to cognitive bias are those who have presentations with high degree of diagnostic uncertainty. I.E. not your open limb fracture or STEMI

Think of what you would do with the following...

Case 1: 39 year old with multiple complaints including chest pain, back pain, emesis, cough, and R arm pain. Discharged with diagnosis of bronchitis.

          Missed STEMI.  

Case 2: 32 year old post-partum patient with headache. Discharged with diagnosis of sinusitis.

         Missed pre/eclampsia and Reversible Cerebral Vasoconstriction Syndrome. 

Pertinent Biases

  • Diagnostic Momentum: What starts as a possibility gathers momentum until it 
  • Anchoring: Tendency to lock onto salient features in a patient’s initial 
  • Premature Closure: Tendency to apply premature closure to a decision-making 
  • Confirmation Bias: Tendency to look for confirming evidence to support a 
  • Search Satisfying: Tendency to call off a search once something is found and 
  • Sutton Slip: Tendency to go for the obvious, the path of least resistance and the 

Strategies for cognitive de-biasing: 

  • Metacognition: Disengage, reflect, and reconsider before action. 
  • Reduce cognitive load: Mnemonics, clinical decision rules and algorithms, hand-
  • Cognitive autopsy: Root cause analysis of the event becomes definite and other possibilities are excluded presentation too early in the diagnostic process. Failure to adjust initial presentation in light of later information. process, accepting a diagnosis before it has been fully verified. diagnosis rather than look for refuting evidence. neglecting concurrent disease processes. low hanging fruit. held devices/apps.

The Quick Hits of ACEP - Open Mic

Esmolol for Refractory VF

  • Retrospective case review looked at 25 patients in refractory VFib (after at least 3 shocks, 3mg epinephrine and 300mg amiodarone) and used 500 mcg/kg bolus of esmolol with impressive results - of the 6 patients, 3 survived to good neurologic outcomes, where only 2/19 did in the control group.
  • Physiologically makes sense in decreasing the B agonist effects (increasing myocardial oxygen demand) of intrinsic and exogenous adrenergic surge of the arrest
  • Practice changing? Not quite there yet - but where there are no other options

Echocardiogram in HF

  • RV - TAPSE - ED Assessment of bedside RV function
    • Easy gross assessment of RV function based on the mobility of the tricuspid valve towards the septum
  • LV - Evaluate for dysfunction with EPSS

SVT - Break it without Drugs

  • 50% success rate (30% higher than valsalva alone) 
  • Valsalva (blowing into syringe) seated upright followed by elevating legs and reclining  for 45 secconds

Routine Treatment of your HIV Patient

  • Absolute lymphocyte count  < 1000 should be concerning for CD4 < 200
  • Absolute lymphocyte count > 2000 should reflect an immunocompetent CD4 count
  • If you are going to do a CT for AMS, HA, AMS - a noncontrast head CT will be sufficient to rule out abscess
  • CD4 > 200 in the setting of headache can be treated as an immunocompetent person would