Grand Rounds Recap 11.15.23

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R1 diagnostics & Therapeutics: ear emergencies - r4 case follow-up - r2 CPC

R1 diagnostics & Therapeutics: ear emergencies WITH DR. lewis

Otologic complaints make up millions of ED visits per year. The feared complications of most external ear complaints are dangerous infections or permanent deformities known as “cauliflower ear."

  • Auricular hematomas should be drained and compressed when patients present with less than 7 days of symptoms. I&D with sewn-in bolster dressing decreases the risk of reaccumulation and deformity, although newer methods such as using molded silicone may have similar effects.

  • Perichondritis, often caused by penetrating trauma such as from high chondral piercings, is differentiated from otitis externa by the sparing of the lobule. It can progress to chondritis with abscess formation and necrosis of the cartilage if left untreated.

  • Oral antipseudomonal & antistaphylococcal antibiotics are recommended for auricular hematomas s/p drainage, perichondritis, and otitis externa.

  • ED providers should be familiar with several extraction techniques for foreign bodies in the external auditory canal including the use of manual extractors, irrigation, and other methods such as adhesives and acetone.

r4 case follow-up WITH DR. milligan

CC: Found down

The case: A young F was found down in a snow bank after a GSW to the head. EMS had reported she had coded en route. She presented with a core temp of 30C and her CT scan did not show a devastating head injury as was expected. She regained pulses with warming on arrival. Her labs and imaging that did not show signs of significant hypoxia/ischemia. It is possible she was just severely hypothermic.

  • Severe hypothermia (<28C): can cause AMS up to being unresponsive with no reflexes and dilated pupils

    • In the setting of trauma, this can greatly confound your exam

    • Even mild hypothermia (<35C) can cause mental status changes if the patient has other reasons to already have an abnormal neuro exam

    • Keep hypothermia in mind, particularly with history of prolonged cold exposure.

  • We make a lot of decisions quickly in the setting of what we believe to be a devastating head trauma

    • Avoid premature prognostication and letting this impact resuscitation

    • Resuscitate the patient regardless as the patient's post-resuscitation GCS is what neurosurgery is using for decision making

  • Hypothermia can lead to cardiac arrest, primarily VF or asystole, with highest risk at temperatures <28C

    • For hypothermic cardiac arrest with VF, some guidelines (European) suggest:

      • 3 attempts at defibrillation and then waiting until patient is rewarmed to >30C prior to additional attempts

      • Withholding epinephrine until >30C and then doubling interval due to prolonged metabolism times with hypothermia

    • The AHA guidelines state it may be reasonable to continue with standard ACLS care at all temperatures.

  • Rewarming:

    • Accidental hypothermia with a core temp <32C, consider active rewarming (bair hugger, humidified oxygen)

    • Consider VA-ECMO for any patient with cardiac instability or in cardiac arrest believed to be secondary to hypothermia

      • The HOPE score https://www.hypothermiascore.org/ can be used to calculate in-hospital mortality for a patient being considered for VA-ECMO for hypothermia

      • While trauma is likely an exclusion at our institution given usual need for anticoagulation on an ECMO circuit and generally poor outcomes in this patient population, it is not an absolute contraindication.

    • If ECMO is not an option, thoracic lavage with 2 chest tubes infusing warm fluids with the level 1 or continuous bladder irrigation are other internal rewarming options.

r2 clinical pathologic conference WITH DRs. lott & nagle

Legionella often causes a pneumonia with atypical symptoms in patients >50 years old with certain risk factors or with known exposures​.

  • Most cases are sporadic, 20% occur among travelers​

  • Outbreaks can occur within buildings, workplaces, hospitals​

  • Accounts for 1-10% of CAP, co-infection uncommon​

  • Consider sending Legionella testing, or treating empirically​

  • Treatment requires at least 5 days of fluoroquinolone or macrolide (levofloxacin or azithromycin recommended)