Grand Rounds Recap - 9/24/2014

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M&M with Dr. Stull

Management of the GI bleed (a review of the Cochrane Reviews): 

  • PPI drips have been shown to decrease the rate of rebleed in patients with known peoptic ulcers. It has not been shown to decrease mortality, hospital stay, transfusion need. It also has not been shown to be beneficial in the undifferentiated upper GI bleed and may have a trend toward harm. 
  • Octreotide doesn't improve mortality but on average decreased transfusion requirement by 1/2u product.
  • Antibiotic coverage (treating for gut translocation with ceftriaxone) has been shown to have lowered mortality from infection and all-cause mortality.
  • Prophylactic intubation: 2 retrospective chart reviews came up with contrasting results on mortality outcome after intubating for prophylactic reasons (patient was protecting their airway). 

Appendicitis

In our specialty we examine more abdomens with appendicitis and without appendicitis than anyone else. Read this to review some of the most important historical and exam features, trust your instinct, and then give really good return precautions. If you have high suspicion, call surgery early.

Immunosupressed and Fever

Patients with ESRD are very prone to infection from a baseline immunosupression and their frequent exposure to possible bacteremia (indwelling catheters, grafts, frequent vascular access). If your patient has ESRD and fever have a very high suspicion for bacteremia, endocarditis, and catheter associated infections. 

Anterior Uveitis (aka iritis)

"Keratic-precipitates" by Jonathan Trobe, M.D. - http://www.kellogg.umich.edu/theeyeshaveit/red-eye/anterior-uveitis.html. Licensed under Creative Commons Attribution 3.0 via Wikimedia Commons - http://commons.wikimedia.org/wiki/File:Keratic-precipi…

"Keratic-precipitates" by Jonathan Trobe, M.D. - http://www.kellogg.umich.edu/theeyeshaveit/red-eye/anterior-uveitis.html. Licensed under Creative Commons Attribution 3.0 via Wikimedia Commons - http://commons.wikimedia.org/wiki/File:Keratic-precipitates.jpg#mediaviewer/File:Keratic-precipitates.jpg

Diagnosed by evaluation of the cornea and anterior chamber with slit lamp. Look for keratotic precipitants (dried white blood cells on the cornea that look like dried water spots on a wine glass) and cell and flare. Cells are floating dots that are literally WBCs floating. Flare has a smoky or hazy appearance. This diagnosis can be made by us but needs urgent ophtho followup (in 24 hrs). The workup needs to be to look for an underlying cause which can be infectious, autoimmune, or related to other chronic conditions. It can be an AIDS defining illness, so don't forget an HIV test. It can also be common in syphilis (technically tertiary neurosyphilis as the eye is an extension of neural tissue). 

3M DRG Assurance with Dr. Naber and Mr. Cain

The hospital has invested in new software that will help the coders and nurse clinicians try to pull terms out of our documentation to accurately capture charges, complexity of the case, severity of illness, and risk of mortality. You may see "coding inquires" in your Epic in-basket asking you to review your chart and consider edits.

Some non-codeable terms to avoid: multi-system organ failure, altered mental status, severe respiratory distress, urosepsis, hemodynamically unstable. 

Work to describe what you think is going on, even if you haven't confirmed it: "suspected PE"

ICD-10 will ask for increased descriptors of diagnosis. Example: "PE" will turn into "acute thrombotic PE related to recent surgery". 

3rd Trimester Bleeding with Dr. Thompson

Placental Abruption is usually painful and associated with dark clotted bleeding. It can be tricky because there may be no visible bleeding. Look for signs of fetal distress (bradycardia) and maternal distress. Diagnosis is made by formal pelvic ultrasound or MRI (2nd line if U/S is unclear). 

Placenta Previa is commonly associated with painless bright red bleeding. Risk factors include: prior c-section, uterine surgeries, smoking, prior previa. Look for prenatal ultrasound results to find if location of placenta is known. 

Vasa previa is when the umbilical vessels get caught in the cervical os. It can cause fetal instability with a stable mother. If the umbilical cord becomes injured it can cause fetal exsanguination. 

CPC with Dr. Devries and Dr. Baxter

62 yo F with myasthenia gravis who presents with SOB with exertion which had been worsening over last few weeks. Had undergone outpatient PFTs which were normal, CXR - normal, and cardiac perfusion scan - normal. NIF performed >40cmH20 (normal). 

  • Diagnosis made by bedside echo (RV dilation with McConnell's sign) followed by CTPA: large bilateral PEs. 
  • Echo findings in RV dilation: measure the RV with an apical 4-chamber view during mid-diastole and compare it to the LV. Normal ratio (RV:LV) is <0.6. 0.6-1.0 is moderate dilation. >1.0 is severe dilation. 

EBM Quick Hit with Dr. Denney

Sensitivity/Specificity: (SpIN and SnOUT - sensitivity rules in; specificity rules out)

Sensitivity: ability to detect those with disease

Specificity: ability to detect those that do not have disease

Likelihood ratios 

Positive likelihood ratio: probably of positive test with disease (true positive)/ false positive

Negative likelihood ratio: probability of negative test with disease (false negative)/ true negative

Open Mic

Dental Resources

Dr. Hooker has an Epic smartphrase (.ehdental) that you can steal. He will also work to make it available on EmergencyKT with all of the local dental resources. Local clinics take walk-in "emergency" appointments first thing in the morning and charge just $5. 

A rant from Dr. Widners

60% of patients using an interpreter phone feel like they aren't being fully understood. Do everything you can to get the best interpreter available for your patient. 

Avoiding alcohol withdrawal with Dr. Kircher 

You can order "diet" --> "other" --> then specify "beers with meals" to help your alcoholic patients avoid withdrawal and they will get beer TID. Suggestion is to order 1/2 of their usual consumption. 

Fluorescing Urine

Fluorescing Urine

Case discussion with Dr. Lagasse

Crazy case of intentional ingestion with pH of 6.67 and urine that fluoresced! Anion gap of 40, serum osm gap of 38. 

Rash in Tanzania with Dr. Selvam 

Great photo presentation of active leprosy lesions (ulcerative, dry, leathery, non-tender). 

E-cigs with Dr. Riddle

Vaporizer solution is unregulated but usually has approx 10mg/cc of nicotine. Toxic dose is 1mg/kg, so pediatric ingestion can be toxic. This stuff can be purchased by the gallon.