Grand Rounds Recap 2/6/19
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Surviving Traumatic and Hemorrhagic Shock WITH Dr. Gibler Visiting Professor and University of Washington EM CHAir (and UCEM alumnus) DR. susan STERN
Exsanguination is the leading cause of preventable death in trauma. It is estimated that about 40% of patients who die from trauma die in the pre-hospital setting, and another large proportion die within the first 48 hours after the injury. Therefore, this is where emergency providers can have a significant impact in saving the lives of trauma patients.
The idea of permissive hypotension was first described in 1918 by Cannon et al. who recognized that restoration of normal blood pressure in patients with active bleeding would likely worsen bleeding.1 For some time, resuscitation with crystalloid was the standard of care, but this practice has changed. In a 1993 study of aortic injuries in swine, stepwise increases in blood pressure using crystalloid was associated with increased hemorrhage and mortality overall.2 This again suggests that resuscitation to normal vital signs may actually be detrimental to the bleeding patient.
It is thought that this increased mortality is related to clot stability with a fairly unstable clot early after the injury that is prone to destabilization from elevated blood pressures. However, the majority of data on this topic is in animal models. The New England Journal of Medicine published a prospective randomized controlled trial of patients with penetrating torso injuries who were treated with early versus delayed resuscitation. They showed a small but statistically significant mortality improvement in patients who received delayed fluid resuscitation by waiting until their operative intervention.3
Additionally, the primary focus for emergency providers often involves controlling hemorrhage and preventing coagulopathy. Current research is focused on targeting clot stability in order to help control hemorrhage. One novel example is a polymer known as PolySTAT which has fibrin-binding sites. This promotes cross-linking of fibrin and contributes to clot stability and hemostasis.4 Studies are ongoing, and researchers are constantly striving to prevent death from hemorrhage in patients with traumatic injuries.
References
Benison S., Barger A., Wolfe E. Walter B. Cannon and the mystery of shock: A study of Anglo-American co-operation in World War 1. Medical History, 1991; 35: 217-249.
Stern S., Dronen S., Birrer P., Wang X. Effect of blood pressure of hemorrhage volume and survival in a near-fatal hemorrhage model incorporating a vascular injury. Annals of Emergency Medicine, 1993; 22(2): 155-163.
Bickell B., Wall M., Pepe P., Martin R., et al. Immediate versus delayed fluid resuscitation for hypotensive trauma patients in penetrating torso injuries. New England Journal of Medicine, 1994; 331(17): 1105-1109.
Chan L., Wang X., Wei H., Pozzo L., et al. A synthetic fibrin-crosslinking polymer for modulating clot properties and inducing hemostasis. Science Translational Medicine, 2015; 7(277): 277ra29.
The Changing Landscape of Leadership in Medicine WITH Dr. Gibler Visiting Professor and University of Washington EM CHAir (and UCEM alumnus) DR. susan STERN
Leadership is intentional and should be nurtured and refined. It is important for physicians to have leadership training for a number of reasons including improving the quality and safety of patient care, educating trainees, and advancing research. There is a somewhat recent push to ensure patient-centered care as opposed to a top-down management approach that was previously standard in the medical field. This has resulted in increased complexity in the healthcare system. In order to succeed in this complex system, physicians need to learn how to lead effectively.
In today’s world, an effective leader influences others through respect rather than wielding clout. Adapting to challenges and fostering relationships allows collaboration in overcoming obstacles. An effective leader recognizes that an organization is a conversation and is sustained through human interactions. Emphasis should be on listening and influencing others, fostering independent thinking and creativity.
What specific traits make a leader successful? Emotional intelligence is crucial. It is the ability to manage ourselves and our relationships effectively. It involves self-awareness, self-management, social awareness, and social skill.1 It has been suggested that there are six different leadership styles (below). The most effective leaders are able to switch between leadership styles according to what the situation demands.
Leadership Styles:
Coercive leaders demand immediate compliance.
Authoritative leaders utilize a “come with me” style.
Affiliative leaders maintain a “people come first” style.
Democratic leaders allow others a voice in decisions and build organizational flexibility.
Pace-setting leaders set high performance standards and exemplify these standards themselves.
Coaching leaders focus on personal development rather than immediate tasks.
References
Goleman D. Leadership that gets results. Harvard Business Review, 2000.
AIDS-Defining Conditions WITH DR. LAURENCE
AIDS is defined as a CD4 count of less than 200 cells/μL or the presence of an AIDS-defining illness. Once a patient develops AIDS, they have it for life even if they have a normal CD4 count later in life. If the CD4 count is unknown for a patient, one can estimate it based on the absolute lymphocyte count (ALC). If the ALC is greater than 2000, it is likely that their CD4 is greater than 200. If the ALC is less than 1000, the CD4 count is likely less than 200, and providers should be concerned that the patient has AIDS.
There are a variety of dermatologic illnesses that are considered AIDS-defining conditions. These include Kaposi sarcoma, disseminated MAC, and disseminated coccidioidomycosis. If the diagnosis is in question, consider obtaining labs, infectious disease, and/or dermatologic consultations.
Neurologic complaints are common in patients with AIDS, and it is the responsibility of the provider to evaluate for AIDS-defining illnesses. Cryptococcal meningitis can have an indolent presentation with the gradual development of symptoms. It is helpful to obtain an opening pressure during lumbar puncture if this is suspected because it will often be elevated in patients with cryptococcal meningitis. The test of choice is an India-ink stain.
Toxoplasmosis classically occurs in patients with CD4 counts less than 100. A head CT will often reveal multiple ring-enhancing lesions which have a predilection for the basal ganglia. The treatment is pyrimethamine and sulfadiazine. If there is no improvement within two weeks of treatment, one should be concerned for primary CNS lymphoma. These patients often have a CD4 count of less than 50. Initiation of anti-retroviral therapy (HAART) and chemotherapy is the treatment of choice.
Progressive multifocal leukoencephalopathy (PML) is seen in patients with CD4 counts less than 50. It more frequently presents with visual symptoms and ataxia. Head CT reveals non-enhancing hypodense lesions, and the treatment of choice is HAART.
Pneumocystis jiroveci (PJP) is a pulmonary AIDS-defining illness. Patients may present with low-grade fevers, a non-productive cough, and difficulty breathing. Evaluation should include obtaining an LDH because this is often elevated in patients with PJP and can be helpful in making this diagnosis. Treatment is bactrim or pentamidine. If a provider suspects this illness but the patient has a normal CXR, a chest CT should be considered because some patients will have normal CXRs.
Tuberculosis (TB) has a more gradual course and often results in night sweats and lymphadenopathy. Classic chest imaging may reveal consolidation or cavitation in the upper lung zones. Recurrent bacterial pneumonia is defined as two or more episodes of bacterial pneumonia within one year. Streptococcal pneumoniae and haemophilis influenzae are most common causative organisms. Pseudomonas and staph aureus are also more common in this population, and this should be considered when choosing empiric antibiotic coverage for patients with suspected pneumonia.
Candidal esophagitis is a common gastrointestinal manifestation of AIDS-defining illnesses. It is seen in patients with a CD4 count of less than 100. It often presents with odynophagia and dysphagia. Definitive diagnosis is made on endoscopy, but empiric treatment with oral fluconazole should be considered if this diagnosis is suggested by history and physical.
Cytomegalovirus (CMV) most commonly presents as retinitis, but esophagitis and colitis are common as well. Patients often report diarrhea, crampy abdominal pain, and fevers. Treatment is valgancyclovir, gancyclovir, or foscarnet.
Ultimately, it should be remembered that every patient with HIV, whether they have a history of AIDS or not, has a chronic inflammatory condition. This puts these patients at increased risk of coronary artery disease, pulmonary emboli, and other potentially dangerous conditions. This is important to consider when evaluating these patients in the emergency department.
