Grand Rounds Recap - 10/1/2014

Consultant of the Month Series: Ear Emergencies with Dr. Golub

Auricular hematoma

https://dailyem.wordpress.com/2012/02/page/3/

Blood separates the cartilage from the perichondrium which supplies the blood-flow to the cartilage. This can lead to cartilaginous ischemia, infection, deformation (cauliflower ear). Treatment: I+D: make cuts parallel to natural lines in the helix to reduce visible scarring. Place a bolster to close the new potential space. Bolster stays for 7-10days. Keep on Keflex while bolster in place and f/u with ENT. 

Perichondritis - By Welleschik (Own work) [CC-BY-SA-3.0 (http://creativecommons.org/licenses/by-sa/3.0)], via Wikimedia Commons

Auricular infections 

Perichondritis has an exquisitely tender auricle but no skin changes that are consistent with overlying cellulitis. Usually has antecedent trauma (ie piercing). Treat with Cipro. 

Cellulitis is usually caused by staph and can be a complication of otitis externa. 

Relapsing polychondritis looks infectious but is autoimmune. It is frequently bilateral. Treat with steroids and work to find a cause.

Otitis Externa

Topical drops have >100x the potency of oral abx. Commonly lots of pain, swelling, debris and drainage in the ear canal. Infecting organisms are commonly staph or pseudamonas but may be fungal if chronic in nature. Treating with ciprodex is safe even if suspect ruptured TM. There is some concern if drops contain neomysin (which is safe in the middle ear but not in the inner ear). Provide dry ear precautions and followup with PMD or ENT in 1 week. Tip: cover external ear opening with cotton ball covered in vaseline when showering to keep canal completely dry. 

Necrotizing otitis externa (aka malignant otitis extera, aka skullbase osteo)

Look for facial nerve paralysis, pain out of proportion to exam. Usually in immunosuppresed patients (eg HIV, DM). Treatment is 4-6 months of IV abx. 

Mastoiditis

Rare, but usually a complication of otitis media. Look for mastoid erythema and tenderness. On CT, true mastoiditis has complete loss of the bony architecture of the mastoid air cells. Fluid filled mastoid does not equal mastoiditis. 

Good resource for ENT clinical practice guidelines (when to CT, what labs to get, etc): www.entnet.org 

Protip: you CAN you lido with epi on the ear and nose!

Protip: Pseudamonas is the most common infecting organism in the outer ear. Use cipro for coverage.

"Mastoiditis1" by B. Welleschik - Own work. Licensed under Creative Commons Attribution-Share Alike 3.0 via Wikimedia Commons - http://commons.wikimedia.org/wiki/File:Mastoiditis1.jpg#mediaviewer/File:Mastoiditis1.jpg

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CPC with Dr. Kircher and Dr. Palmer

54yo F with HTN, HLD, COPD, h/o aorto-innominant bypass in 2011 for recurrent TIAs who presents with CC: spells. She reports brief episodes of blacking out, jerking upper extremities, lasting 10-30 sec preceeded by jaw pain and diaphoresis. No incontinence, tongue biting, post-ictal state. 2 episodes witnessed in ED. Basic labs, EKG, CXR, CT head normal. 

Test of choice: cardiac monitor

Patient found to have Adams-Stokes Syndrome with 7-10 second periods of asystole resulting in syncope and seizure-like activity from hypoxia. Post-episodic flushing is common with reperfusion of the body. Treatment: pacemaker

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EBM Quick Hit: RR vs OR with Dr. Loftus

Relative Risk and Odds Ratio are both measures of association. 

Risk is the probability of an event happening (chance or likelihood). Relative Risk is commonly used in epidemiologic studies (cohorts or large RCTs). RR = (A/A+B)/(C/C+D)

Odds is the probability of an event occurring vs probability of event not occurring. It is a relative probability. Commonly used in case-control studies to compare exposure and outcome. OR = AD/BC. 

When prevalence of disease is very low then RR very closely approximates OR. 

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Leadership Curriculum: How to Pitch an Idea with Drs. McDonough, Schaninger, Stull, Stettler, Hill

Have a definitive ask. ie, "let's meet about this later..." or "I will gather more information and then let's meet next week"

The delivery matters. Develop yourself: confidence, enthusiasm, engage your listener, practice. Develop your idea: research your topic, know your objective, know the audience (their goals, their needs, anticipate questions). Make a first impression. We make quick judgments on a visual basis in 1/10sec. 

The elevator speech. Be able to sell your idea in the time it takes to ride the elevator so you can take advantage of a quick interaction to get buy in for the next step.

9 C's of the elevator speech 

Concise: as few words as possible. 

Clear: no fancy words. 

Compelling: why you're qualified to solve the problem. 

Conceptual: not too much detail. 

Concrete: specific and tangible. 

Customized: address the interests/concerns of the audience. 

Consistent: convey the same basic message. 

Conversational: start with a dialogue with your audience. Hook them in. 

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R4 Capstone Lecture: Febrile Neutropenia with Dr. Redmond

Neutropenia is ANC <500 or expected to be <500 in the next 48hrs. ANC = total WBC x % of neutrophils. 

Fever: >38.3 or >38 for an hour. Recommend against rectal temps to avoid translocation of bacteria. 

Treatment: empiric antibiotics should be started immediately after blood cultures obtained. Goal <2hrs. If you have high enough suspicion, you can do this prior to ANC resulting. First antibiotic needs to cover gram negatives (cefepime first line. alternatives carbapenem or zosyn). Vancomycin is NOT recommended as part of the initial antibiotic regimen unless: patient is hemodynamically unstable, has HCAP, has positive blood cultures with gram + organisms, suspect catheter-related infection, or skin/soft-tissue infection. 

In our ED, mean time to appropriate abx administration is 3:45 (based on study of 67pts over the last year with admitting diagnosis of febrile neutropenia). 

New protocol coming to EmergencyKT. If solid organ malignancy and chemotherapy administered within 14 days and temp >38(100.4) don't wait for labs, just give antibiotics (2g cefepime or meropenem if severe PCN allergy). If last chemo >14 days ago, wait for labs to result. 

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R1 Radiology Series: Hip Radiology with Dr. Goel

Review the modules on types of imaging which include: AP pelvis- good for supine patients, frog-leg lateral- good to evaluate femoral heads, necks, and acetabulum, cross-table lateral- good to look at proximal femur, Judets- best for acetabular fractures, inlet/outlet- best to assess for pelvic ring fractures. 

Posterior dislocations. 90% of hip dislocations are posterior. Look for associated fracture, especially on the posterior acetabular lip. The longer the hip is out the higher the incidence of hip necrosis. 

Pelvic ring fractures: follow the lines around the inlet and outlet. Look at the SI joint. Look for symmetry. 

SCFE: scoop of ice cream falling off the cone.