Grand Rounds Recap 04.28.21
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MORBIDITY & MORTALITY WITH DR. LI
Case 1: Methamphetamine Intoxication
While previously more common on the west coast, methamphetamine use has become more common throughout the U.S. and especially in Ohio (most common drug used in Hamilton County, OH for the past 3 years)
Concomitant rates of patients assaulting nurses, residents, and attending physicians is high
Methamphetamine intoxication can be a great masquerader, like syphilis and TB, presenting similarly to sepsis, anticholinergic toxicity, etc.
Half-life of methamphetamine is 10-12 hours, so when patients do get discharged from the ED after supportive management it is usually after a prolonged length of stay
The complication rate of methamphetamine intoxication is high, with rhabdomyolysis and AKI being most common - IV fluids and supportive management is therapy of choice
Observational study from Northern California in 2018 noted that nonocclusive mesenteric ischemia and bowel perforation was rarely present in meth use patients, however was associated with high morbidity and mortality
Research continues to look for effective treatment for methamphetamine use disorder, with one study showing that injectable naltrexone had an overall treatment effect of 11% (negative UDS) for a NNT of 9
Case 2: Pembrolizumab-Induced Thyroiditis
Not all fever and tachycardia is sepsis; consider thyrotoxicosis
The Burch Wartofsky Point Scale (BWPS) predicts the likelihood for thyrotoxicosis
While we often consider the extremes of thyroid dysfunction including myxedema coma and thyroid storm, there are several etiologies of thyroiditis that should also be considered - always consider drugs (amiodarone, interferon alfa, interleukin-2, kinase inhibitor)
Drugs with immune checkpoint blockade, such as pembrolizumab (Keytruda), can cause thyroid dysfunction; these should trigger type 1 thinking just like active chemotherapy makes us think of neutropenic fever
7-21% of patients receiving this class of immunosuppressants have immune related adverse events
Case 3: Mesenteric Ischemia & Pneumobilia in Sepsis of Unknown Source
The proportion of CT use in the US has outpaced the increasing rate of ED visits
The “medical pan-scan” can be used for sepsis of unknown source with some low quality studies to support its use
Diagnosis: 25% of admission diagnoses were changed after CT in one study (Pandharipande, 2016)
Management: There was a change in management, such as change in antibiotics, in 22-33% of those undergoing CT chest and 42-47% of those undergoing CT abd/pelvis (Ahvenjarvi, 2008 & Schleder, 2017)
Interventions: Comparative study that demonstrated 19% of patients who presented with sepsis NOS had CT abdomen/pelvis completed that identified a source of infection that was a candidate for procedural intervention (Barkhausen, 1999)
Case 4: Serotonin Syndrome
Serotonin syndrome occurs more commonly with multiple serotonergic medications rather than a single agent
Hunter Toxicity Criteria Decision rule has 84% sensitivity and 97% specificity for diagnosing serotonin syndrome, and is easier than using Sternbach’s criteria
The majority of patients (61%) will develop symptoms within 6-24 hours, and 57% of patients will have resolution of symptoms within 24 hours
There are several commonly used medications that have some serotonergic effects: ondansetron, methadone, tramadol, cocaine, MDMA, dextromethorphan, oxycodone, fentanyl, lithium, metoclopramide, ciprofloxacin, fluconazole
Cases are more severe if patients presents with a temperature >41.6C, rhabdomyolysis, and/or seizure
Treatment is supportive including stopping the offending agent
Benzodiazepines for agitation, tachycardia, hypertension, and neuromuscular abnormalities
Cooling since antipyretics do not work
Intubation consideration for uncontrollable agitation, chest wall rigidity affecting ventilation, profound hyperthermia requiring paralyzation and cooling
Cyproheptadine (first generation antihistamine) is an oral medication, thus needing oral access or an OGT/NGT; no serious side effects have been found though benefits are inconclusive
Case 5: Clostridium Difficile Colitis
C diff is an anaerobic, gram positive, spore-forming, toxin-producing bacillus that causes exotoxin-mediated colitis and diarrhea
Risk factors include antibiotic use, old age, and PPI use
Healthcare-mediated C diff has decreased; this is likely multifactorial including decreased use of fluoroquinolones, less false positives with better assays, and increased pay for performance incentives
Community-related C diff is still present with more than 50% having recent antibiotic use
Mortality rates remain high with 35-80% despite surgical intervention, 50-70% with medical management
IDSA 2017 classification and treatment:
Consider involving acute care surgery early in treatment for complicated and fulminant C diff
Hypotension, fever>38.5, ileus or significant abdominal distention, mental status change, WBC >35K, lactate >2.2, end organ failure, failure to improve after 5 days of medical therapy
While we commonly refer to the smell of C diff, this has poor predictive value as demonstrated by one small study
Case 6: Out-of-Hospital Cardiac Arrests (OHCA)
Out-of-hospital cardiac arrests (OHCA) are common, occurring in 347K US adults each year
While in-hospital cardiac arrests (IHCA) have better chances of survival, OHCA survival rates fluctuate tremendously by region, stable at ~10% in the last several years for a shockable rhythm
Predictors of survival from OHCA include witnessed arrest, bystander CPR, initial shockable rhythm, and ROSC in the pre-hospital setting (strongest predictor)
While 53% of OHCA were witnessed in one study, only 32% of them had bystander CPR making this a continued area of intervention from public health standpoint
A single center, open-label randomized trial published in 2020 Lancet study by Yannopoulos et al showed that adult patients with OHCA with initial vfib/vtach with no ROSC after 3 defibrillations [n=29] had better survival if brought straight to the cath lab and placed on ECMO versus receiving standard ACLS
ULTRASOUND GRAND ROUNDS: GAME CHANGERS WITH DR. HARTY
Case 1: Female in her 60s presenting with epigastric/substernal chest burning with pain into the inframammary fold. Increased belching. Minimally TTP in RUQ. EKG with some nonspecific ST/T wave changes. Bedside TTE completed and demonstrated a hyperdynamic LV, small pericardial effusion, no RV dilation appreciated, and plethoric IVC. Descending aorta slightly generous, however, so CT aorta obtained and demonstrated Type A aortic dissection.
Tip 1: Perform an early TTE for chest pain and/or shortness of breath
Can make diagnoses that can significantly alter patient’s clinical and management course
Case 2: Female in her 30s at ~10wk gestation (prior confirmed IUP) who presents with abdominal pain and hypotension. BP 80s/40s on presentation. Bedside US completed and demonstrates free fluid in splenorenal space, free fluid in the pelvis with concern for a significant amount of clot. Diagnosed with right cornual ectopic pregnancy with hemoperitoneum.
Tip 2: Trust but verify; use ultrasound to assess for IUP despite prior reports of US imaging if clinical context is concerning
Ectopic pregnancies: interstitial 3% (most commonly misdiagnosed as IUP), isthmus 11%, ampulla 70%, fimbria 10%, ovarian 3%
Myometrial mantle should be >6mm or endomyometrial mantle >8mm
Case 3: Female in her 80s with PMH saddle PE s/p EKOS not on anticoagulation who presents with confusion and pre-hospital EKG concerning for a STEMI. Tachycardic and hypertensive on presentation. Bedside TTE demonstrated underfilled LV, RV two times the size of the LV indicative of significant dilation. CTPA obtained and demonstrated saddle PE.
Case 4: Male in his 40s who presents from clinic with an abnormal EKG and chest pain. Mild tachycardia and tachypnea on presentation. Bedside TTE obtained and demonstrates large circumferential pericardial effusion and concern for cardiac tamponade.
Tip 3: POCUS for STEMI: looking for LV function and wall motion abnormality, aortic dissection, pulmonary embolism, cardiac tamponade, LV aneurysm
Diagnosing cardiac tamponade: looking for RV diastolic collapse when the mitral valve leaflet opens.
RV diastolic collapse: Use M mode on parasternal long to get a static image of dynamic movement to better assess the above (ensure your line is through the pericardial effusion, the RV, and the mitral valve leaflet).
MV inflow variation: Assess for sonographic pulsus paradoxus - compare mitral valve inflow velocities on apical 4 view, any variation >25% is concerning.
Plethoric IVC: Assess IVC for minimal respiratory variation, <50% collapse is concerning
Valve-closed RA collapse
Case 5: Female in her 50s presenting with SOB and cough x3 days with intermittent fevers. Swelling in her right thigh. Possible COVID contacts. Febrile, tachycardic, tachypneic on presentation. Noted to have a large area of induration and erythema to the right thigh near the inguinal area. Soft tissue ultrasound obtained and demonstrates dirty shadowing in the subcutaneous tissue concerning for gas and fluid tracking along deeper fascial lines that was confirmed on CT imaging as necrotizing fasciitis.
Tip 4: Ultrasound is great for deeper soft tissue infections!
Retrospective study with prospective enrollment of 95 patients presenting with concern for necrotizing fasciitis, ~50% of the cohort diagnosed with necrotizing fasciitis
Patients with necrotizing fasciitis had a statistically significant presence of fluid accumulation and irregular or thickening of fascia.
Specificity of ultrasound for diagnosing necrotizing fasciitis increases with each 1mm of depth demonstrating fluid accumulation on ultrasound (i.e. fluid at 1mm less specific - 48.9% - than fluid at 5mm - 97.9%)
Case 6: Male in his 30s with remote history of IVDU who presents with left ankle pain that started this morning. No trauma, no falls. No systemic symptoms. Slightly tachycardic on exam with limited active ROM, some TTP. XR demonstrates soft tissue edema. Bedside US demonstrates large tibio-talar joint effusion. Diagnosed with septic arthritis.
Case 7: Male in his 70s with left ankle pain and swelling x2d. No injury or trauma. On anticoagulation, recent change due to anticipated surgery in the next several days. Exam demonstrates anterolateral edema and TTP, some limited active ROM. XR demonstrates edema. Bedside US without effusion, however laterally the patient has a sizable fluid collection surrounding the flexor digitorum tendon. Diagnosed with inflammatory tenosynovitis.
Tip 5: Musculoskeletal exams can significantly alter diagnosis and patient management!
Case 8: Male in his 60s who presents after a bicycle accident and flips over his handlebars and has pain in his left chest. Imaging demonstrates left 1-8 rib fractures and small pneumothorax. US-guided serratus anterior block performed for analgesia control.
Tip 6: Serratus anterior blocks for rib fractures can provide better pain relief and possibly save patients from ICU admissions!
Hold probe transversely at ~4-5 rib in the midaxillary plane. Can perform the serratus anterior block by injecting anesthetic either superficial or deep to the serratus anterior muscle. This works because the thoracic intercostal nerve travels along the serratus anterior muscle when it exits the intrathoracic space.
Case 9: Male in his 70s who presents with back pain after working in his yard the day before. Bedside aortic ultrasound demonstrates abdominal aortic aneurysm measuring 6cmx6cm. CT imaging confirmed 7cmx9cm infrarenal aortic aneurysm.
Tip 7: Consider POCUS AAA in the appropriate patient population presenting with abdominal pain, back pain, flank pain, testicle pain, and syncope
Case 10: Male in his 50s presenting unresponsive from the lobby. Takes methadone. Tachycardic and hypotensive on presentation. RUSH exam performed demonstrates large complex free fluid in the hepatorenal space and splenorenal space. CT imaging demonstrated liver mass with laceration and hematoma.
Tip 8: RUSH Exam
Can be used for hypotension NOS, guiding resuscitation, etc. Includes cardiac, FAST, aorta, and lung
R4 CAPSTONE WITH DR. MODI
Chicago suburban student group including 38/40 minority children associated mispronunciations of their name with microaggressions and social discomfort. (Kohli)
Racial microaggressions: subtle verbal and non-verbal insults, layered insults and assaults, cumulative insults and assaults
Asians had decreased chances to get called back for a job opportunity if they had an Asian name versus an Anglo name with the same educational qualifications. (Banerjee)
Things you should NEVER say
“I’m never going to remember that”
“Do you have something shorter for that?”
“Can I just call you ___ instead?”
Equally inappropriate actions
Tapping the person on the shoulder because you’d rather not get their name wrong
Pointing to them at a meeting
Using pronouns instead of the person’s name
STEP 1: Ask the person to pronounce their name and actively listen
STEP 2: Don’t make it a big deal
STEP 3: Observe and practice
STEP 4: Clarify if needed
STEP 5: Be an ally
R3 SMALL GROUPS WITH DRS. BERGER, IRANKUNDA, AND URBANOWICZ
Pediatric Orthopedics: Lower Extremity w/Dr. Berger
Toddler’s Fracture
Normal radiographic image in a small child who refuses to bear weight is a toddler’s fracture until proven otherwise - place in long leg cast/CAM boot and discharge, follow up with orthopedic surgery. Will usually follow up with X-ray in 1 week that demonstrates bone reformation that is easier to see sometimes than the initial fracture.
Rickett’s
Rare in the developed world, more common in developing countries due to dietary deficiencies of Vitamin D (can be due to calcium and phosphate metabolism derangements as well)
Legg-Calve-Perthes disease
Most common in ages 4-10yo. Can be unilateral or bilateral, is seemingly spontaneous as there is nothing that predisposes patients to have this.
Bucket handle fracture
Highly specific for non-accidental trauma
Nearly 50% of patients in a cohort with non-accidental trauma had a bucket handle fracture
Requires involvement of child protective services in addition to orthopedic surgery
Osteosarcoma
Bimodal distribution: 10-25yo and elderly
Most commonly in long bones of lower extremity > humerus > pelvis
Requires orthopedic surgery evaluation as soon as possible, likely in addition to oncology
Developmental Dysplasia of the Hip
Epiphysis of the affected hip may seem underdeveloped
Affected hip will appear more elevated with a foreshortened lower extremity
Kocher criteria may be used to distinguish between transient synovitis and septic arthritis
Weight bearing status, fever, WBC, ESR
Salter-Harris fractures
Type 1: Slipped/separated growth plate
Type 2: Above the growth plate
Type 3: Below the growth plate
Type 4: Through the growth plate
Type 5: Erasure of the growth plate
Pediatric Orthopedics: Upper Extremity w/Dr. Urbanowicz
Medial epicondyle fracture
Usually in boys, 10-14yo
Often avulsion type injuries that do not require immobilization
Can be coupled with posterior elbow dislocation and possible joint incarceration that requires operative repair
Seymour fracture
The one nailbed injury you probably should not fix at Liberty
Distal phalanx fracture with overlying nailbed injury
Considered open fracture and often gets pins placed with washout
Warrants hand surgery evaluation and empiric antibiotics
Pediatric compartment syndrome mnemonic (AAA)
Anxiety, analgesia needs, agitation
Out of proportion is key. Serial exams and observation are more often required
Most commonly seen with supracondylar fractures
Non-accidental trauma
As always, be suspicion about how injuries occur
In patients <3yo, humeral shaft fracture is NAT until proven otherwise
Anterior interosseous nerve is a branch of the median nerve. Usually a neuropraxic injury resolving in 6-12 wks
Proximal humerus fracture
Significant plasticity and remodeling potential
Tolerate up to 45deg angulation and 50% translation in kids <12yo
Nearly all patients can be placed in a sling and made NWB with outpatient follow up
Radial head subluxation
Toddler age group, should outgrow this injury pattern by age 3-4
Not visible on XR. if you feel inclined, use US
Hyperpronation >> supination + flexion for reduction
Both bone forearm fractures
>90% do not require operative management
If <15deg angulation and <50% translated, likely does not need significant reduction and can be just splinted in place
Rule of 10s: if >10yo, cannot have more than 10deg angulation
Up to 20deg in children <10yo
Bones are more likely to break in adults than children with the same mechanism
Pediatric patients do not suffer sprain/strain injuries
Responsible for 10-15% of all pediatric ED visits
Most fractures occur between the ages of 10-14yo
Scary supracondylar fracture
Any displacement likely needs operative management or at minimum orthopedic surgery assessment
Growing evidence that intervention within 24hr of injury is acceptable
Place patient in a posterior slab + sugar tong splint with ability to conduct easy neurovascular checks for transport
Lateral epicondyle fracture
Last bone to join the party, expect a somewhat normal radiographic appearance around age 11-12
Second most common pediatric elbow fracture
High risk for complications!
Pediatric Skin and Soft Tissue Infections w/Dr. Irankunda
Nevus simplex (salmon patch)
Microvascular lesion in infancy in about 40% of newborns. Lesions usually fade after 2 years but can be more prominent with crying or straining.
Tibial spine fracture, Segond fracture - concerning for underlying ligamentous injury
Treat like ACL injury
Weight-bearing as tolerated
Perhaps immobilization
Follow up with orthopedic surgery
Dacryocystitis
Warm compresses, decongestants, antibiotics
Toddler fracture
Inability to bear weight
CAM walking boot
Fracture visible on initial visit - Repeat X-ray with PCP follow up
No fracture visible on initial visit - Treat the same with orthopedic follow up
CAST fracture: childhood accidental spiral tibial fx
Molluscum contagiosum - papules with central depression
Can last for several months to one year
Supportive management
Kawasaki disease
Fever does not respond to antipyretics
Painless adenopathy
Nonspecific polymorphous rash
Scarlett fever
Fever responds to antipyretics
Tender adenopathy
Rash blanches, fine papillae, pastia lines
