Grand Rounds Recap 1.3.24
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R4 Capstone: violence against healthcare workers WITH dr. wosiski-kuhn
Nearly half of emergency physicians report being physically assaulted at work
85% of emergency physicians believe that the rate of violence experienced in emergency departments has increased over the past five years, with 45% indicating it has greatly increased.
None of the physicians in the study believe that the rate of violence has decreased at all.
89% agree that violence in the emergency department has harmed patient care. Responses to how it harmed patient care included: loss of productivity, emotional trauma, increased anxiety, increased wait time & decreased focus on other patients (violence takes resources from other patients when it happens), increases in those who LWBS (other bystanders who are also patients are literally afraid).
Physicians believe the biggest factors contributing to ED violence are a lack of adequate punitive consequences toward the attacker and the absence of adequate protective mechanisms for staff. Additionally, ED boarding is a now a larger factor than in 2018. (ACEP, 2022 available at https://www.emergencyphysicians.org/siteassets/emphysicians/all-pdfs/acep-emergency-department-violence-report-2022-abridged.pdf)
In 2020, the Bureau of Labor Statistics found that health care workers make up for more than three quarters of all workplace violence nationwide, and are almost four times more likely to suffer a serious injury from workplace violence than workers in any other workplace setting
Rates of violence against healthcare workers is 12x higher than violence against the general workforce in the USA (Government Accountability Office, 2016 report)
An April 2022 survey by National Nurses United revealed more than a 100 percent increase in workplace violence compared to a prior survey of nurses in March 2021
Ohio’s current and only law relating to workplace violence for healthcare professionals: “violence against healthcare personnel is a punishable offense where offenders can be charged with a 5th degree felony and fined up to $5,000”. There is one current bill in progress regarding this issue at the state level – Ohio house bill 681, that is currently in the house committee and focuses on violence prevention and gathering data.
There are 38 states where it currently is a felony of some level to assault a healthcare worker BUT there is currently no federal law that protects hospital employees from assault or intimidation.
Current bills in progress: US H.R.2663 & S.1176 focuses on violence prevention (introduced for the 3rd time 4/18/23); US H.R.2584 & S.2768 aka the SAVE act (introduced for the 3rd time 9/12/2023) which establishes a new criminal offense for knowingly assaulting or intimidating hospital personnel during the performance of their official duties in a manner that interferes with their performance of the duties or limits their ability to perform the duties.
You can support these bills by contacting your legislature or signing letters of support on stopedviolence.org
r1 diagnostics/therapeutics: vascular access WITH dr. guillaume
Peripheral vascular access may be obtained using a variety of methods including traditional PIV, UGPIV, IO, EJ, and peripheral IJ. When deciding on a method, consider the urgency of the situation, equipment available, duration of access, and intended use.
In patients with favorable anatomy, consider EJ cannulation. EJs can be performed quickly and with the same supplies as a traditional PIV.
PICC line complications commonly seen in the ED include bleeding, infection, malpositioning, and obstruction. Remember to get a CXR, optimally position your patient, grab a 3cc syringe, and if all else fails, consider cathflo.
R4 Case Follow-up: SCAD WITH dr. Martella
Spontaneous Coronary Artery Dissection (SCAD) is a diagnosis confirmed via imaging: Coronary Angiography, Optical Coherence Tomography, Intravascular Ultrasound
Therefore, treatment in the ED is the same as atherosclerotic ACS: ASA, heparin gtt and possible statin.
It usually takes 4-6 weeks for a coronary artery to heal from dissection. If patients re-present to the ED close to their initial dissection, non-invasive imaging may be utilized (e.g. coronary artery CT scans) in conjunction with cardiology.
The rate of recurrence can be as high as 10% in certain patient populations. Therefore this should remain high on the differential if a patient with history of SCAD presents with similar symptoms.
r3 taming the sru WITH dr. haffner
Calcium channel blockers (CCBs) inhibit the L-type calcium channel found on vascular smooth muscle, cardiac myocytes, and pancreatic beta-cells
Different CCBs are selective for different targets
Dihydropyridines (nifedipine, nicardipine, amlodipine): target vascular smooth muscle
Nondihydropyridines (verapamil, diltiazem): preferentially target cardiac myocytes, though at high-doses they all lose selectivity
Initial management includes controlling the airway, obtaining central access, and administering IV calcium
Further management is guided by the type of shock, including vasopressors for vasoplegia and inotropes for cardiogenic shock, though evidence suggests that Hyperinsulinemic-Euglycemic Therapy (HIET) may be superior to pressors
Refractory shock may require nitric oxide scavengers (Methylene Blue, Hydroxocobalamin), Lipid Emulsion Therapy, Pacing, and ECMO
ekg quick hit: subtle ischemia and STEMI equivalents WITH dr. lang
Subtle signs of ischemia:
EKG not meeting STE criteria
Hyperacute T waves (including DeWinters)
Reciprocal STD and/or negative hyperacute T Waves
Maximal STD V1-V4 (posterior MI)
Consider evaluating posterior leads V7-V9 where 0.5mm STE is indicative of a posterior MI
STE in aVR with diffuse STD
Typically due to strained heart/subendocardial ischemia, triple vessel disease or left main occlusion with collaterals
Can represent left main occlusion or very proximal LAD with high degree of myocardium involved; rare to show up in ED due to high likelihood of immediate fatal MI or arrhythmia
Wellens Syndrome
r2 Qi/kt: alcohol withdrawal WITH drs. della porta & Hajdu
Alcohol withdrawal syndrome is a highly prevalent and morbid condition. Approximately 50% of patients disorder will go onto develop AWS throughout their lifetime.
The treatment of alcohol withdrawal should be proactive as opposed to reactive with consideration of which patients are at the highest risk.
Phenobarbital has been proven to be equivalent to benzodiazepines with regard to clinical, pharmacologic and utilization outcomes.
Phenobarbital should be dosed based on IBW and patient risk factors.
A phenobarbital protocol has the potential to streamline nursing workflow, increase disposition options, and simplify clinical decision making.
Final protocol will be published on Taming’s Clinical Guidelines in the coming months
panorex WITH dr. urbanowicz
Orthopantomography (OPG): specially protocoled panoramic radiographic tool which can visualize the teeth, mandible, upper limits of maxilla
Convenient, inexpensive and rapid way to evaluate gross anatomy of jaws and related pathology
Limitations: positioning requirements, artifact and incomplete total face evaluation
Applications include dental infections, isolated mandibular trauma, TMJ dislocations, bony hard swellings of the mandible
Do not order in patients with soft tissue lesions, neck masses, nasal or zygoma fractures
Examples: mandibular fracture
Most common facial bone injury, direct force to mental region most common
Consider tongue blade test, which requires bilateral evaluation to be diagnostic
OPG may be an option for patients who are awake & cooperative, can close their mouth and are able to sit fully upright without limited neck mobility
community corner WITH dr. baez
Pro-tips for working in a busy community shop with a variety of cases when you’re single coverage on a holiday weekend overnight.
Scrutinize but don’t overthink (interpret your EKGs with context)
Know your splints
Be comfortable with OMI EKGs
Know your resources & know when to ask for help
Be creative
