Grand Rounds Recap - 8/13/2014

R4 Simulation Series: Genitourinary Emergencies with Dr. Moschella and Dr. Verzwyvelt

• Fournier's Gangrene (ie necrotizing fasciitis of the perineum): Case simulation of 19 yo M with tachycardia, hypotension, altered mental status found to have erythema, induration, and crepitus of the perineum. Initial steps are aggressive treatment of sepsis (broad spectrum antibiotics to cover skin and gut flora as this is commonly polymycrobial) and early surgical debridement. Either Urology of Acute Care Surgery will mobilize to perform the debridement.
• Oral boards case: Consider ovarian torsion in young female with acute onset pain in lower abdomen or pelvis. You may find adnexal fullness or tenderness on exam. Diagnostic test of choice is transvaginal duplex ultrasound. Remember to include ectopic pregnancy, appendicitis, TOA in your differential.
• Priapism procedure lab: A dorsal penile block can be achieved by placing wheals of local at the base of the penis in the 11 and 1 o'clock positions. Initial step is to drain the corpus cavernosum using a butterfly needle and syringe (18-23G will work). You can drain from anywhere along the penis but do not go through the glans. You only need to drain one side as they are connected. You can also irrigate with cold water or phenylephrine (2cc into 98cc NS bag; then inject 1cc into cavernosum) if the initial drainage does not achieve detumescence. Send a blood gas from the drained blood as pH is one of the most predictive factors in future erectile function.

Case Follow up with Dr. Doerning

• 32yo Hispanic F with "worst headache of life" associated with photophobia and nausea without fever or meningismus. CT and CTV were performed and negative. LP showed: Tube 1 35k RBC; Tube 4 33k RBC and 67 nucleated cells. Subsequent CTA showed 2 saccular aneurysms that were repaired with a craniotomy and clipping.
• Tips: there is no defined ratio of RBC to WBC to help determine traumatic tap versus SAH. Xanthochromia takes 6-12 hours to develop and is subjectively measured, so hard to rely on it. A traumatic LP should have: normal opening pressure, no xanthochromia, diminishing progressive RBC count.

Case Follow up with Dr. Mudd

• 29 yo M restrained driver who arrived hypotensive receiving blood transfusion. FAST positive in Morrison's pouch and splenorenal view. Additionally, FAST showed "spine sign" which is the ability to see the vertebral bodies in the thorax due to presence of fluid. Patient stabilized, brought to scan, and found to have traumatic dissection of his aorta. He subsequently underwent intubation, line, esmolol gtt, and TVAR (thoracic aortic endovascular repair) which went well and was discharged home on day 6!

Case Follow up with Dr. Scupp

• 33 yo F with 2 weeks of viral syndrome (cough, fever, two ED presentations for "I don't feel well", vomiting, myalgias). Found to have prominent cervical LAD. Remained tachycardic despite IV fluids (120s - 140s) and elevation of Cr and mild transaminitis identified. Inpatient team sent IgM an IgG which were both positive and lead to diagnosis of acute CMV.
• Acute CMV can look like EBV but monospot is negative. The vast majority of patients are asymptomatic but severe illness can lead to hepatitis, pneumonia, pancreatitis. Can see in immunocompentent people but most common in the immunocompromised (15-20% of all BMT patients). Also keep it in the differential for HIV with CD4 <400 and neonates (TORCHES).

Kawasaki Disease with Dr. Chan

"Kawasaki symptoms B" by Kawasaki_symptoms.jpg: Dong Soo Kimderivative work: Natr (talk) - Kawasaki_symptoms.jpg. Licensed under CC BY 2.0 via Wikimedia Commons.

• An acute self-limited vasculitis of unknown etiology.
• Most common demographics: young children (mean 2yo), more boys than girls, most common in winter and spring.
• If left untreated up to 1/4 develop coronary artery aneurysms or ectasia which can lead to MI, sudden death, ischemic heart disease.
• Diagnostic criteria: 5 days of fever + 4 of the following: extremity changes (erythema or swelling of hand/feet), polymorphous exanthem, conjunctivitis (bilateral non-exudative), changes in lips or oral cavity (dryness or strawberry tongue), lymphadenopathy. Additional testing can include ESR and CRP, LFTs, echo.
• Treatment options: high dose ASA (80-110mg/kg/day) followed by low dose ASA (3-5mg/kg/day) or IVIG. All patients need to be admitted.

Cervical Spine Injuries in Children with Dr. Chan

• These injuries are rare in peds (<1% of blunt trauma)
• Location of injury varies by age. <8yo high c-spine (c1-4) is most common. >8yo low c-spine (c5-7) is most common. This is due to the fulcrum of the weight of the head, weaker neck muscles, and poor protective reflexes.
• Canadian C-spine rules were derived, tested, and validated in adults so are not useful in kids.
• NEXUS was validated in all ages, but only 3,000 of the 34,000 patients were under 18yo. Actual injuries were found in 88 patients under the age of 2 and 817 under the age of 8. While this still yielded 100% sensitivity the confidence interval is much wider due to the low incidence of injury.
• PECARN: 540 cases with matched controls suggest imaging if any high risk factors: AMS, focal neuro deficit, torticollis, substantial torso injury, predisposing condition, or high risk MVC.
• Imaging
  • Start with xrays (2-3 view). If negative, can get CT
  • How good are xrays?
    • Restrospective subanalysis of PECARN 90% sensitivity. Children <8 sensitivity only 83%
  • Don't use flex/ex films. Based on retrospecive look at NEXUS - 6 new injuries identified, but already had positive findings on 3view
  • When to CT?
    • High pre-test probability (unable to get reliable exam, high mechanism, multisystem trauma)
    • Further eval of +plain films
    • Can't obtain adequate plain films
  • Normal variants on imaging
    • C1- posterior arch fuses by 3yrs; anterior arch fuses by 10yrs.
    • Pseudosubluxation of C2 on 3 is common
    • Wide predental space (between dense and C1)
    • Growth plate between body of C2 and dens
    • Anterior wedging can be normal

"Emergency Thoracotomy" by Cothren and Moore; licensee BioMed Central Ltd. - http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1459269/figure/F2/. Licensed under CC BY 2.0 via Wikimedia Commons.

Consultant of the Month with Dr. Makley: ED Thoracotomy and REBOA

• Goals of damage control resuscitation: stop the bleeding, stop the contamination, quick into the OR and quick out of the OR.
• ED thoracotomy: 4th intercostal space from the sternum to the bed.
• Clamshell: start with a triage chest tube of the right chest. If drains hemothorax, then extend the incision across the sternum with Lebsche knife.
• Tip: placing an OG tube can help differentiate between an empty aorta and the esophagus.
• Goals: direct inspection of injury, open cardiac massage (2x the cardiac output of closed chest CPR), relieve tamponade, repair cardiac injury, control lung hemorrhage, cross-clamp of the aorta.
• Best outcomes seen in stab wounds to the heart with shortest CPR time. Current UC protocols: Blunt <10min CPR, Penetrating <15 min of CPR, non-torso trauma <5 min of CPR.
• High risk procedure for you and the patient. Risks to patient: lacerations to heart, phrenic nerve transection, damage to esophagus, lung laceration, laceration of internal mammary arteries. Risk to you: incidence of your skin to patient blood contact 50%! Incidence of your blood to patient blood contact 6-10%.
• REBOA (Resuscitative endovascular balloon occlusion of the aorta) = "the new thoracotomy". This may help in damage control resuscitation when the patient still has a pulse. The balloon goes into the chest, so don't use this if severe chest trauma. This is newly available in the UCMC trauma OR and hopes to move to the SRU.
• This requires an arterial line, so if you are sticking for a femoral line and get artery, go ahead and thread the a-line which can then be dilated up to accept the REBOA (14F sheath, 120cm catheter).
• See article for more details about the procedure: Stannard, et al. Journal of Trauma 2011. PMID: 22182896