Grand Rounds Recap 03.10.21

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JOURNAL CLUB WITH DRS. HASSANI, HILL & PULVINO

The Safety and Effectiveness of Droperidol for Sedation of Acute Behavioral Disturbance in the Emergency Department. Calver et al, 2015.

  • Study type: Prospective observational, multi-center study including 6 EDs in Australia/New Zealand (2009-2013)

  • Objective: To investigate the safety of high-dose droperidol used in ED patients with acute behavioral disturbance

  • Population: Adults >18yo presenting with acute behavioral disturbance, at risk to themselves or others, or with Sedation Assessment Tool with a score of 2-3, and were not willing to receive oral medication (n=1781)

  • Intervention: Droperidol 10mg or 20mg IM or IV as initial agent

  • Comparison: None

  • Outcomes: Primary: Prolonged QT (EKG to be done within 2 hours of administration). Secondary: Adverse events - new-onset arrhythmias including torsades de pointes, oxygen saturation <90%, airway obstruction, SBP <90mmHg, RR <12 breaths/min

  • Results:

    • Primary: 1.3% with prolonged QTc - majority of these reportedly on known QT-prolonging medications but 0.6% of these without assumed cause

    • Secondary:

      • No episodes of torsades de pointes

      • 69% effectively sedated after initial dose of droperidol

      • 7.8% of patients with oversedation, although some of these patients had subsequent benzodiazepine administration

      • 5.0% of patients with adverse events

        • 28 patients with hypotension

        • 22 patients with desaturation

        • 8 patients with airway obstruction with 1 requiring intubation

      • 2.7% of cases had staff injuries and/or patient injuries

  • Limitations: No baseline EKG with QTc (utilized QTc nomogram to assess HR-QTc), not all patients were able to get EKG within 2 hours of droperidol administration, non-consecutive patient enrollment, did not include route of administration (IM vs IV likely affect QT differently), did not include patient comorbidities or home medication list

Midazolam-Droperidol, Droperidol, or Olanzapine for Acute Agitation: A RCT. Taylor et al. 

  • Study type: Double blind, randomized, triple dummy, 2 EDs in Australia, 24 hour psych services

  • Objective: Determine the most efficacious medication regimen amongst 3 common sedatives 

  • Population: ED patients age 18-65 years needing IV medications for acute agitation determined by the attending physician, n = 361

  • Intervention: IV droperidol 5 mg + midazolam 5 mg, droperidol 10 mg, or olanzapine 10 mg

  • Comparison: Comparison between the 3 groups

  • Outcomes: Primary outcome was sedation on their scale in 10 minutes, with adequate being less than 3. Secondary outcomes were 1) time to sedation, 2) need for more sedation in the first 60 minutes, 3) medication failure, and 4) adverse events including QTc prolongation

  • Results:

    • IV droperidol + midazolam had the shortest time to sedation (6 minutes)

      • Fewer additional doses

      • No difference in adverse events, though trend towards respiratory depression

      • No statistical difference in length of stay

    • IV droperidol alone trended toward lower LOS

  • Limitations: no ECG on file, potency of the drugs are different IV vs IM, no external validation, patient population may have been less agitated in the droperidol + midazolam combination group

RCT of IM droperidol versus midazolam for violence and acute behavioral disturbance: The DORM Study. Isbister et al. 

  • Study type: Randomized control trial, single center in Australia (2008-09)

  • Objective: Determine which is more effective at IM sedation - droperidol 10 mg, midazolam 10 mg, or combination of both 

  • Population: 91 agitated adult ED patients 

  • Intervention: Blinded IM sedation medication 

  • Outcomes: Primary outcome was length of time security at bedside, a practice that was already established at the institution. Secondary outcomes were 1) time until additional sedative was needed and 2) adverse drug effects. 

  • Results: No difference in median duration of acute agitation. Midazolam required additional sedation medication more commonly, which ended up leading to more oversedation events. There were no issues with QTc. 

  • Limitations: When a second sedation medication was needed, the blinded fashion of the initial medication could have impacted the choice of the second sedative.

GLOBAL HEALTH GRAND ROUNDS WITH VISITING PROFESSOR DR. KENNETH ISERSON

  • To do global health right, you ideally should dedicate your career to it, though there are other ways to educate yourself, support global health, and get involved without going all-in

  • Opportunities for those interested in global health career:

  • There are risks for you and the patient population you serve when you engage in independent or one-off medical tourism. When vetting or supporting global health programs:

    • DO look for groups that have established, long-term relationships and work within the country’s existing system.

    • DO go for four weeks if possible to maximize your time to adjust, learn, and provide as much assistance as possible

    • DON'T donate supplies unless you have closely coordinated with people in country

  • Logistical, educational, and mental preparation is key!

    • Familiarize yourself with epidemiology and medical practice local to the area (eg, diagnoses, equipment, medications)

    • Make sure you have important documents in hand and are aware of health and safety issues in area where you will be traveling

    • Think about how you will process some of the conditions you see. How will you cope with feelings about inequity, morbidity, and mortality that may be different from what you see in the US? What support system will you have in-country and back home to help you continue to process (faculty, family, co-residents)? How will you be a good advocate and partner before, during, and after your trip?

SPORTS MED INTEREST GROUP: ELBOW, HAND & HIP WITH DRS. BETZ, GAWRON & IPARRAGUIRRE

 HIP

  • Basic exam: 

    • Look: Skin (requires undressing the patient), bone, gait

    • Touch: Tenderness, warmth, pelvic instability, AP/lateral compression, log roll

    • Neuro/Vascular: Pulses (femoral, DP, PT), sensation, motor function, ROM 

    • Pearls: Look for referred pain from the knee and the back 

  • Hip dislocation: 

    • Posterior dislocations significantly more common (90%) than anterior dislocations (10%)

    • Native hip dislocation requires high velocity trauma, whereas prosthetic hips can dislocate easily

    • For native hip dislocations, the risk of osteonecrosis increases with time. Ideally reduction should occur within 6 hours, though there are some studies that suggest a longer period is acceptable

    • Relative contraindications include 1) associated femoral neck fracture and 2) ipsilateral knee injury 

    • Reduction maneuvers include: Allis maneuver, captain morgan, & Whistler technique

  • Pelvic fracture:

    • Up to 40% of elderly patients with negative pelvis XR have an occult femoral fracture; CT is adequate but MRI may be required as it is the gold standard 

  • Pediatric hip pain:

    • Slipped Capital Femoral Epiphysis: Older group (avg age 12-23), obesity is major risk factor, need to go to operating room emergently due to risk of avascular necrosis of the femoral head

    • Legg-Calve Perthes: Younger group (age 4-8), more prevalent in males, idiopathic avascular necrosis of femoral head and thus doesn’t need emergent operative management

ELBOW

  • Anatomy: Made up by the humerus (capitulum is the portion that articulates with the radius), radius, and ulnar (coronoid process)

  • Septic joint:

    • Joint aspiration occurs at the triangle of radial head, lateral epicondyle, & tip of the olecranon 

    • Can use ultrasound via lateral approach (start mid-forearm with linear probe, find the radius, move proximally, looking for elevation of the fat pad) or posterior approach (start in longitudinal axis on the back of the arm, find the humerus, move distally)

  • Elbow dislocation:

    • Most common mechanism is a FOOSH in adolescent male playing sports

    • Most common dislocation is posterolateral (80%)

    • Most common nerve injury is the ulnar nerve (20%)

    • Traction-countertraction method: Hold elbow in 30 degrees of flexion and supination to help coronoid to clear the joint, have assistant stabilize the humerus, grab at the wrist/forearm and apply steady traction

    • Immobilize in 90 degrees of flexion via posterior splint with extra elbow padding

    • Follow up in 1-2 weeks, as you don’t want the elbow immobilized more than 3 weeks due to negative impacts on ROM

  • Simple radial head fracture

    • Mechanism is a FOOSH

    • Most common elbow injury but often missed, both on exam and x-ray

    • Test supination and pronation, both of which should reach 90 degrees

    • Doesn’t need as much immobilization as you’d think; sling is sufficient

HAND 

  • Fingers: 

    • Assess flexion & extension at each of the MCP, PIP, and DIP joints

    • Check for scissoring; should have a normal finger flexion cascade when the hand is at rest

  • Hand:

    • Scaphoid fracture: Look for snuffbox tenderness, ulnar deviation, axial loading of the thumb 

    • Hook of the hamate fracture: Easily missed on x-ray so need to assess for tenderness directly over the bone

    • Assessing motor via thumbs up (radial), peace sign (ulnar), okay sign (median), thumb opposition with little finger (recurrent median nerve, “million dollar nerve”) 

  • Mallet finger: 

    • Rupture of extensor tendon at the DIP

    • Splint the DIP in extension, leaving the PIP free, for 24 hours a day for 6 weeks

  • Jersey finger:

    • Rupture of the flexor tendon at the PIP (flexor digitorium profundus)

    • This is a surgical issue that needs a full splint and follow up with a Hand Surgeon 

  • Central band rupture

    • Elson test: Bend PIP 90 degrees over edge of a tabe and extend middle phalanx against resistance

    • Splint the PIP in extension for 6 weeks

  • Dorsal PIP dislocation:

    • Should be in 20-30 degrees of flexion due to injury of the volar plate 

  • Lunate/Perilunate dislocations:

    • Always look at the lateral, as these are easily missed on x-ray

PEM SIMULATION WITH CCHMC PEM FELLOW DR. CLEMENS

Case 1: Previously healthy, fully immunized toddler girl presents from outside hospital with vomiting and lethargy for the past 2 days. Doesn’t eat much but does drink cow’s milk.  No pre-arrival notification was performed but IO was in place, though no medications administered.  On history, her speech had been regressing but otherwise passed newborn screen, had been meeting milestones, and had been gaining weight appropriately.  Vital signs notable for hypothermia to 94F and hypoxic to 83% on RA.  On exam, she is significantly pale, has dry mucous membranes, and an S3 gallop is present. Labs showed a profound metabolic acidosis with respiratory compensation, hypernatremia to 154, and anemia to 1.5.  CXR showed cardiomegaly.  POCUS showed depressed LV function.

Iron-deficiency anemia

  • Often parents are blissfully unaware of how pale the child is because of onset chronicity

  • Ask about feeding as calcium from cow’s milk has a dose dependent inhibition of iron absorption; malignancy should also be on the differential  

  • Because cow’s milk induced iron deficiency anemia is a slow process, patients often need an extremely slow blood infusion as they are in decompensated high-output cardiac failure 

  • While oxygen delivery is predominantly dependent on hemoglobin, a non-rebreather can help with oxygenation - especially important since pulse oximeters are unreliable with hgb < 8.0 

Case 2: Previously healthy, fully immunized teenage male presents with progressive shortness of breath for 3-4 weeks, associated with fatigue, exercise intolerance, and 10 pound weight loss.  No associated abd pain, chest pain, n/v.  Had COVID 5-6 months prior.  Vital signs notable for tachycardia to 150’s and tachypnea to 30.  Exam notable for dry mucous membranes, subcostal retractions, right-sided crackles, diminished breath sounds, and no leg asymmetry.  Labs showed normal pH, inappropriate pCO2 of 44 given level of tachypnea, and hyponatremia to 128.  CXR showed widened mediastinum with right sided effusion.  EKG shows sinus tachycardia to the 150’s without PR depression, ST elevation, or electrical alternans.  POCUS showed what looked like a pericardial effusion on PSL but was confirmed to be a pleural effusion with additional views. 

Pericardial versus Pleural Effusions

  • Two views are necessary to make a diagnosis on ultrasound 

  • The ascending aorta needs to be in view with pericardial effusions tracking anteriorly

Mediastinal Masses

  • Worsening shortness of breath when lying flat should increase suspicion for mediastinal mass

  • Allow patients to remain in comfortable position, as laying them flat can cause cardiopulmonary collapse from direct compression of the trachea and/or right ventricular compression

    • If forced to lay them flat, place in left lateral decubitus

    • If forced to intubate, consider rigid bronchoscope to stent open airway as tracheal obstruction can be distal to the ETT

  • Occasionally, CT chest is unable to be performed until after emergent radiation due to compression

  • Hodgkin’s lymphoma classically presents with B symptoms (fever, weight loss, night sweats) such as seen with this patient