Grand Rounds Recap - 2/18/2015

M&M with Dr. Gozman

By Mikael Häggström (All used images are in public domain.) [Public domain], via Wikimedia Commons

Hyperthyroidism: 1.3% of the US population has hyperthyroid. Thyrotoxicosis = too much thyroid hormone activity. Remember, T4 is a prohormone and T3 is the bioactive form. Causes of hyperthyroidism are broad and include: inappropriate thyroid stimulation, autonomous release of excess thyroid hormone, excessive release of thyroid stores, extra-thyroid sources of hormone. Hyperthyroidism increases risk of all-cause cardiovascular mortality and incidence of Afib. Diagnosis of hyperthyroid made by TSH <0.1 and high free T4. Iodine uptake test helps to find nodules and differentiate from thyroiditis. 

Thyroid Storm: an exacerbation of thyrotoxicosis leading to multi-organ failure. Mortality is high at 10-30%. Precipitating factors include: thyroid surgery, radioiodine treatment, medication and medication adjustment. Symptoms: febrile, tachycardic, agitation, seizures, psychosis, delirium, transaminitis. Diagnostic scoring system based upon signs and symptoms, not lab values. Treatment: propylthiouricil is available but not commonly recommended due to hepatic toxicity. Methimazole is preferred, but takes several hours to work. In the mean-time, use propanolol to decrease the effects of the hormone (the only beta blocker that crosses the BBB so is ideal at treating CNS symptoms). 1 hour after giving methimazole, can give iodine. 

Acute Chest Syndrome: Any new pulmonary illness in sickle cell disease should be considered acute chest, although current diagnostic criteria require fever and/or respiratory symptoms plus infiltrate on CXR. Acute chest is the 2nd leading cause of hospitalization in SCD. It is most commonly brought about by infection (atypical pathogens, RSV, influenza) but can also be caused by fat embolism due to bone marrow infarction, micro-pulmonary infarcts, and hypoventilation from pain. Children are more likely than adults to present with fever. CXR findings may not be apparent until day 2 or 3 of illness. Treatment: IV or oral hydration, adequate analgesia to prevent splinting, incentive spirometry, bronchodilators, emperic antibiotics for pneumonia, blood transfusion. Our hematology group prefers exchange transfusion, especially if patient deteriorate despite other therapies, require intubation, or have history of prior intubation. There is no role for steroids. 

Inferior MI: constitute 40-50% of all acute MIs. Can frequently be associated with RV or posterior ischemia. Complicated by bradycardia and hypotension. More likely to present with GI symptoms and not classing crushing CP. EKG findings: ST depression in aVL or TWI in aVL. Remember, repeat EKGs save lives!

Serotonin Syndrome: 14-16% of cases are due to intentional overdose. Symptom onset is usually rapid (12-24 hours). Symptoms include 1) AMS: confusion, hypomania, agitation, disorientation, coma, seizures 2) neuromuscular abnormalities: clonus, rigitidiy, hyper-reflexia, increased tone, ataxia 3) autonomic instability: fever, mydriasis, diaphoresis. Labs are non-specific so must rely on history and physical for the diagnosis. Treatment: supportive therapy and withdrawal of offending agent: IV fluids, benzos for aggitation, cyproheptadine is a seratonin angatonist that can be used in severe cases. If you need to intubate, don't use succinylcholine. 

Tumor lysis syndrome: Can occur 3 days before or up to 7 days after initiation of therapy. Release of potassium from tumor cell intracellular contents leads to dysrhythmia; phosphate release can lead to hypocalcemia and seizure; DNA release can lead to uric acid formation and AKI. Workup: CBC, renal panel, mag, phos, uric acid, EKG. Treatment: lots of IV fluids, liberal use of dialysis to treat low urine output, peristent hyper phos, hypo Ca, or hyperK. Rasburicase drastically reduces uric acid levels but no proven mortality benefit. Rasburicase currently recommended for treatment of tumor lysis syndrome. 

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EMS Grand Rounds with Dr. McMullan, Ms. Vonderschmidt, Dr. Benoit

Upcoming EMS studies (look out for more details to come) 

• PROHS (Prehospital Resuscitation on Helicopter Study): observational, multicenter clinical study looking at HEMS organizations that carry blood vs those that don't. Treat patients like you usually do and transfuse as indicated. Scene patients coming to UCMC may be included. 
• TXA in TBI: First ever blinded RCT on AirCare. Will include patients with TBI (GCS 3-12) who are hemodynamically stable (ie would not otherwise qualify for TXA) coming from scene to UCMC. 

Tempus Pro Monitor: 4 units deployed on CFD that can be used as monitor, video laryngoscope, capnography, and telemedicine device! From our ED laptop can log into the device and see the monitor in real time, see the transmitted EKGs, and see photos of scene/patient. 

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Capstone Lecture with Dr. Moschella

New antibiotics to be on the lookout for:

• Dalbavancin: once weekly IV dose for skin infections. It is a synthetic analogue of vancomycin with a much longer half-life (258 hours). Study showed non-inferiority to BID vancomycin with single dose on day 1 and 1/2 dose on day 8. 
• Oritavancin: single IV dose vancomycin analogue that can be used in VRE. 

The miracle of capsaicin: The active compound present in chili peppers can be used as topic therapy for chronic pain. 2014 Cochrane review recommended it's use for chronic neuropathic pain thought to act by suppressing the cytokine and substance P release via negative feedback suppressing the nerve. Also some evidence that may work for cannabinoid hyperemesis syndrome. 

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Foot X-ray by Dr. Titone

Best views: oblique for the 4th and 5th metatarsals, lateral for the hind foot, AP for the 1st and 2nd metatarsals. 

By Thomas Steiner [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

Calcaneal fractures: look for Boehler's angle (20-40 degrees is normal). Intra-articular fractures are seen in 75% of calcaneal fracture. 10% will get compartment syndrome. 10-15% will have spinal compression fractures based on mechanism. 

Talar neck fractures are associated with very bad mechanisms and commonly develop AVN. Seen in dorsiflexed axial loading mechanism (ie foot on brake pedal). 

Lisfranc fracture dislocation: 2nd metatarsal is the keystone of the joint. 1st - 3rd metatarsals articulate with the cuneiforms and 4th and 5th articulate with cuboids. Look for space widening and Fleck sign (avulsion fracture off the metatarsal). Can get stress views of the foot if unable to get CT.​