Grand Rounds Recap - 7/23/14

Residents as Teachers with Dr. Palmer

In general, the best way to learn is to challenge yourself.  Teaching styles should take into account different learner types and levels

Learner levels:

• Beginner: early 3rd year medical student
  • Can be an observer initially but transition these learners to the next stage
  • Keeps you on point as you have to really know what you are talking about
  • Incorporate them into your H+P
  • Transitional: ask them to perform supervised H+Ps as this prevents them from developing bad habits
  • Advanced:OMP (one minute preceptor) or SNAPPS model

What learners require from preceptors: empathy, enthusiasm, humor, respect, fairness, flexibility, consistency, dependability, support and warmth

     - You do not have to be all these things all the time but always try to start off strong

Learner Needs: space and time, concrete illustrations, control over pace, allow time for reflection, feedback, awareness of past experience level, contribute to care

Participation, repetition and reinforcement enhance learning

Constraints to teaching in the ED: lack of time, space, interest or resources

One Minute Preceptor Model:

Start by laying groundwork for their presentation

• Get a commitment: what do you think is going on, what lab test would you like to order, what is the disposition, etc
• Probe for supporting evidence: why do you think this is going on, etc
• Teach a general rule
• Reinforce what was done well
• Correct mistakes

SNAPPS:

 Learner Centered

• Summarize H+P
• Narrow differential diagnosis
• Analyze differential diagnosis
• Probe preceptor (ask questions)
• Plan for management
• Select a case related learning point

Complications of Bariatric Surgery with Dr. Watkins

Tachycardia = peritonitis in an obese patient, until proven otherwise

Bypass patients are always vitamin deficient.

Always think Thiamine (B1) deficiency in a vomiting patient and just give a bypass patient Thiamine when they are in the ED

Do not give NSAIDS to bypass patients as this increases risk of stricture

Bariatric patients do not need a lot of PO contrast as their stomachs are small

Obese patients have lots of complications in every body system.

There is a 95% improvement in their quality of life and 89% reduction in 5 year mortality after bariatric surgery

Roux-en-Y Gastric Bypass Source: U.S. National Institute of Diabetes and Digestive and Kidney Disease (NIDDK). Wikimedia Commons. http://commons.wikimedia.org/wiki/File:Roux-en-Y_gastric_bypass.png

Gastric Bypass: stomach is stapled into a small pouch and connected to distal intestine

There is no digestion/absorption until later in the intestine, meaning that these patients have lots of vitamin deficiencies

Early complications: leak, GI bleed, wound infection, Pulmonary (PE, hypoventilation, sleep apnea)

• Leak presents with abdominal pain, tachycardia, fever and dyspnea
  • Diagnose with gastrograffin UGI
  • GI bleed: usually managed conservatively if > 48 hours after surgery
  • Gastric Remnant distention: rare and potentially fatal if ruptures
    • Can be due to ileus or obstruction
    • Symptoms: pain, hiccups, shoulder pain, tachycardia, SOB
    • Needs immediate decompression
    • PE: pt's at higher risk as they are hypercoagulable 2/2 high estrogen

Late complications: malnutrition, obstruction, stricture, fistula, marginal ulcer, cholelithiasis, nephrolithiasis, kidney stone, hernia, dumping syndrome, hypoglycemia

• Internal hernia: increased risk after laparoscopic procedure
  • Incidence 3-5%, most common cause of SBO
  • Symptoms: postprandial crampy pain that can be preceded by symptoms of intermittent mild obstruction
  • CT: mesentary swirling
  • Marginal Ulcer: at site of gastrojenjunostomy
    • Present with epigastric pain and dysphagia
    • Jejunum does not have an acid buffer
    • Treat with PPI/sucralfate for 3-4 months
    • Dumping syndrome: due to high osmolar food bolus into the small intestine
      • Crampy pain, diarrhea, nausea, vomiting, flushing, hypotension, tachycardia, diaphoresis

Vitamin deficiencies after bypass: very common to have thiamine deficiency, anemia and Ca deficiency

Gasric Sleeve:

 #1 surgery for weight loss

• Take out 80% of the stomach
• Appetite suppressive
• Complications: leak, bleeding, volvulus, GERD, motility issues

Adjustable Gastric Banding Source: .S. National Institute of Diabetes and Digestive and Kidney Disease (NIDDK), Wikimedia Commons. http://commons.wikimedia.org/wiki/File:Adjustable_gastric_banding.png

Gastric Bands: Adjustable ring around stomach

Complications: upper pouch dilation, erosion, port problems

• Dilated pouch: symptoms of severe GERD due to increased pressure
  • Diagnose with UGI
  • Erosion: this occurs when the band is too tight
    • Symptoms: weight regain, no restriction with maximal fill
    • This does not present with peritonitis as it seals itself
    • Treatment: band removal
    • Commonly associated with port infection
    • Issues with the port: saline leak, infection, tube disconnect

When is it safe to use BiPaP in these patients?

After 1 week in Bypass surgery and after 1 month in sleeve patients, though overall this is very provider dependent

Clonidine Overdose with Dr. Axelson

Mechanism of action

• Central alpha agonist: this leads to negative feedback to NE/E and hypotension
• Peripheral alpha2 agonist
• Leads to release an a beta-endorphin that acts as an agonist to opioid receptors

It can be tough to tell clinically clonidine vs opioid overdose

Should you give Narcan to clonidine overdose?

Sure but it may not work because it only works on peripheral receptors so will only work early. You might see hypertension in children but this will usually autocorrect.

CPC with Dr. Baxter and Dr. Mudd

44 yo M with chronic back pain and wrist arthritis presents with 2 weeks of N, V, D, minimal dyspnea on exertion and cough. Has a Hg 8.6, WBC 5, Cr 1.7, proteinuria. Most significant complaint was dyspnea on exertion, so the pt got an EKG and CXR that showed cardiomegaly. Diagnostic test of choice is echocardiogram which showed a large pericardial effusion with tamponade. He gets admitted to the hospital with ultimate diagnosis of Lupus.

SLE: there are 11 diagnostic criteria and if you have 4/11, you can diagnose with Lupus.

Pericarditis is one of the diagnostic criteria and pericarditis with effusion is common in Lupus but tamponade is rare.

Acute complications of lupus:

• ACS: most common cause of death, Relative risk 6
• Pulmonary: alveolar hemorrhage, ARDS, respiratory failure
• Cricothyroid joint arthritis, angioedema
• Cardiac tamponade
• Renal failure
• Infection

Somatoform Disorders with Dr. Betham

0.5-2% of patient encounters include some component of factitious symptoms

Somatization disorder:

the patient has multiple unrelated complaints in several body systems.

• Usually in young females
• The pt is not aggressive
• The pt is not consciously lying about their symptoms
• There is no external gain

Malingering: patient consciously make up their symptoms for external gain

Factitious disorder: The patient consciously fabricates symptoms for primary gain (psychological gain in order to play the sick role)

Munchausen disease:

2 types

• Classic peregrinating migrating
  • Commonly seen in males
  • Patients are aggressive and grandiose
  • Patient undergo lots of aggressive testing and have a poor prognosis
  • Common nonperegrinating
    • Commonly seen in females with some medical training
    • Patient is not aggressive
    • The patient has chronic health problems, high incidence of substance abuse and personality disorder

Management in the ED

• Focus on objective data
• Avoid risky tests and treatments
• Be consistent
• Establish limits
• Focus on whats best for the pt

Digoxin Toxicity with Dr. Loftus

The pt presents with feeling "unwell", vomiting and irregular heart rate. HR varies from 145 to 38 to 101 to 83 to 26. Labs show K 2.5, Cr 3.6, Ca 13.3

• Digoxin works by blocking Na/K ATPase. This leads to increase in intracellular Na which inhibits Na/Ca exchanger and decreases intracellular Ca.
• Hypokalemia and hypomagnisemia can worsen digoxin toxicity even with a normal level
• Hyperkalemia is a marker of badness. K > 5.5 is an indication for digibind.

Stone heart theory -  We used to believe that you cannot give Ca to dig toxic patients however that is no longer believed to be true. While Ca is not recommended to use in hyperK patients with dig toxicity, it is unlikely to be harmful

Digoxin toxicity can cause ANY arrhythmia

• Scooped ST segment
• PAT with AV block
• Sinus bradycardia with SA block
• Transcutaneous and transvenous pacing may be dangerous in these patients as digoxin creates an irritable myocardium and pacing can cause a higher risk of V. Fib

Indications for Digibind

• Life threatening arrhythmia
• K > 5.5
• Renal failure

Bidirectional Ventricular Tachycardia - associated with digitalis toxicity. From: Edward Burns. Life in the Fastlane. http://lifeinthefastlane.com/ecg-library/basics/bvt/

Ramsey Hunt Syndrome (aka Herpes Zoster Oticus) with Dr. Toth

This is a polycranial neuropathy secondary to VZV or HSV

• Usually affects CN 7, 8, 9, 5, and 6 (in order of frequency)
• 20% of the patients present with pain only without any cutaneous findings
• Treatment: acyclovir and prednisone
• Can give gabapentin for pain
• Lidocaine eye drops for pain