Grand Rounds Recap - 11/13/14

SBIRT (Screening, Brief Intervention, Referral, & Treatment) for Substance Abuse

with Visiting Professor Dr. Kerry Broderick

Why should we care?

• Prevalence of this disease is impressive with greater than 33,000 deaths attributed to alcohol in 2012 alone (287,000 MVC's in Ohio alone attributable to alcohol)
• Medical problems attributable to alcohol use costs the US $100,000,000,000 annually (from health care bills to lost productivity)!
• Approximately 33% of inpatient admissions in a country hospital population were attributable to alcohol
• One in five Americans can be defined as at risk drinkers

How much is too much?

• The NIAAA defines at risk drinker as a male drinking more than 4 drinks on a single occasion or greater than 14 in a week (females as 3 drinks/occasion and greater than 7/week).

But I don't have time for an "intervention..."

• Make it a conversation, instead of thinking about the trite sitcom-style interventions we think of, it can take the form of a single question about how alcohol was involved in what brought them to the ED
• Consider asking all your patients in an MVC involving alcohol, "do you think your drinking played a role in your accident?"  It may not prompt any more conversation for you but has often impacted future behavior.  This alone can save a lot of lives.
• It is simple to screen and intervene for at risk drinking in everyone within 15 seconds just by asking "When was the last time you had 'X' drinks in a day?"
• If people do screen positive for at risk drinking or are concerned about the role alcohol played in their visit to the ED, a simple intervention can be telling them what normative behavior should be (i.e. anything less than the NIAAA recommendations)
• For every $1 spent on these sorts of brief interventions, you save $5 on future health care
• You can easily slip these into the discharge discussion/return precautions (as when they arrive they may be too intoxicated or anxious to pay attention to your initial discussion)

Uhh ohh, they actually said they need help, what do I do now?

• Talk to Social Work, they can often provide resources
• Refer them to a 12-step program (i.e. AA or NA), these tend to have proven track records for success

Now they're mad because I asked them about their alcohol use

• This tends to be a myth, as most patients are at least willing to entertain the question with physicians, especially as their substance use has finally lead to a bad outcome (i.e. them landing in the ED)
• If they truly do not want to talk about it, it's easy to end the conversation simply with "Well if you ever do need help, we're always here to help if you change your mind."

---

Career Pearls from the Pit with Dr. Kerry Broderick

• It is often said patients come to the ED for 2 reasons: pain or fear.  While this might be true, most are just looking for hope.  Give patients the hope they are looking for with the "WOU" (We + You) Factor.  Explicitly state what "we" will do for "you" when you see patients to help them.
• Whenever you're frustrated with a patient remember they have a story to tell, traveled, and waited to be cared for by you!
• If the facts in the case don't add up, go back and ask the patient for their story, sometimes everything will fall into place.
• Permissive Truthfulness (aka give patients your permission to tell the truth) and you'll be surprised about their insights to their disease.  For example, don't ask IF a patient takes their medication, ask them when the last time they were ABLE to take it.
• Use your judgement, but don't judge as every patient is someone's son, sister, brother, mother, etc.
• You are never as special as you think you are - each time you make a mistake step back and learn something from it and don't hesitate to ask your colleagues how you can be better
• Life is short, make it amazing

---

R1 Radiology Lecture: Ankle X-Ray with Dr. O'Brien 

• The ankle mortise is made up of the talus and medial/lateral malleoli
• Medial stability of the ankle depends on the deltoid ligament, while lateral stability is dependent on the calcaneofibular ligament, anterior inferior talofibular ligament, and posterior talofibular ligament.
• The syndesmosis can often transfer forces placed on the ankle higher up the leg leading to "high ankle sprains" or proximal fibular fractures (Maisonneuve Fracture).  Assess for syndesmotic injury with the Tibial Squeeze Test (squeezing the proximal tib-fib together and produces ankle pain) and the more sensitive Forced External Rotation Test (slight external rotation of the ankle leads to anterior shin pain)
• Think of the ankle as a ring and should any 2 parts of it be fractured, expect that this will require surgical intervention at some point. Presume that any tibiotalar dislocation is accompanied by a fracture

An adequate ankle film requires 3 views

1. AP: Assess the malleoli and look for widening of the syndesmosis
2. Lat: Assess the posterior tibia
3. Mortise: Assess the medial clear space and overall preservation of the spaces

Consider using the Weber Classification System for Ankle Fractures:

• A: Distal fibular fracture that is below the joint line
• B: Distal fibular fracture above the joint line (often associated with medial malleolus fracture or Deltoid ligament injury)
• C: Distal fibular fracture with associated syndesmotic injury

---

R4 Capstone Lecture: Ketamine with Dr. Verzwyvelt

Ketamine is an amazing drug with many uses

• It was originally derived from PCP and is a noncompetitive NMDA receptor agonist and is still used recreationally
• Chronic ketamine use can lead to a chronic cystitis leading to incontinence

Ketamine Myths Debunked

• A review by Cohen (2014) showed no adverse neurologic outcomes, increased ICU time or mortality in TBI patients
• A prospective study by Drayna (2012) showed no clinically significant increased in intraocular pressure in ketamine doses up to 4mg/kg

Dosing

• Ketamine dosing is a continuum from adequate analgesic dosing at 0.1 - 0.3 mg/kg to the dissociative dose of 0.8 mg/kg
• Ketamine can be an effective analgesic, especially to lower opioid dosing, in low doses but comfort with its use is still growing, so be mindful of using it anywhere other than well monitored areas currently
• The RSI dose of ketamine is 1.5 mg/kg, go big or go home when dosing it for RSI as there tends not to be a significant increase in side effects when used for RSI in higher doses

When using ketamine for DSI, awake looks, or procedural sedation be sure to push it over 1 minute, as fast pushes have been associated with increased incidences of bronchospasm and apnea

While there have not been patient-centered outcome studies, physiologically ketamine makes the most sense if needing to sedate a patient with an asthma exacerbation

---

SIDS with Dr. Sterrett

SIDS: Sudden Unexplained infant Death Syndrome

• < 1 yo in previously healthy infant

Pathophysiology is multifactorial

• Genetics: serotonin receptors and Na channels have been implicated
• Environmental
• Behavior

Risk factors:

• Smoking
• Male gender
• Prone/side sleeper
• Overheating
• Soft bedding
• Inadequate prenatal care
• Young mother
• Prematurity or low birth weight
• Minority parent

Incidence of SIDS has decreased since 1990s due to "Back to sleep" campaign

Pacifiers have been proven to decrease risk

Bed sharing is a huge risk, especially if child is younger than 3 months, if the parent is a smoker or if there are other children in the bed

---

ALTE with Dr. Sterrett 

50% occur during daytime

Common parent complaints: breathing problems, color change, seizure-like activity

Differential diagnosis:

• Infection, especially pulmonary or meningitis
• Seizure
• Congenital malformations
• GERD
• Trauma
• Apnea of prematurity
• Periodic breathing
• Breath holding spells

50% of the time you will not have a diagnosis

Diagnostic testing: no consensus. A good H+P to come up with a differential and your differential should guide your work up

• If unsure, it is always ok to admit

Apnea monitors do not prevent SIDS

---

Pertussis with Dr. Sterrett 

Infants frequently present with apnea, bradycardia and/or cyanosis

• High risk for morbidity and mortality

7-10 day incubation period and the patient is contagious until 1 of the 2 happens:

• 5 days of antibiotics -or-
• 21 days after onset of cough

3 stages of disease

1. Catarrhal: common cold
2. Paroxysmal
3. Convalescent: can last weeks-months

If you do get labs, which you don't always have to, you will see a lymphocytic predominance

• WBC > 60,000 is a poor predictor

Diagnosis is clinical: 14 days of cough with 1 of the following:

• Inspiratory w hoop
• Paroxysms of cough
• Post-tussive emesis
• Household contact with affected individual

This is not uncommon: about 10 cases/week at CCHMC

Reasons to hospitalize: respiratory distress, age < 3 months, PNA, unable to feed, cyanosis, apnea

Treat these patients with antibiotics as they may decrease symptom severity and for sure decrease spread of disease

Indications for treatment

• Positive PCR
• Patient with clinical characteristics suggestive of pertussis (see above)
• High risk patients: pregnant, immunocompromised or taking care of infants

1st line treatment is a macrolyde (azithromycin)

• Can use Bactrim if allergic
• Can increase risk of pyloric stenosis in children < 2 weeks old

Post exposure prophylaxis

• All close household contacts and child care workers regardless of immunization status

Adults need Tdap every 10 years and maybe sooner as immunity wanes

---

Measles with Dr. Sterrett 

Symptoms: malaise, fever, rash, coryza, cough, conjunctivitis

• 5th leading cause of mortality for children < 5 yo worldwide
• Very contagious with 75% attack rate, incubation period of 6-9 days
• Patients are contagious for 5 days before and 4 days after rash onset

Stages

1. prodrome stage

Koplik Spots. By CDC [Public domain], via Wikimedia Commons

• Fever, malaise
• Conjunctivitis, cough, coryza
• Koplik's spots: these appear 48 hours before rash onset

2. Exanthem: correlates with disease severity

• Maculopapular and blanching
• Spreads head to toe

Neurologic complications: seizure, encephalitis, acute disseminated encephalomyelities, subacute sclerosing panencephalitis

Diagnosis: serum IgG and IgM titers

Treatment is mainly supportive

• Antibiotics for secondary infection
• Vitamin A
• Ribavirin has been shown to work but not FDA approved

MMR provides life long immunity