Grand Rounds Recap 1.9.19
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Leadership Curriculum: Leadership Styles WITH DR. Stettler
Leadership Styles
There are seven leadership styles commonly used to describe one’s approach to leadership:
Transformational: Typically inspire staff by creating an environment of intellectual stimulation.
Transactional: Establishes a clear chain of command utilizing a carrot and stick approach to management activities.
Servant: Prefers power-sharing models of authority and engages in the tasks of the group.
Autocratic: Have significant control over staff, rarely considers worker suggestions or sharing of power.
Laissez-faire: Characterized by their hands off approach allowing employees to get on with tasks as they see fit.
Democratic: All parties involve participate in discussions surrounding decisions that need to be made.
Bureaucratic: Implemented in highly regulated environments where strict adherence to the rules is important. Structures an organization into a hierarchy with clearly defined rational decision-making rules.
Action Logics
The Harvard Business Review outlines seven ways in which leaders interpret their surroundings and react when their power or safety is challenged termed “Action Logic”.
Opportunist: “Wins any way possible”. These individuals are self-oriented and can be manipulative to make their way to the top. They are strong in emergencies and in some sales opportunities; however, these individuals rapidly lose political capital and team morale often suffers under their leadership.
Diplomat: “Avoids overt conflict”. These individuals want to belong, tend to obey group norms, and rarely suggest ideas that will be controversial. They are strong as a supportive figure within a group and can bring people together. They struggle with making controversial decisions.
Expert: “Rules by logic and expertise”. These individuals try to exert control by perfecting their knowledge about a specific subject. They tend to view collaboration as a waste of time and instead rely on their own expertise to guide them to success. They tend not to value emotional intelligence or the contributions from others. Their strength lies in their solo contributions but they are weak in anything involving team dynamics.
Achiever: “Meets strategic goals”. These individuals focus on achieving goals through effective utilization of teams. They tend to focus on deliverables rather than perfection. They are effective in managerial roles but can clash with subordinate individuals who fall into the Expert category.
Individualist: “Interweaves competing personal and company action logics”. These individuals are described as similar to Achievers in their goal driven approach to success; however, they differ in that they aware of possible conflicts between their principles and their actions. They tend to ignore rules that they regard as irrelevant. They are excellent at bridging gaps between individuals within an organization who follow different ‘‘action logics’’.
Stategist: “Generates organization and personal transformations”. They focus on organizational perceptions and constraints, which they treat as transformable. They excel in creating a shared vision across different individuals in an organization.
Alchemist: “Generates social transformations”. This is a very rare “Action Logic”. They have the ability to reinvent themselves and their organizations in historically significant ways. They have the capacity to deal simultaneously with many situations at multiple levels.
R4 Case Follow-up: cardiomyopathy in the young WITH DR. sabedra
Case
A male in his twenties presented to the emergency department with a chief complaint of shortness of breath and anxiety. His mother accompanied him and contributed to the history of present illness. She describes that approximately 1 hour ago they got into a verbal argument when the patient suddenly became unable to speak. Since that time he has improved such that he could speak in short sentences but continued to endorse difficulty with speech.
His review of systems was negative for chest pain, cough, sputum production, headache, numbness, or weakness and positive for bilateral lower extremity swelling for the past few weeks. He denied prior cardiac or thromboembolic disease history.
His past medical history was significant for asthma and anxiety. He was taking no medications. He denied the use of tobacco, alcohol, or illicit substances.
Vital Signs: T: 97.6F, HR: 118, BP: 156/109, RR: 23, SpO2: 95% on room air
Physical Exam: He appeared very anxious. Lung auscultation revealed bilateral expiratory wheezing. Cardiac auscultation revealed tachycardia but was otherwise unremarkable. There was 2+ pitting edema of bilateral lower extremities to the knee. He was able to speak in short 2-3 word phrases with frequent long pauses but otherwise had a non-focal neurologic exam.
EKG: Sinus Tachycardia
Chest X-ray: Cardiomegaly with bilateral pulmonary edema
Labs: Elevated troponin and BNP
On reassessment the patient was noted to have an acute change in his neurologic status. At that time he was unable to lift his right arm and also was noted to have a slight facial droop with the complete inability to speak but was able to follow commands with his left side.
He was taken for emergent CT head/neck imaging including angiography which revealed an acute left middle cerebral artery occlusion. Ultimately, he was sent for intervention by interventional radiology and admitted to the neuroscience intensive care unit. Four months later the patient underwent a cardiac MRI due to persistent lower extremity edema and worsening evidence of heart failure which demonstrated concern for non-ischemic cardiomyopathy. The leading suspicion from the inpatient teams was for a prior myocarditis with resultant persistent cardiac dysfunction.
Ischemic Stroke in the Young Patient
Approximately 50% of strokes that occur in persons 15 - 44 years old are ischemic.
Psychiatric illness can bias us against this diagnosis especially in the younger patient. Hispanic and African American individuals have a higher risk of missed ischemic stroke on initial presentation. Females also have a higher rate of missed ischemic strokes than males in the younger populations.
Myocarditis
There are many different etiologies including: viral, bacterial, medication related, and autoimmune disease
21% of patients with a diagnosis of myocarditis go on to develop a dilated cardiomyopathy.
Myocarditis is the leading cause of the need for heart transplant world-wide.
EKGs have a low sensitivity; however, you can see non-specific repolarization abnormalities.
The gold standard for diagnosis is cardiac biopsy; however, in many institutions cardiac MRI is being performed more routinely as the primary diagnostic modality.
Resultant impaired ventricular function, arrhythmias, and other conduction disturbances can persist for months to years.
R1 Clinical knowledge: colitis WITH DR. berger
Classic presentation: Abdominal pain, fever, diarrhea, and possibly bright red blood per rectum
Etiologies include infectious, autoimmune, ischemic, and allergic.
Necrotizing Enterocolitis:
Most commonly affects children born premature; however, 13% of children with normal birth history go on to develop necrotizing enterocolitis.
Most commonly occurs within the first week up to a month of life.
Presentation: feeding intolerance, abdominal distention, blood in stool, toxic appearance.
Abdominal X-ray of pneumatosis is diagnostic.
Allergic Colitis
Allergic colitis is an IgE mediated process, most commonly to milk or soy.
Affects 1-2% of all children 1-3 years of age, but commonly starts from 2 weeks to 6 months of age
Presentation: Well appearing child with blood in the stool without other explanation by physical exam.
Most common initial management strategy includes removing all milk based products from both the mother’s and child’s diet.
Infectious Colitis
Viral colitis is most commonly caused by cytomegalovirus
Parasitic colitis causes include Entamoeba, Giardia, and Schistosoma. Commonly diagnosed with stool ova and parasite test.
Bacterial colitis causes are many and include Salmonella, Shigella, Yersenia, Campylobacter, and E. Coli.
Autoimmune Colitis
Inflammatory bowel disease such as Crohn’s Disease and Ulcerative Colitis.
Consider these diagnosis when you see colitis and joint pain, skin abnormalities, uveitis, or biliary pathology.
Ischemic Colitis
Caused by acute or chronic disruption of the blood supply to the large bowel.
The acute presentation classically presents with abdominal pain out of proportion to your physical exam and is associated with embolic phenomenon.
The chronic presentation classically presents with food aversion as the patient will experience pain after eating due to the increased splanchnic blood demand that cannot be met.
Risk factors for both include hypercoagulability, history of vascular disease, and atrial fibrillation.
Diagnosis is made by CT angiography of the abdomen, which should be considered despite renal dysfunction given the severity of bowel necrosis if missed in the acutely ischemic bowel. Chronic disease can also be evaluated by MRI and ultrasonography.
Child abuse WITH DR. gray
Child abuse, commonly referred to as non-accidental trauma, requires a high level of suspicion and a methodical approach in order to ensure the safety of the pediatric patients that present to your emergency department. There have been efforts to develop a more standardized approach to the evaluation for child abuse and below we present two clinical decision rules that can help assist in determining the need for further evaluation.,
TEN 4 FACES-P
TEN 4 FACES-P is a clinical decision rule used to evaluate high risk bruises and injuries to determine the need for further evaluation or transfer to a facility with the resources necessary to evaluate for child abuse. The presence of any one of the below injuries suggests a mechanism that may be consistent with child abuse and should prompt further work up.
High Risk Bruises:
These are divided into two categories based on age.
Less than 4 months: any bruise is considered high risk
Less than or equal to 4 years: bruising to the Torso, Ears, or Neck.
High Risk Injuries:
FACES-P: any injuries to the following regions are considered high risk
Frenulum
Angle of the Jaw
Cheek
Eyelid
Subconjunctival hemorrhage
Patterned bruising or burns: Bruises or burns in a pattern such as those caused by a cigarette, lighter, immersion, hand
QI/KT: NSTEMI WITH Dr. Hughes and Dr. gottula
NSTEMI Definition
The newly released fourth universal definition of myocardial infarction from the American College of Cardiology differentiates myocardial injury from myocardial infarction.
The term acute myocardial infarction should be used when there is acute myocardial injury and detection of a rise and/or fall of cardiac troponin values with at least one value above the 99th percentile and at least one of the following:
Symptoms of myocardial ischemia
New ischemic EKG changes
Development of pathological Q waves
Imaging evidence of new loss of viable myocardium or new regional wall abnormality in a pattern consistent with an ischemic etiology
Identification of a coronary thrombus by angiography or autopsy (excludes types 2 or 3 myocardial infarction)
There are five defined types of myocardial infarction:
Type 1: Primary coronary process such as plaque rupture
Type 2: Reduced myocardial oxygen supply or increased demand without plaque rupture.
Type 3: Sudden cardiac death
Type 4: Post-procedure elevation of troponin that is five times the upper limit of normal.
Type 5: Post coronary artery bypass graft troponin elevation that is ten times the upper limit of normal.
Risk Stratification for Patients Presenting with Chest Pain
HEART Score
A score of 0-3 has a rate of major adverse cardiac events of 1.7% at 6 weeks
ACEP clinical practice guidelines provide a Level B recommendation after review of 91 studies related to the HEART score.
High sensitivity cardiac troponin
The ACEP Clinical Policy states that a single negative high sensitivity troponin below the level of detection OR serial high sensitivity troponin values at zero hours and two hours below the 99th percentile sufficiently suggest a low rate of major adverse cardiac events.
Pickering et al describes that patients with a single high sensitivity troponin below the level of detection are at very low risk for major adverse cardiac events.
Peacock et al showed in a 4 year prospective observational study a negative predictive value of 99.4% using high sensitivity cardiac troponin at zero and three hours with cut-off values of 6ng/L and 19ng/L respectively.
The ADAPT trial showed that patients with no ischemic EKG changes and two negative high sensitivity cardiac troponins at zero and two hours had a low risk of major adverse cardiac events with a sensitivity of 99.7%.
Medical Management of NSTEMI
Oxygen
A 2018 meta-analysis of seven studies (n=7702) found that the routine use of oxygen did not decrease the individual risks of all-cause death, recurrent ischemia, heart failure, or occurrence of arrhythmia events.
Hyperoxia can cause vasoconstriction and increased oxidative stress leading to increased size of myocardial infarction.
Antiplatelet agents
Non-enteric-coated, chewable aspirin should be given to all patients with NSTEMI without contraindications as soon as possible after presentation and a maintenance dose of aspirin should be continued indefinitely. Clopidogrel is the second line agent if there is anaphylaxis to aspirin.
ACEP guidelines state that P2Y12 inhibitors and glycoprotein IIb/IIIa inhibitors may be given in the ED or delayed until cardiac catheterization.
Anticoagulation
NSTEMI patients should receive anticoagulation, in addition to antiplatelet therapy, irrespective of initial treatment strategy.
A meta-analysis from 2007 compared enoxaparin to unfractionated heparin in acute coronary syndrome and found a marginally significant reduction in the combined endpoint of death or myocardial infarction at 30 days in favor of enoxaparin.
Pain Control
The IMPRESSION trial showed that morphine lowers absorption of ticagrelor by 36% with a delay in maximal plasma concentration.
The CRUSADE trial suggested an association between treatment with morphine and increased mortality (odds ratio 1.49).
Fentanyl is an effective analgesic in the prehospital treatment of myocardial ischemic pain but has not been extensively studied related to effect on mortality.
