Grand Rounds Recap 4.24.24

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Morbidity and Mortality WITH Dr. Kletsel

  • Case 1: Chest Pain​

    • Consider the underlying etiology driving the elevated HR and try to correct it prior to administering a rate control agent. ​

    • During times of acute illness, blunting a patient’s underlying compensatory tachycardia may be dangerous.​

    • We should be comfortable with the different types of advanced care documents that we may encounter in the field and in the ED. ​

    • We need to improve our conversations with patients, as well as amongst providers, pertaining to code status in the ED. ​

  • Case 2: Deep Vein Thrombosis​

    • Isolated distal DVTs have about a 15% risk of propagation if left untreated.​

    • Treatment of these isolated calf clots remains controversial, yet surveillance with weekly ultrasound can be considered in patients with a high risk of bleeding. ​

    • While AC can typically be initiated a few weeks following a hemorrhagic stroke for at-risk patients, cerebral amyloid appears to have a higher risk of re-bleeding and providers should be cautious prior to initiating anticoagulation in these patients. ​

  • Quick Hit Case A: Shoulder Injury​

    • Posterior shoulder dislocations are rare and commonly missed on initial presentation.​

    • We need to be proficient at reading normal A/P and lateral shoulder x-rays. ​

    • Look for joint space widening, a positive lightbulb sign, and/or improper alignment on a Y view to suggest a posterior dislocation. ​

  • Quick Hit Case B: Ankle Pain​

    • When looking at an ankle radiograph, start by looking for a uniform ankle joint mortise that measures <4mm​

    • Next, look for a fibular bone fracture and grade it based on the Danis-Weber classification system. ​

    • If you are concerned for a Danis-Weber B, perform stress views of the ankle to assess for instability. ​

  • Quick Hit Case C: Abdominal Pain​

    • A definitive IUP requires a yolk sac within a gestational sac, in the same plane as the endometrial stripe, and surrounding with a endomyometrium measuring at least 8mm.​

    • When there is clinical concern for an ectopic pregnancy, always assess for the presence of a moderate or significant amount of free fluid in the pelvis/RUQ- as these are highly specific for a ruptured ectopic.  ​

  • Case 3: Chest Pain​

    • Lactic acidosis is not always caused by tissue hypoperfusion. ​

    • Type B lactic acidosis involves impaired clearance of lactate by the liver/kidneys or certain medications/toxins that impair typical cellular aerobic respiration. ​

    • Metformin toxicity impairs the electron transport chain in the mitochondria and leads to production of excess lactate. ​

    • Patients typically present with vague symptoms, including GI distress and confusion, and dialysis remains the mainstay of treatment.​

  • Case 4: Cardiac Arrest​

    • Consider massive PE as the underlying etiology when a patient presents with undifferentiated cardiac arrest.​

    • Predictors that suggest PE include a non-shockable rhythm, history of a prior clot, and lack of a cardiac history.​

    • If suspicion if high, you consider administration of intra-arrest thrombolytics, yet there is conflicting data about the benefits. ​

    • Furthermore, there is no consensus about dosage and/or duration that CPR should be extended for. ​

R1 Diagnostics and Therapeutics: Neuromuscular Weakness WITH Dr. Onuzuruike

  • Thorough neurological exam along with cardiac and respiratory exam

  • With NM, try to locate source of weakness. There are various ways to do this, but elucidating the timing and pattern of distribution is key for finding source

  • Motor unit pathway gives us pathophysiology of disease, and if it comes with or without pain or sensory changes

  • Employ your knowledge of neurolocalization and anatomy to identify NM weakness and suspected etiologies

    • The neurological exam is key

  • Use bedside respiratory parameters, ETCO2 for monitoring of respiratory function and know the signs of impending failure; maximize treatment of other variables (ex. secretions)

EKG Quick Hits: Artifacts and Errors WITH Dr. Urbanowicz

  •  There are many common artifacts in EKGS, but they can include: motion, interference, placement distortion, and machine dysfunction

    • Limb lead reversal is common, can incorrectly suggest inferior ischemia, and is most commonly reversal of right vs. left

    • Electromagnetic interference can be either intrinsic (simulation devices) or extrinsic (cell phones, machinery, etc)

  • How to troubleshoot artifact: 

    • Check the cable location, on both patient and box​

    • Replace the electrode stickers (shave if needed!)​

    • Remove all cables and electronics from bed​

    • Try a different machine​

    • Try a new physical location

Social Emergency Medicine GR WITH Drs. Pulvino and kimmel

  • Socially conscious emergency medicine is good for patients and performance measures

    • Examples: Case management for ED frequent users, MOUD, street medicine

  • Social EM is cost effective

  • You can align your practice with Social EM without ruining your workflow. You can do this by:

    • Working SEM into your reading rotation

    • Check yourself before discharge, including if the plan is realistic and what barriers the patient may face

    • Know what resources you have within your hospital system and local community, and phone a friend when you don’t know (social work, pharmacy, EIP/SUD, etc)

    • Advocate for resources within your emergency medicine group, hospital system, and community(24/7 social work, substance use teams, voting, community advocacy) 

    • You can bill for your work! New billing rules make it possible, and MDM templates can be found online

    • Incorporate SEM into your presentations, and collaborate with other departments and sub-departments (IM, palliative, ultrasound, research, etc)    

Landmark Studies of EM: Critical Care WITH Drs. Richards, GIllespie, and Wosiski-Kuhn

  • Early goal directed therapy, while some of the initial principles have now been proven harmful or ineffective, still has a great impact on our care of the critically ill septic patient

    • Focused on early recognition and treatment of sepsis in the emergency department

    • Protocolized treatment pathways & treatment goals

    • Model for acute, time-sensitive conditions in the emergency department

  • Low tidal volumes based on patient’s ideal body weight with ARDS significantly decreases mortality in these patients

  • Non-invasive positive pressure ventilation benefits include reduced mortality, reduced intubation, decreased hospital length of stay, and lower composite risk of in-hospital complications including pneumonia, barotrauma, and sepsis