M&M - Ankle injuries - trach management - fluids in septic shock

Morbidity and Mortality Conference: Lecture Topic WITH DR. Ludmer

Spontaneous Coronary Artery Dissection (SCAD)

SCAD is considered a type 1 coronary artery dissection. With new diagnostic tools, the prevalence of SCAD is thought to occur in up to 4% of all patients presenting with ACS-like symptoms. The prevalence of SCAD is highest in females, under the age of 50. In retrospective reviews of patients with SCAD, 70% of lesions occur in the LAD. EKGs can show TWIs and ST depressions and 90% of patients were found to have elevated troponin.

Hemophilia Management

Hemophilia A is due to decreased production of factor VIII. Hemophilia B is due to decrease production of factor IX.

Hemophiliacs are categorized as mild, moderate or severe, based on their underlying level of factor production and their frequency of bleeding. A patient's severity classification affects their personal bleeding prophylaxis and management. In the setting of major bleeding, due to either the volume of blood loss or the location of the bleed, hemophiliacs require immediate full factor replacement and admission. This usually means empiric loading dose of 50 IU/kg of factor VIII or 100 IU/kg of factor IX and checking a factor level 15-30 minutes later. In the setting of major bleeding DDAVP is not indicated. In the setting of minor bleeding, guidelines recommend discussion with the patient's hematologist, checking a factor level, and replacing a patient's factor level according. If these resources are not available, the goal replacement is 50% of their factor, so the loading dose is 25 IU/kg of factor VIII and 50 IU/kg of factor IX. If patients know that they are a "responder" to DDAVP, then this is indicated in the setting of minor bleeding as well.

Pleural Effusions

Pleural effusions are most commonly diagnosed on chest xray. However, ultrasound has been shown to be more sensitive and specific at diagnosing pleural effusions, as compared to chest xray, and can help to differentiate between simple and complex effusions. Guidelines recommend thoracentesis in patients with new pleural effusion not in the setting of heart failure.

Light's criteria can be used to different between a transudate and exudative effusion. For more information about how to perform a thoracentesis check out our procedure page! Without manometry it is recommended not to remove more than 1500cc of fluid as this can lead to lung re-expansion injury.

Inadequate Paralysis

There are usually three main reasons why refractory paralysis can occur; due to inadequate drug delivery (IV malfunction, BP cuff inflated, etc), an imbalance between the drug to receptor ratio (neuro disease, additional drugs on board, etc), or a problem with timing of paralytic administration in relation to the timing of intubation attempt. In the setting of inadequate paralytic delivery this is usually due to either problems with IV access. Hypotension can also cause inadequate drug delivery due to decreased flow and circulation of drug. Studies are starting to be published that suggest a higher dose of paralytic is required in the setting of hypotension. Studies have shown that some patients can be hypermetabolizers of succinylcholine. Additionally, there are many drug-drug interactions for succinylcholine as it acts through the P450 system. With succinylcholine, fasciculation occurs prior to onset of maximal receptor blockage which can lead to a premature intubation attempt. Consider the use of end-tidal CO2 monitoring to help establish when a patient is apenic.

Complications of Acute Leukemia

Neutropenia
Thromboembolism
DIC/coagulopathy
Leukostasis

Leukostasis

Leukostasis is a microvascular congestion due to clumping of blood cells. This is more common in ALL and AML because blast cells are larger and less malleable, leading to more frequent microvascular occlusion. This can present as a variety of symptoms depending on where the microvascular congestion and infarct occurs. Leukostasis often presents as pulmonary infiltrates. In AML, leukostasis can occur with leukocytosis >50k. Initial management in the ED should start with supportive care with IV hydration. Ultimately these patients require chemotherapy, hydroxyurea, and dexamethasone. These interventions should be given in conjunction with hematology/oncology. It is also important to consider leukopharesis in these patients. Leukopheresis is contraindicated in the setting of coagulopathy.

Sports Medicine: Ankle pain WITH DR. Betz

Ankle Pain

Ankle pain accounts for about 15% of all ED visits. Of the patients who present with the chief complaint of ankle pain, 15% will have a fracture and 10% will have a high ankle sprain.

The ankle and foot are a complex weight bearing joint make up of 26 individual bones, and 33 joints. The medial ankle ligaments are about twice as strong as the lateral ankle ligaments

Lateral Ankle Sprain

Lateral ankle sprain can be a tear of the ATFL, CFL, and/or PTFL. Ankle sprains are graded, grade 1 is due to over stretching of the ligaments, grade 2 is due to tears within the ligaments, and grade 3 is due to a complete tear of the ligament. There is no correlation between the severity of the initial sprain and the residual disability.

A mainstay of management of ankle sprains should be around NSAIDs. There is no evidence for "RICE" which stands for rest, ice, compression, and elevation. Functional support is preferred over immobilization and an ankle brace is the preferred functional support device. Most patients should be made weight bearing as tolerated. Additionally, an exercise program such as physical therapy is recommended for optimal recovery of joint function. In summary, low grade sprains should get an ankle brace and have PCP follow-up. High grade ankle sprains should be placed in an ankle brace, given crutches, made weight-bearing as tolerated and given orthopaedic follow-up.

Ankle Sprain Mimics

There are many different causes of xray negative, ankle sprain mimics. It is important to ask the direction of force applied as external rotation injuries should be a red flag feature of a patient's history. In patients with medial ligament tenderness it is important to obtain a tib/fib xray to rule out injury to the syndesmosis.

The syndesmosis is an immovable joint in which bones are jointed by connective tissue. This is on the continuum of a high ankle sprain. It helps to maintain the integrity between the tibia and fibula. It acts to resist axial, rotational, and translational force. This is usually an external rotation injury. This can also occur in conjunction with an deltoid ligament injury. You should see incongruence of the ankle joint articulation. Patients with this present with toe-touch weight bearing. Provocative test is the "squeeze test", squeeze the mid calf and this should reproduce ankle pain. These patients should be treated with non-weight bearing. These injuries have a high morbidity.

Talar Injury. Talar injuries occur with inversion ankle injuries and are easily missed on xray. They are a a common etiology of continued ankle pain and highly comorbid articular cartilage injury.

5th Metatarsal fractures. It is important to get a foot xray and to palpate the 5th metatarsal. Depending on location of the fracture, 5th metatarsal fractures may require extended casting vs early mobilization.

R1 Clinical Knowledge: Tracheostomies WITH DR. Shaw

Indications

Difficult ventilatory wean, anatomic issue, or need for continued airway protection.

Sizing

Tracheostomies are measured by their inner and outer diameter. In the ED setting, the inner diameter effects what can go through the tube, for example an ETT or bougie. The outer diameter matters because it describes the size of the patient's stoma.

Unique Features

XL tubes are used to add length in either the proximal portion, used for patient's with more neck meat, or in the distal portion to bypass an area of stenosis
Fenestration allows for communications of the patient's innate vocal system
Montgomery T tube which allow for support of the upper airway as well.

Complications

Early complications: decannulation, bleeding, infection, pneumothorax

R4 Clinical Soapbox: Fluids in Septic Shock WITH DR. Renne

Fluids is more delicate than a stamped 30 cc/kg in every septic patient. These are the ways, in Dr. Renne's residency and critical care experience, that he has seen fluids been used inappropriately:

"Fast death" occurs due to a large rapid fluid bolus in the setting of a weak RV. This leads to RV dilation and then biventricular failure. This occurs in a very small subset of patients.
"Slow death" is a common occurrence in the septic shock patients. Due to volume overload, this places patients at risk for downstream effects which can lead to multi-system organ failure, difficulty with ventilatory wean and morbidity.

Studies are starting to suggest that less than half of patients in septic shock are fluid responsive and of those who are responsive there is usually only a minimal improvement in MAP and the improvement is transient. Dr. Renne recommends starting with conservative fluid boluses in septic patients while also concomitantly starting vasopressor agents to help increase vascular tone and improve preload, while frequently assessing their fluid responsiveness, bringing some nuance and individuality to fluid management.

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