Grand Rounds Recap 02.15.17

Ultrasound Guided Regional Anesthesia of Lower Extremity with Dr. Carleton

Maximize Safety

• Understand indications/contraindications
• Know the relevant anatomy
• Constant visualization of needle tip
• Use smallest effective injection volume
• Know how to recognize and treat LAST
• Get consultant buy-in for block if injury is high risk for compartment syndrome or other pathology requiring rapid and frequent neurologic exam (closed tibia fracture, etc.)

Ankle block

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• Indications
  • Acute pain management of leg and foot injuries
  • Anesthesia for painful procedures
    • i.e. injection pain in sole of foot “have you ever had that done? Holy moly.”
• Why use ultrasound instead of doing it blindly?
  • improved analgesia (77% vs 39% rated as “good” or “outstanding” effect by patients)
• Tips
  • Optimize ergonomics: position patient and machine in a way where you won’t have to ask them to change position during procedure
  • Interrogate all planned injection sites with 2D and doppler
  • Plan on 2-5 mL of anesthetic per nerve
  • Avoid epinephrine with circumferential blocks
  • Work from posteromedial to posterolateral
    • posterior tibial to saphenous to deep perineal to superficial perineal to sural nerve
  • Posterior tibial nerve lies just posterior to tibial artery pulse
• Saphenous nerve
  • Provides sensation to lateral calf and leg
  • has no motor function
  • block 3-10 cm proximal and anterior to medial malleolus
    • between medial malleolus and tibilalis anterior tendon
• Superficial peroneal nerve
  • Field block between lateral malleolus and extensor digitorum tendon
• Sural nerve
  • Runs just posterior to the lateral malleolus
  • Can field block if poorly visualized (field block between achilles tendon and lateral malleolus)

Distal Sciatic Block

• Muscular blockade that will result
  • Muscular innervation of tibial nerve
    • TIP (Tibial nerve Inverts and Plantarflexes foot)
  • Muscular innervation of peroneal nerve
    • FED (Fibular nerve Everts and Dorsiflexes)

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Oral Boards Cases with Drs. Powell and Stettler

Case 1 - The Worst GSW

• Young female, pregnant, gunshot wound (EMS reporting patient on her porch, heard 5 gunshots, found laying on porch in pool of blood).  Tachycardia to 150, blood pressure 80/50, tachypnea to 25.  Airway intact, decreased breath sounds on left, fundus above umbilicus, fetal heart rate 180.  Wound consistent in appearance with gunshot overlying left scapula.  Hemothorax noted on left on portable chest x-ray, pressure release of air and blood with improvement on vital signs with chest tube placement.  CT of chest shows bullet abutting the aorta

Pregnant Trauma with Tension Hemothorax

• Diagnosis of pneumothorax: CXR has traditionally been used for diagnosis of pneumothorax, however, in the trauma bay with supine films or with a small apical pneumothorax the findings may not be present on x-ray due to anterior layering in the supine patient. Ultrasound may be used or a simple pneumothorax may be picked up on CT in the stable patient. As many as 1/3 of traumatic pneumothorax may not be discovered on initial CXR. In the case of tension pneumothorax, treatment should always precede imaging.

  Hemothorax diagnosis: It requires 200-300ml of blood to blunt the costophrenic angles. The supine chest view can be less accurate due to layering.

  Changes in physiology: BP declines in the first trimester, levels out in the second trimester, and then returns to normal pre-pregnancy levels in the third trimester. The decline in systolic is 2-4 mm Hg while the diastolic declines 5-15 mm Hg. After 20 weeks gestation the uterus has raised to the level of the IVC resulting in compression when the patient is supine. The caval obstruction diminishes cardiac preload which can decrease cardiac output as much as 28% resulting in decreased systolic BP upwards of 30 mm Hg. In order to avoid this, the pelvis should be tilted to the left if possible given other injuries (15-30 degrees is optimal). Blood volume also increases during pregnancy beginning at 6-8 weeks to as much as 45% above normal and peaking at 32-34 weeks. Blood volume increases even more for multiple gestations. The blood flow to the uterus increases from 60 ml/min to 600 ml/min during pregnancy so the uterus can be a major site of injury. The uterus is at the umbilicus at 20 weeks and costal margins by 34-36 weeks. The diaphragm also raises 4cm with compensatory flaring of the ribs. Tension pneumothorax can develop more quickly given these changes. For chest tube placement, the tube should be placed one to two rib spaces higher.

  Mother stable/fetus stable: 1-3% of minor trauma to the mother can lead to fetal loss usually from placental abruption. Once the mother is deemed stable the fetus should be evaluated. Direct abdominal trauma is not necessary for significant fetal injury so even if the mother has no abdominal pain she should still be evaluated with continuous monitoring if viable. Close follow up may also be necessary

Case 2 - The Night's Not Getting Easier

• Young female presents after a suicide attempt via hanging.  BP 80/60, HR 120, agonal respirations, Sat 86%.

Hanging Case

• Hanging injuries are typically seen in the setting of suicide attempts and occasionally assaults. Hangings in which the body is suspended and the feet do not touch the ground are termed complete. All other positions of the body, when the feet are in contact with the ground, are referred to as incomplete. If a victim drops a distance equal to his or her height, death usually results from fracture of the upper cervical spine (Hangman’s fracture) and transection of the spinal cord. If a hanging is incomplete or the victim drops a distance less than his or her height, the cervical spine is spared. Constriction causes jugular venous obstruction, stagnant cerebral blood flow, and brain ischemia. Loss of consciousness then results. Muscle tone decreases, and compression of vital structures increases. Complete arterial occlusion and/or airway compromise result in death. Alternatively, cardiac arrest may occur due to carotid sinus stimulation and increased vagal tone.

  Endotracheal intubation should be performed if airway problems or respiratory abnormalities are evident. Cervical spine immobilization is best until spinal injury is excluded. Imaging of the cervical spine and neck vasculature should be considered. Neurogenic pulmonary complications are best treated with controlled ventilation and positive end-expiratory pressure. Cardiac monitoring is essential for the identification and management of dysrhythmias. Cerebral edema and increased intracranial pressure can be difficult to treat and often requires intracranial pressure monitoring to direct the use of hyperventilation, diuretics, and fluid restriction.

Case #3 - Maybe You Should Have Stayed Home

• 6 year old female presents as the unrestrained backseat passenger in a T-bone MVC, BP 100/palp, HR 150, unresponsive, intubated in field with oxygen saturation 93%.  Right mainstem bronchial intubation, scalp laceration, skull fracture, epidural hematoma with midline shift
  • Current testing recommendations consider crystalloid resuscitation as critical action prior to blood transfusion in pediatric trauma
  • Look for bleeding source and control
  • Updating and talking to family is critical action for exam

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Simulation session with Drs. Denney, Lafollette

• 60 year old male patient to SRU with chief complaint of altered mental status brought in via EMS, reports BP 130/120, “stable” heart rate, “normal” O2 saturation, fingerstick blood sugar of 90.  Vitals in ED found to be HR 167, Saturation 87% on NRB, BP in the ED of 80/43.  EKG shows atrial fibrillation with RVR.  Chest X-ray shows right lower lobe infiltrate.  pH of 7.1 with base deficit of -8, pCO2 of 25, serum lactate 6, hemoglobin 16, WBC of 10, troponin 0.06, urinalysis with no signs of infection.  After 2 liters of crystalloid BP is 94/52, heart rate 175, saturation 93%.  Oxygen saturation improves on CPAP to 99%.  Intubated after resuscitation with vasopressor assistance, antibiotics, admitted to MICU.
  • Discussion points
    • Atrial fibrillation if undifferentiated shock
      • It is prudent in the ED to resuscitate first as rate control in undifferentiated shock is high risk for poor outcome
      • Sepsis is a common precipitant of first time atrial fibrillation (10% sepsis, 40% septic shock). Consider if the tachycardia (RVR) is actually a physiologic and necessary compensatory response to the shock
      • If blood pressure is not responding to resuscitation matters, the question becomes, do you take measures to change the rate or rhythm?
        • Remember that rate control would be dangerous in this situation
        • Synchronized cardioversion has the advantage of diagnostic evaluation if the afib is primary cause of hypotension, but has the risk of sedation and theoretical risk of cardiac stunning
        • In sepsis cardioversion will have 35% conversion rate as compared to 90% in primary afib
        • Half dose of etomidate (0.15 mg/kg) for sedation when patient is hypotensive is a consideration if going towards shock in the awake patient
        • Be cautious of use of amiodarone if there is possibility of WPW, although its use has been advocated elsewhere when patients are more hemodynamically stable
        • Patients in septic shock are at a higher hemorrhage risk and unless evidence of neurovascular compromise from stroke, anticoagulation can safely be deferred to the inpatient team after the acute illness is stabilized

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Postpartum Pre-eclampsia with Dr. Grosso

• Patient is a young female with shortness of breath x 3 days as well as bilateral lower extremity swelling for 6 days.  Bradycardia to 46, BP 164/96, normal temperature, saturation 95% on room air.  Appears uncomfortable, labored breathing with audible crackles, diminished to auscultation in bilateral lower lung fields.  Edema in lower extremities to mid-shin level, one beat clonus in lower extremities with increased reflexes.  On history noted to have undergone C section 6 days ago (scheduled at 39 weeks, uncomplicated).  LFT mildly elevated, normal UA.  Echo by cardiology show normal systolic function. 
  • Severe postpartum pre-eclampsia (when delivering the baby is no longer an option)
    • Preeclampsia
      • 5% of all pregnancies
      • Early onset if before 34 weeks
      • Blood pressure elevation greater than 140/90 after 20 weeks gestation with >3gram/24h urine
      • Late onset is greater than 34 weeks to postpartum period
        • this group is thought to be more of a physiologic response to the demands of pregnancy in those pre-disposed to hypertension and vascular disease
      • Order uric acid, LDH, LFT, UA, CBC (platelets)
        • uric acid serves as surrogate marker for GFR
      • Preeclampsia is a clinical diagnosis
        • HTN with neurological symptoms regardless of labs in a pregnant or recently pregnant patient should be suspicious for preeclampsia
      • BNP in preeclampsia/pregnancy
        • level should stay relatively normal during pregnancy (at least below 100)
        • can have a wide range of possible BNP in preeclampsia (even to normal range)
    • Eclampsia
      • 1/3 patients with eclampsia will have mild range BP (140-160/90-110)
        • 16% will have normal BP
      • most common cause of death in eclampsia patients is intra-cerebral hemorrhage
    • Postpartum preeclampsia
      • Most cases present within 24-48 hours of delivery
      • Headache is most common symptom (>80%)
      • Management
        • blood pressure control
          • goal BP <160/110
            • labetolol or hydralazine
        • magnesium for prevention of eclampsia
          • stabilizes cellular membrane potential
          • acts as NMDA antagonist
          • not an antihypertensive
        • Lasix?
          • consider if signs of pulmonary edema
        • The only way to prevent eclampsia is to treat preeclampsia aggressively

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Lateral Chest Xray with Dr. Axelson

• Approach
  • Diaphragm, darkness, cardiac, markings (Axelson Memory Pearl - Di Dark Car Mark)
    • Diaphragm
      • Should be able to see two diaphragmatic structures, lighter being right overlying lobe of liver.  
    • Darkness
      • It is supposed to be dark in lower spine (darker the lower it goes)
      • Costophrenic angle
      • Posterior cardiac
      • Retrosternal space
    • Cardiac
      • Borders should be crisp with no opacification
      • Cardiac insicura: cardiac fat pad can prevent lung from reaching front, creates distinct line
    • Markings (lung)
• Cases
  • 37 year old male with fever of unknown origin
    • PA view non-diagnostic, on lateral view cannot distinguish 2 diaphragmatic lines on lateral view with positive spine sign, able to diagnose pneumonia
  • 39 year old male, crohn’s disease with abdominal pain
    • On lateral view able to see free air under the diaphragm not viewed on PA
      • if you center the lateral view on the diaphragm it is more sensitive for free air in abdomen than PA/AP views
  • 2 year old female with cough
    • PA view with some air bronchograms over left cardiac border, clarified on lateral view with positive spine sign an consolidation
  • 76 year old female with cough for 2 months
    • not clear pathology on PA view
    • on lateral view noted to have consolidation and collapse of lingula, eventually diagnosed with cancer obstructing bronchioles
  • 54 year old female with shortness of breath and anemia
    • Irregular border on PA view of left cardiac border
    • Lateral view shows retrocardiac opacity with distinct border, eventually diagnosed with diaphragmatic hernia

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R4 Clinical Soapbox: ED Management of the Hospice Patient with Dr. Richardson

• Why combine emergency medicine and palliative medicine?
  • So much overlap
    • Pain and symptom management
    • Team approach
    • Caring for patients on their worst day
    • “Generalist” specialty: we take care of everything
• Palliative care does not equate with hospice care
  • Palliative care is symptom management and runs concomitantly with disease care
• A case
  • A male patient in his 40s with history of GBM s/p resection, chemotherapy and radiation now in home hospice presenting with mental status change and fever.  Has had a week of progressively worsening headaches, utilizing fentanyl patch progressing to morphine PCA.  Worsening mental status with cloudy urine.  Febrile to 102.3F, HR 123, BP and respiratory rate stable, O2 saturation 93%.  Exam with mostly flaccid paralysis, slight motor flicker of RUE, somewhat responsive to wife’s voice and seems to nod in response to her questions.  
    • How to manage?  What are the goals of care?
• Hospice care in the USA
  • Most patients “in hospice” live at home (70%)
    • 95% of total costs are from home hospice care
  • Eligibility criteria
    • Prognosis is less than 6 months if disease runs its usual course
    • Does NOT require DNR status
  • Multiple disease processes considered, guidelines in place for each
    • Cancer
    • Heart failure (resting symptoms in spite of maximal therapy)
    • Dementia (unable to perform ADLs)
    • Liver failure (not a transplant candidate etc)
    • HIV/AIDS
    • etc
  • Medicare hospice benefit (MHB) covers about 80% of all hospice care
    • Medicaid and most private insurance companies also offer similar plans
  • Hospices get paid 150-190 dollars per day, as such, they want to:
    • Enroll patients likely to live a long time (even >6 months)
    • Attract patients without severe symptoms or complications
    • Keep their patients out of the ED (and especially out of the hospital)
      • Often will have 24/7 call coverage by physician to address immediate needs
      • With that in mind, consider why would a hospice patient arrive in the ED and look to address concerns.
        • Patient/caregiver factors
          • poor symptom control, stress, fear, inability to cope with impending loss, etc
        • Hospice factors
          • failure to communicate hospice resources
          • equipment failure
          • resuscitation in patients who are not DNR status
  • Rapid palliative care assessment
    • Exacerbation of serious illness? 
      • Stabilize and treat symptoms
      • Establish decision making capacity
        • If not present do so with power of attorney
      • Establish goals of care
  • Best practices
    • Notify hospice staff as soon as possible
    • Edentify the trigger for the visit
    • Edentify and address the anxiety or stressors of patient and/or caregiver that is present