Grand Rounds Recap - 1/28/15

Mortality & Morbidity Conference with Dr. Bohanske

When volumes are high remember the patient experience can be improved by the acknowledging the wait times when you enter the room and apologizing for their wait

Transverse myelitis is a result of partial inflammation of the spinal cord that can sometimes lead to necrosis

By Frank Gaillard [GFDL 1.3 (www.gnu.org/licenses/fdl-1.3.html), GFDL 1.3 (www.gnu.org/licenses/fdl-1.3.html) or CC BY-SA 3.0 (http://creativecommons.org/licenses/by-sa/3.0)], via Wikimedia Commons

• The disease process is often progressive and function does not always return after treatment
• Most commonly this is idiopathic in nature but it is often attributed to a post infectious inflammatory state
• Differential diagnosis should always include cord ischemia versus compression.  Diagnosis hinges on a T2 weighted MRI
• You should also consider LP in these individuals as you can often see a CSF pleocytosis
• Treatment for transverse myelitis is high-dose steroids (Solumderol 1gm qday), IVIF, and plasmapheresis
• Neuromyelitis optica (aka Devic Syndrome) is a type of transverse myelitis that typically includes more than 3 vertebral levels of the cord and optic nerve lesions, it can often be mistaken for MS
• 5 year survival from transverse myelitis is approximately 70 percent and neurologic recovery can often be incomplete

Anytime a patient complains of chest pain and has neurologic dysfunction seriously consider aortic dissection

• Consider dissection in severe stroke or patient's cannot necessarily articulate chest pain
• Estimations vary for the presence of chest pain on presentation between 10-55% 
• While chest x-ray is often sited as a screening test for dissection greater than 20 percent with a dissection will have a normal chest x-ray
• Most studies of the management of aortic dissection encourage surgical intervention though many of these are retrospective.  Thus those in the medical treatment arm often were much sicker than those in the surgical treatment arm
• CTA is the definitive test to assess for vascular dysfunction in patients with neurologic symptoms such as stroke

Treatment with calcium channel blocker in patients with A. fib with RVR is relatively contraindicated in patient's with decompensated heart failure per AHA guidelines

• Studies of diltiazem in patients with heart failure who present with A. fib with RVR did not demonstrate any mortality differences but increased cardiac morbidity including increased decompensation of CHF
• There are many pharmacologic treatments for A. fib with RVR besides diltiazem including beta blockers, amiodarone and digoxin (note our UCMC cardiologists suggest digoxin if the patient is otherwise stable with A. fib with RVR, if you need to urgently control them consider esmolol, if they are unstable electricity is your friend)

With the rising rates of IVDU, once rare disease processes such as endocarditis and spinal epidural abscess are on the rise

• SIRS + prosthestic valve should make you seriously consider endocarditis

Remember when dispositioning a patient that "destination is destiny," be sure to seriously consider a more generalist service if there is more than a single problem contributing to an admission

Palliative care in the ED can be difficult to accomplish but is becoming more important all the time

• Keep in mind that the dying patient often requires escalated care to manage their symptoms, so consider opioid or benzo drips or PCA's
• Don't forget that a patient can choose to rescind a DNR at any time, but often they present for symptom control or family/friend anxiety at the end of life
• Attached is a wonderful summary from Chris Richardson and Robbie Paulsen's Palliative Care session from 2013-2014 GR

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Pediatric Airway with Dr. Carleton

In terms of airway management most children over the age of 8 years are really just little adults, however, those less than 8 years of age require a bit more thought about their anatomy and physiology

• Reduce your cognitive load when intubating children, always carry a reference card for ET tube sizes and drug dosing
• Your approach and indications to airway in children are the same as usual, always follow the universal airway
• Predictors of difficulty in children are not as well established as in adults

Anatomy differences in children (most notably up to 2 yo) include:

•   Preferential nose breathing
•   Larger tongues
•   Small jaws
•   Longer epiglottis
•   Higher glottis (at level of C3)
•   Larger occiput
•   Poor neck landmarks
•   Smaller airway calibers
•   Increased chest compliance 

The angle to visualize the glottis and children is more acute and you will need to look more anterior to visualize cords

• Consider the use of straight blade went into being children and be sure to use a shoulder support in the very young to align the airway
• Remember that they have a very short trachea (so be careful with your lip to tip distance)

More recent studies have shown that cuffed tubes are safe in kids as the most narrow area of the airway in functional studies are at the vocal cords

When bagging kid try the phrase "squeeze, release, release" to help keep time

Physiology differences in children (most notably up to 2 yo) include:

• Increased O2 consumption (2x adults)
• Decreased FRC (50% adults)
• Increased dead space
• Respiratory compensation leads to increased respiratory rate but no change in volumes
• Increased rate of respiratory fatigue to do less slow twitch muscles in the chest
• They tolerate hypercapnia better but do worse with hypoxia

Children only have ~3-4 minutes of apnea before they require bagging

• In more recent studies 25 percent of peri-operative arrests and children occurred due to hypoxia (with two thirds of these children being assessed as an AHA class I-II anesthesia risk)

Can't Intubate, Can't Oxygenate (CICO) situations are rare in children (mostly due to syndromes)

• Always focus on oxygenation in the child (go to EGD's early)
• In multiple RCT's the LMA has been shown to be effective to oxygenate a child
• In children insert the LMA similarly to the way you insert an oropharyneal airway with it turned toward the hard palate and once slide into position turn the device so it covers the glottis

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Seizure Management with Dr. Privitera

One in 26 adults in the US have epilepsy.  Forty percent of adults with a first-time seizure will never had a seizure again, the only 50 percent of seizures were discovered to have a cause

It can be a huge help to the neuro follow-up to provide a clear sense of how it started (focal vs. generalized)

When evaluating for syncope versus seizure consider the three key types of seizures:

• Absence: Brief stopping of activity for mere seconds without warning and the patient often is unaware of this, often associated with photosensitivity
• Temporal Lobe Seizure: Often associated with auras and automatisms and then usually lead to a postictal language disturbance
• Generalize Tonic-Clonic Seizure: Starting with an initial extension of the extremities then the classic clonic jerking motions and on average take ~15 minutes to recover

Approximately 50% of epilepsy patients are easy to control with a single medications, however, 36% are difficult to control and will fail multiple medications

Any patient diagnosed with pregnancy who is taking AED's should be started on folate to help prevent neural tube defects

Ohio law leaves driving rules to the physicians discretion, though most of neurologists will say that someone must be seizure free for 90 days to drive

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MRI Spine with Dr. M. Miller

With MRI becoming more readability available it is being used more and more in the ED. While EP's are not expected to read an MRI, it's vital for us to be able to know the big picture of these increasingly common diagnostic tests

• Create a system for reading all imaging, with the MRI spine take a look at the vertebrae and then look through the canal/cord
• When mass or infection is on the differential then use contrast when ordering the MRI
• Indications for emergent MRI include spinal epidural abscess and cauda equina syndrome
• When considering this pathology and imaging, urgency is needed as any neurological deficits that are present can persist despite treatment