Grand Rounds Recap 2.20.19
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Morbidity and Mortality WITH DR. Colmer
Case 1: End Stage Liver Disease
Epidemiology and Pathophysiology
Of those with ascites, 15% die within a year, 44% die within 5 years
Cirrhosis leads to portal hypertension and splanchnic vasodilation. This leads to a reduced arterial volume and chronic arterial hypotension. The body attempts to combat this via the RAAS and sympathetic nervous system; this leads to increased total volume and ascites.
Hypotension
These patients tend to run on the lower spectrum of normal for blood pressure. However, how low is normal is a difficult question to answer, when possible try to compare to prior values
This study MAP lower than 82 associated with increased mortality
Hepatorenal Syndrome
Two Main Types
Type 1: rapidly progressive. Onset within 2 weeks, typically due to some event (like SBP)
Type 2: indolent reduction in kidney function. Typically presents in outpatient setting due to refractory ascites
In one study, only 15% of patients with hepatorenal syndrome were still alive at 3 months
Important to remember that cirrhotics have a lower creatinine at baseline, so don’t look at absolute value, compare it to the patient’s baseline creatinine
Case 2: Nephrolithiasis
Epidemiology
12% of people with experience kidney stone in their lifetime, of this population 50% with develop recurrent disease
Indications for Urgent Interventions (American Urological Association)
Evidence of proximal obstruction with infection
Impending renal deterioration (single kidney patient, severe AKI)
Pain refractory to analgesics
Intractable nausea/vomiting
Patient preference
Interventions
Extracorporeal Shock Wave Lithotripsy
Lower complications but less effective in stone removal than ureteroscopy
Ureteroscopy (often first line)
Mechanically remove stone
Laser treatment to fragment stone
Lithotripsy to fragment stone
Many of these patients will have a stent placed which will need to be removed either by the patient or the urologist
Spontaneous Passage
This review showed smaller stones < 5-6mm and more distal stones are more likely to pass
This study showed that stones can take up to a month to pass
Pain Management/Medical Expulsive Therapy
NSAIDs at least equivalent to opioids for pain control in renal colic in this meta-analysis
Tamsulosin
This study showed no difference in stone passage when tamsulosin used, but another study showed stones 5-9mm may benefit from tamsulosin
Tamsulosin is recommended by the American Urological Association for stones <10mm, although these recommendations came out in 2016, before the previous two studies
Case 3: Subclavian Lines
Choice of Location for Central Lines
Literature is mixed
This study showed subclavian lines typically better for infection and thrombosis, but worse for mechanical complications
This study showed no difference in infection between the three sites
CDC recommends avoiding femoral vein and to use subclavian vein
Ultrasound-Guided Subclavians
This study showed greater success, fewer complications, and less time for ultrasound guided subclavians
This study showed arm abduction and external rotation can help to improve visualization of subclavian vein in 70% of patients (however, 14% got worse)
The literature suggests that ultrasound-guided subclavians has real benefit over landmark approach
Troubleshooting Arterial vs Venous Placement of Central Lines
This study showed that adding manometry to subclavian placement eliminated arterial cannulation
Can compare blood gas of known arterial source to central line blood (in sick patients arterial gas may look more like venous gas)
Look at pressure waveform to see if it is arterial or venous
Case 4: Hypertension
Asymptomatic Hypertension
ACEP states that routine screening is not required
No difference in MACE in patients referred to ED for hypertension found in office visit vs patients not referred to ED
JNC-8 Recommends starting thiazide or calcium channel blocker for patients with hypertension; ace-inhibitor in patients with CKD
If you are starting someone on an anti-hypertensive in the ED, make sure you recheck blood pressure to make sure the elevated triage BP is reflective of true hypertension, although markedly elevations in BP (>165/105) have good correlation with elevated outpatient pressures requiring treatment.
Quarterly Simulation WITH DRs. LaFollette and Lang
Informed Consent:
Key components
Education of the indications of the intervention and how it will be performed
Alternatives to the intervention
Discuss common adverse reactions from the procedure (HA in LP, discomfort with CVC, etc)
Discuss rarer but more serious events (pneumothorax for CVC, persistent CSF leak requiring blood patch, etc)
These are good to have sources of just-in-time information on % chance of complications
Discuss rare complications that would alter life and limb (paralysis in LP, resp failure from sedation, etc)
It is important to recognize the gravity of many of the decisions patients need to make and tailor the conversation to their priorities (stroke affecting dominant hand, for example)
Using visual aids can be helpful, especially to give concrete numbers
Oral Boards Cases WITH DRs. McDonough and Hill
Triple Case:
Melanoma
Least common form of skin cancer, but most deadly
Concerning Nevi
Asymmetry
Border Irregularity
Color Variation
Diameter > 6mm
Evolving
ED management primarily involves ensuring patient has close dermatology follow up
See this review for more information
Thiamine Deficiency
Vitamine B1, responsible for metabolic pathways involved in ATP production; primarily affects nervous system and cardiovascular system
Risk factors include alcoholics, eating disorders, bariatric surgery, heart failure, sepsis
Two main presentations
Wet BeriBeri: high output heart failure caused by formation of AV fistulas. They may have typical heart failure signs/symptoms such as lower extremity edema, cardiomegaly.
Dry BeriBeri: more common, and associated with muscle weakness that begins in lower extremities and progresses proximally (mimics GBS), decreased proprioception, and muscle pain. Can also present as Wernicke’s encephalopathy (confusion, ataxia, ophthalmoplegia) or Korsakoff psychosis (amnesia, confabulation).
Treatment involves replacing thiamine. This is done using 500mg IV thiamine, a very high dose. These patients need IV thiamine for several days and so get admitted.
Appendicitis/Anaphylaxis
Appendicitis: classically a younger patient with periumbilical abdominal pain that migrated to the RLQ, fever, anorexia. However, it can be variable. Labs are generally not helpful, but an elevated WBC can support the diagnosis. Diagnosis is typically with a CT scan with IV contrast. Once diagnosis is made, patients are started on antibiotics (gram negative and anaerobic coverage) and admitted for surgery.
Anaphylaxis: anaphylaxis to IV contrast dye is rare but serious. Treatment is with IM epinephrine. Other agents such as steroids, H1/H2 blockers are typically given with questionable effectiveness.
Cavernous Sinus Thrombosus:
This is a septic thrombophlebitis of the cavernous sinus. It typically spreads from another infection of the face/head, the most common pathogen is Staphylococcus Aureus.
There are many important structures that travel through the cavernous sinus (CN III, IV, V, VI, internal carotid artery) and the symptoms from the conditions are typically due to compression/invasion of these structures.
Symptoms include fever, proptosis, chemosis, headache, ophthalmoplegia (either from mass effect of CN effect). They often start in one eye, but can spread to both.
Diagnosis is via cross-sectional imaging. MRV is study of choice, but CT with IV contrast is a reasonable first test due to availability.
Treatment is with broad spectrum antibiotics covering gram positives, gram negatives, and anaerobes. Appropriate choices include vancomycin/ceftriaxone/flagyl or vancomycin/piperacillin/tazobactam. Anticoagulation is controversial. It is important to get consultants on board as surgery is sometimes necessary.
