Grand Rounds Recap 5.9.18

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Intra-arrest care - Global Health - Quarterly Sim - Oral boards

QI/KT : Intra-arrest care WITH DRs. Gauger & Harty

Three Phase Model of Cardiac Arrest

  1. Electrical Phase (0-4 minutes)
    • Fatal arrhythmia
    • Defibrillation most important
  2. Circulatory Phase (4-10 minutes)
    • Decreased coronary perfusion pressure
    • Compressions most important
  3. Metabolic Phase (>10 minutes)
    • Global hypoperfusion
    • Severe acidosis
    • Pharmacologic management

The Basics

  • High quality compressions with limited interruptions
  • Early defibrillation
  • Think critically and use the data available to you

Understanding PEA

Narrow PEA
Causes

  • Mechanical
    • Cardiac tamponate
    • Tension PTX
    • Hyperinflation
    • Pulmonary Embolism
  • Acute MI
    • Myocardial Rupture

Management: wide open fluids, ultrasound looking for reversible causes (pericardiocentesis, needle thoracostomy, thrombolysis, etc.)

Wide PEA
Causes

  • Metabolic
    • Hyperkalemia
    • Sodium-channel toxicity
  • Agonal rhythm
  • Acute MI
    • Pump failure

Management: pharmacologic (calcium, bicarb, etc.)

Airway

Arrive intubated: confirm tube placement with end tidal CO2
Ventilation via BVM: recommend placing ETT vs placing iGel, either way do not interrupt compressions for airway
Arrive with EGD: leave in place and confirm, recommend exchanging for ETT if...

  • Suspect respiratory arrest
  • Difficulty bagging
  • Poor EtCO2
  • Vomiting

Ultrasound

Multiple studies prove we are not good at pulse checks but US can give us a direct look and can identifies underlying causes
Recommend using a 2 person team separate from rest of resuscitation
Get view during compressions and then take clip during 1st pulse check, analyze this clip after compressions have resumed
Do not delay compressions!

Arterial Lines

Proved better than pulse check
Can provide you with real-time feedback on resuscitation
Goal DBP >25 mm Hg
This access, obtained early, can be important if ECMO is to be initiated later
Recommend placing femoral arterial after the first pulse check

Pharmacology

Epinephrine

  • Intended for positive alpha effect
  • Improves ROSC, but no proven improvement in patient-centered outcomes
  • Dose: 1 mg q3-5 min or we recommend starting an early epi drip at .5 mcg/kg/min (35 mcg/min for 70kg patient)

Amiodarone for ventricular fibrillation or pulseless ventricular tachycardia

  • Antiarrhythmic, may improve defib success, may decrease recurrence
  • May improve ROSC but again no patient-centered outcomes improvement
  • Dose: 300 mg bolus

Bicarbonate

  • Intended to decrease acidosis, improve pressor response, osmol load
  • May cause intracellular acidosis, rebound alkalosis, extravasation 
  • No data to support improved outcome
  • Not recommended in "all comers"
  • Consider in wide-complex PEA

Calcium

  • Inopressor with few adverse effects
  • No data to support improved outcomes
  • Useful in hyperkalemia, hypocalcemia, sodium channel blockade
  • Consider in wide-complex PEA

Esmolol

  • Reduced myocardial oxygen requirement
  • Improved post-rosc myocardial function
  • Driver study: Sustained ROSC and survival to admission improved
  • Consider .5 mg/kg bolus in refractory vfib/pvt

Thrombolytics

  • Troica trial: no improvement in PEA when given to all comers
  • PEAPETT trial: In confirmed PE, significant improvement in all outcomes
  • Consider 50 mg alteplase bolus + 50 mg infusion in narrow complex PEA if PE highly suspected

Extracorporeal Cardiopulmonary Resuscitation

VA-ECMO in cardiac arrest
Several small studies show promising outcomes
CHEER trial and Minnesota study for out of hospital cardiac arrest show promising date in the early stages
No large randomized trials but the EROCA trial out of Michigan ongoing so keep an eye out for the results  

Global health Curriculum : global em - Adventures beyond b-pod WITH DR. kristiana kaufmann

International Emergency Medicine

  1. Humanitarian Aid: disaster situations, resource poor environments
  2. EM Systems Development
    • EMS / 911 Systems
    • Improving trauma care (WHO trauma care checklist)
    • Consulting
    • Foundation of international residency programs (Resources from the IFEM)
    • Idea for education: suture/splint labs, trauma labs including splints, tourniquets etc, ultrasound education, disaster preparedness
    • More resources here at the Consortium of Universities for Global Health

Asset Based Community Development: local assets are the primary building block of sustaining community development

  • Individuals: everyone has assets and gifts
  • Associations: people discover each other's gifts
  • Institutions: people organized around assets
  • Place based assets: people live here for a reason
  • Connections: individuals connect into a community

quarterly simulation WITH DR. bryant

The Case

HPI
15 year old previously healthy male who recently moved from Micronesia presenting with difficulty breathing and fatigue. +DOE with intermittent chest pain. Myalgias and arthralgias all over but particularly in the knees and ankles. No belly pain, nausea or vomiting. Has had a rash for the last week that looks like "pink bubbles" and come and goes. +tactile temps. No current URI symptoms but did have a sore throat about a month ago.

Vitals
HR 142  O2 Sat 94% on RA   BP 92-63   RR 28   Temp 102.2

Exam
HEENT: Normal
Cardiac: Holosystolic murmur
Lung: Crackles at the bases
Abdomen: Hepatomegaly with no splenogmegaly
MSK: Right knee is swollen and erythematous and very tender to touch, has a lot of pain but will range it fully, Left ankle is swollen and tender with FROM  

Diagnostics
CXR: cardiomegaly with pulmonary edema
Bedside Echo: mitral regurgitation with normal EF
CBC: WBC 12   Hgb 11.9    Plt 44
BMP: WNL
EKG: First degree heart block
ESR 73    CRP 9
Arthrocentesis of knee shows 700 WBCs and no organism on gram stain

Discussion

Diagnosis: Acute Rheumatic Fever

Classic Jones Criteria: requires proof of a prior strep infection (Anti-streptomycin O or anti-DNAse B) plus 2 major OR 1 major and 2 minor criteria

  • Major: carditis (mitral most common), polyarthritis, chorea, erythema marginatum (pink rings/lines on the torso and inner surfaces of the limbs/extensor surfaces which come and go), and subcutaneous nodules
  • Minor: arthralgia, fever >101.5, elevated ESR and CRP, and prolonged PR interval 

Revised Jones Criteria: changes to major criteria based on risk of population 

  • Low risk populations: carditis, arthritis (polyarthritis only), chorea, and erythema marginatum 
  • High risk: carditis, monoarthritis, chorea, erythema marginatum, and subcutaneous nodules
    • Major difference is that you do not need to prove a prior strep infection and you only need one joint involve
    • Groups at highest risk: in the US seen mostly in Hawaii, developing countries, Australian New Zealand native population

Symptom Prevalence

  • Carditis and valvulopathy (50-70%)
  • Arthritis (35-60%)
  • CNS involvement (10-30%)
  • Nodules (0-10%)
  • Erythema marginatum (<6%)

Management:

  • Transfer to pediatric hospital with high level of care and cardiology consultants
  • Penicillin prophylaxis for years to life
  • Steroids are controversial but most recommend it in the acute setting however IVIG does not have good data behind it
  • NSAIDs work remarkably well for the joint pain
    • If joint pain not improving with NSAIDs then rethink your diagnosis
    • Aspirin is an option in an older child however unlike Kawasaki's the aspirin itself is not needed for the cardiac effects and you can avoid Reye's syndrome by using Naproxen or Indomethacin 

mock oral boards WITH DRs. Lafollette & Stettler

Case 1: Single Patient Encounter

HPI
18 y/o male with no significant past medical history who presents with fever and headache for 7 days duration. He was recently put on PO antibiotics for sinusitis, and has been taking them, but his symptoms have gotten worse. He initially reports he had a lot of pressure around his right eye, which is what prompted his doctor to put him on antibiotics. However, despite the medication, he has had worsening right eye pain, headache, neck pain and now fever. He also reports blurry vision in that eye.

Initial Vitals
HR 120   BP 82/55   T 39.0  RR 30/min  O2 sat 96% RA

Exam and Clinical Course
An 18G IV is placed and 1L of LR is hung wide open. The patient’s exam is notable for swelling and erythema around the right eye with a right-sided lateral rectus palsy. He does have some pain with neck flexion as well. His exam is otherwise unremarkable. Despite the fluid bolus, the patient remains hypotensive, and more fluids are given as well as Tylenol, solumedrol, ceftriaxone and vancomycin. Blood cultures are drawn. Labs are notable for a lactate of 6.7, an AKI with a Cr of 1.6 and a WBC of 15.

He remains hypotensive and a third liter of fluid is ordered. A repeat lactate is 4.2. A non-contrast head CT is unremarkable. An LP is performed and the results are unremarkable. Despite aggressive fluid resuscitation, the patient remains hypotensive. After informed consent is obtained, a central line is placed and he is started on norepinephrine. A CTA is notable for a cavernous sinus thrombosis. The patient is started on a heparin drip and admitted to the ICU.

Critical Actions

  • Administration of crystalloid fluids 
  • Recognition of sepsis and initiation of broad spectrum antibiotics
  • Appropriate initiation of vasopressors
  • Informed consent and placement of a central line
  • Correct ordering of appropriate imaging to diagnose cavernous sinus thrombosis
  • Initiation of appropriate treatment with a heparin drip
  • Disposition to a medical ICU

Case 2: Triple Patient Encounter

HPI 1
62 y/o male who presents via EMS with chest pain. The patient reports sudden onset retrosternal chest pain that began while he was performing yard work. He denies SOB but does report numbness in his left foot that began around the same time his chest pain started. He reports a history of HTN, HLD and DM, as well as tobacco abuse. He took a baby ASA this morning, and is on a statin and beta-blocker.

Initial Vitals
T 98.9    HR 102   BP 215/83   RR: 25   O2 Sat 99% on RA

Exam and Clinical Course
He appears uncomfortable and diaphoretic on physical exam. He has diminished sensation on the lateral aspect of the left leg from approximately the knee down. 8mg of IV morphine is given and an EKG is obtained. This is notable for sinus tachycardia with nonspecific ST changes, but no evidence of STEMI. A chest xray is notable for a widened mediastinum. A troponin is slightly elevated at 0.08. Given concern for aortic dissection, a CT angio of the chest, abdomen and pelvis is obtained. This reveals a Type A aortic dissection. The patient is started on an esmolol drip to improve BP and HR. Cardiac surgery is consulted and the patient is transferred to the OR for definitive care.

Critical Actions

  • Diagnose aortic dissection
  • Diagnose inferior STEMI on EKG
  • Activate Cardiothoracic Surgery for repair
  • Blood pressure and rate control with Esmolol or beta blockade


HPI 2
35 y/o male who presents with cough and malaise for one week. He reports a productive cough of green sputum as well as intermittent fevers. He does describe bilateral rib pain with coughing, and some mild associated dyspnea on exertion. He has a history of HIV; his last CD4 count several months ago was in the 700s. He reports compliance with Truvada.

Initial Vitals
T 101.1   HR 93   BP 120/80   RR 24   O2 Sat 92% on RA

Exam and Clinical Course
His exam is notable for diminished lung sounds in the right base. A chest xray reveals a right lower lobe infiltrate. Labs are sent and blood cultures are drawn. He is given supplemental oxygen for his hypoxia and is started on azithromycin, cefepime and vancomycin, as well as 1L of NS. His labs are notable for a WBC of 18, a normal BMP and a lactate of 2.5. Due to his HIV, the patient is admitted to the hospital for further care.

Critical Actions

  • Identify pneumonia
  • Identify relative immunocompetent status with HIV
  • Initiate appropriate antibiotics


HPI 3
The patient is a young male with no other past medical history who presents after a knee injury during a soccer game. The patient reports that someone ran into his leg while playing soccer, and he heard a pop.

Exam and Clinical Course
The patient is in extreme pain and received 50 mcg of fentanyl prehospitally. He is given additional analgesics in the ED. On exam, the patient has a very swollen and painful knee with translation of the tibia posteriorly, but is neurovascularly intact distally. An xray reveals a knee dislocation. The patient then undergoes a joint reduction under conscious sedation after informed consent. A CTA of the knee shows a popliteal artery injury. Vascular surgery is consulted and the patient is transferred to the OR for operative repair. 

Critical Actions

  • Identification of knee dislocation
  • Reduction with conscious sedation
  • Identification of popiteal artery Injury
  • Involvement of orthopedic/vascular surgery for operative fixation