Grand Rounds Recap - 11/19/2014

Mortality and Morbidity Conference with Dr. Gozman

Thrombocytopenia

Always consider medications as a key cause of throbocytopenia

Recommendations for platelet transfusion currently include:

• Patients on chemotherapy with <10K
• Patients requiring central venous access with <20K
• Patients requiring an LP with <50K
• Patients requiring non-neurologic surgical interventions with <50K
• Patients requiring CNS surgical intervention with <80K

There is not data to support platelet transfusion in patients with intracerebral hemorrhage on an antiplatetlet agent

Transfusion Reactions

The incidence of transfusion reactions is only ~1%

One of the most severe transfusion reactions is Acute Intravascular Hemolysis (AIH), which is due to ABO incompatibility, more typically mistakenly giving a patient the wrong blood

• AIH typically has nonspecific symptoms including fever, nausea, malaise, and shortness of breath but the mortality can approach 50%

Simple febrile reactions occur far more commonly and are a result of cytokine activation with the transfused blood

• Symptoms of simple febrile reactions can be similar to AIH, thus any transfusion patient developing a fever should have the blood stopped immediately until the type of reaction can be determined

Other transfusion reactions can include anaphylaxis and transfusion related acute lung injury (TRALI) but these are more common in FFP transfusion and Graft vs. Host Disease (which typically only occurs in immunocompromised patients)

Treatment and Pre-treatment

• If a patient develops a reaction, stop the blood and repeat Type & Cross, hemolysis labs (Uric Acid, LDH) and UA
• Treatment for transfusion reactions is typically supportive care with volume resuscitation and anti-pyretics
• Premedication of transfusion patients with benadryl and tylenol to prevent a simple febrile reaction has a number needed to treat of 334, however the only study demonstrating this was in BMT patients receiving transfusions limited the generalizability

Complications of Sickle Cell Disease

Patients with sickle cell disease (SCD) have a higher risk for infection than the general population due to functional asplenia, decreased complement activity, and a relative Zinc deficiency.

• The incidence of bacteremia in febrile SCD patients is estimated to be 3-5%, but keep in mind that other risk factors such as indwelling lines increase this risk
• One study of pediatric SCD patients with fever had a rate of <1% positive blood cultures and the only significant predictors of bacteremia in their regression model was Temperature >39 (with an LR of 2.5) and PMN's >85% (LR of 5)
• Each case depends on the clinical circumstances but there may be some role if a patient is well enough to discharge for a single dose of ceftriaxone while blood cultures are pending

Herpes Zoster

John Pozniak, with zoster blisters on his neck and shoulder. Taken May 5, 2006, in San Jose, California, United States.  Copyright © 2006, John Pozniak, and released under the terms of the GNU Free Documentation License ver. 1.2 or any later version.

The lifetime incidence for zoster is 10-20% and risk for the disease includes older age, steroids use, and life stressors

Zoster can have a 4 day to 2 week prodromal phase with dermatomal burning/itching pain before the pathognomonic rash develops

The incidence of postherpetic neuralgia is nearly 35% and risk factors include older age, severity of disease, or a multi-dermatomal rash

• Treatment for postherpetic neuralgia is primarily gabapentin, whild antivirals and steroids during zoster outbreak has not been shown to prevent neuralgia

Zoster encephalitis is a rare sequelae of zoster and presents with altered mental status with a wide variety of presentations that can mimic seizure, stroke and demyelinating disease

• Patients with a trigeminal distribution of zoster have the highest risk of zoster encephalitis
• LP results for zoster encephalitis include a lymphocytic predominance of white blood cells, normal to elevated protein, and normal glucose
• Remember to consider a Zoster PCR of the CSF as HSV PCR is not as highly sensitive for Zoster as it is for HSV1/2
• Treatment for zoster encephalitis is high dose acyclovir (10-15 mg/kg) every 8 hours for 14 days
• Zoster encephalitis can often lead to longer term symptomatology including prolonged delirium or even precipitate dementia

Burn Complications

There are over 450,000 burns presenting to ED's annually and ~17% of those patients develop infection of their burns

After the acute burn, infection is the leading cause of mortality among burn patients

• Typical causative organisms include S. aureus and Pseudomonas
• There is no evidence to support antibiotic prophylaxis for burn patients in the ED
• Silver sulfadiazine may actually increase the risk of infection of the burn

Multiple Myeloma

Multiple myeloma (MM) is the second most common blood malignancy in the US and is a malignant proliferation of mast cells.  It often presents with nonspecific symptoms such as fatigue, nausea/vomiting, and bone pain

Use the acronym C-R-A-B to remember the key associated signs and symptoms of MM include:

By Jer5150 (. ') [GFDL (http://www.gnu.org/copyleft/fdl.html) or CC-BY-SA-3.0 (http://creativecommons.org/licenses/by-sa/3.0)], via Wikimedia Commons

• C: Calcium (hypercalcemia)
• R: Renal (AKI)
• A: Anemia
• B: Bone lesion

Treatment of MM include steroid, bisphosphonates, chemotherapy, and stem cell transplant

The most common acute complications include hypercalcemia and CKD

• Findings on EKG of hypercalcemia include short QT and Osbourne Wave

Treat hypercalcemia if the patient is symptomatic (bones, stones, moans, and psychiatric overtones) with fluids, loop diuretics, pamidronate/zoledronic acid, and if necessary dialysis

Palliative Care in the ED

Surveys indicate that most people hope to die with dignity at home, yet over 80% of deaths occur in a health care setting.  Don't forget to ask about a patients goal of care whenever initiating care for an end organ disease and you can always engage Palliative Care in these patients (not just those whose death is imminent)

40 to 70% of dying patients experience unnecessary pain and 50 to 60% experience unnecessary shortness of breath

Palliative care can help not only better define/explore patients goals of care but also are experts at symptomatic management of dying

Against Medical Advice

About 1-2% of discharges from ED's are against medical advice

These can be high risk as there is a high readmission rate and are usually younger men without much access or resources to receive care

Patient's must have capacity (not competence, this is a legal term) to decide to sign out against medical advice

Be sure to document your assessment of their capacity, your disclosure of the patient's risks, provide other treatment options, and still provide all the appropriate discharge care/information that you usually would

Signing out AMA does not necessarily insulate you from liability but does help demonstrate that your duty to treat has been diminished by patient's autonomous decisions

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CPC with Drs. Winders & VanZile

Case: Diabetic male with painless vision loss

Always work to determine if vision loss is monocular (likely localized to the eye) or binocular (CNS problem)

Be sure to assess the medial aspect of the visual fields as it is much smaller than the lateral aspect and you can miss subtle presentations/hints if you miss it

Transient monocular vision loss often involves the vasculature, while persistent is likely an intraocular issue (may still be vasculature of the eye, but intraocular vessels)

The DDx for painless monocular vision loss is vitreous hemorrhage, retinal detachment, central retinal vein occlusion, or central retinal artery occulsion

There is still utility to the red reflex in adults as a lack of it can signal vitreous hemorrhage 

Emergent vitrectomy is only required in vitreous hemorrhage if it is associated with retinal detachment, these folks can be discharged with close Ohptho follow-up, encouraging elevation of HOB, and precautions against ASA and strenuous activity

One study demonstrated that after a 2 hour training, ED physicians were 100% sensitive in detecting ocular pathology in the ED

If using US on the eye be sure to set it to "ocular mode" with the high frequency probe

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Quick Hit EBM on Power with Dr. Latimer

Null Hypothesis = No relationship between 2 phenomena

• Type 1 error (alpha) = Rejecting the null hypothesis when it is true = False positive
• Type 2 error (beta) = Not rejecting the null hypothesis when it is false = False negative

Power = Ability to detect the effect when there is one aka the truth

Aspects of a study that affect power include the sample size, changing the degree of acceptable Type 1 error, or changing the size of the effect you are attempting to detect