Grand Rounds Recap 05.27.20
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Morbidity and Mortality WITH Dr. Klaszky
COVID-19: Spectrum of Severity, Serologic Markers, and DIC
Spectrum of disease in COVID-19
Patients who are asymptomatic or have only mild respiratory symptoms generally can be managed at home with supportive care and self-quarantine.
“Happy hypoxemia” is a well-known phenomenon in which a well-appearing patient with no respiratory distress at rest may show an alarmingly low SpO2 with light exertion. It can be difficult to know which way this type of patient will go.
ARDS in COVID-19 is understood to be physiologically different than traditional ARDS and is an area of ongoing research.
At the extreme end of the spectrum, patients may develop multi-organ failure with a high mortality rate.
Labs can be helpful for risk stratification and prognostication (lab: avg value in non-survivors; avg value in survivors)
Lymphocyte count: 0.6; 1.1
CRP: 125; 40
LDH 520; 250
Ferritin 1400; 500
D-dimer 5.2; 0.6
DIC in COVID-19
Unlike traditionally understood DIC, in COVID-19 it appears to be tied to cytokine storm.
Increased circulating IL-6 leads to increased fibrinogen and hypercoagulability.
DIC is managed by individualized supportive care and treatment of the underlying disease. Unfortunately, at this point there is no cure for COVID-19.
Transfusion can be considered if platelets < 10 or fibrinogen < 100. However, transfusion can lead to worse coagulopathy.
TEG can help guide you by offering clues as to where on the DIC spectrum the patient falls. This disease does appear to be dominated by hypercoagulability.
What about anticoagulation?
DVT ppx is recommended for all patients.
What about empiric therapeutic heparin?
Heparin has been found to be ineffective empirically in DIC.
It’s also contraindicated when platelets are < 30.
Although some hospitals have adopted practices of anticoagulating all COVID patients above an arbitrary d-dimer cutoff, no evidence supports this without objective evidence of a large vessel clot.
NSTEMI Management
2014 AHA guidelines for management of NSTEMI recommend risk stratifying patients with a type I NSTEMI into two categories of management: an ischemia-guided strategy and an early invasive strategy.
The decision point rests on the patient’s TIMI score, which preceded the now more common HEART score that we use to risk stratify patients with suspected ACS.
Ischemia-guided strategy TIMI </= 2
Early invasive strategy TIMI > 2
Heparin/enoxaparin is recommended for all patients to prevent procedural complications.
This is a class I recommendation for patients in the early invasive cohort.
However, there actually is no good evidence for benefit for patients in the ischemia-guided group in the absence of PCI. While heparin and enoxaparin reduce rates of death and recurrent MI while the patient is anticoagulated, the benefit is lost when the medication is stopped, there is a rebound ischemia phenomenon, and there is increased risk of bleeding.
Sacral Ulcers and Sepsis
Sacral decubitus ulcers can be large, deep, and appear as though they would be an obvious source of infection in patients who present with sepsis.
However, studies looking at sacral ulcers have shown that they are actually rarely the cause of sepsis. Usually patients will be found to have an alternative source such as urosepsis, pneumonia or other SSTI.
Bacteremia appears to be overall a rare complication of sacral ulcers.
Ulcers involve the skin and thus spontaneously decompress, which acts to control the source and makes them unlikely to generate a significant inflammatory response.
Exceptions to this would be if there is necrotizing infection or if the ulcer has penetrated into the retroperitoneum.
Remember to completely undress and examine the patient's skin and extremities when searching for a source of their sepsis.
Traumatic Injuries Following CPR
Sternum and rib fractures are by far the most common injuries sustained after CPR.
Lung injuries are less prevalent, but still common.
Left pneumothorax and hemothorax are most common (19 and 16%), followed by the same injuries on the right (11 and 5%).
Tension PTX
Physical exam findings are very uncommon - breath sounds, tracheal deviation, and JVD are very uncommon
How does tension PTX present differently in the spontaneously breathing and the ventilated patient?
Spontaneously breathing patients develop tachycardia and hypoxia before hypotension.
Ventilated patients develop hypotension before hypoxia because positive pressure causes the PTX to rapidly expand and the higher FiO2 keeps SpO2 normal. Other clues in the ventilated patient include:
Increased peak pressures
Decreased tidal volume
Elevated plateau pressures
You can also perform lung ultrasound to assess for signs of PTX.
Have a lower threshold for decompression when you suspect PTX in ventilated patients.
Court-Ordered Exams and Procedures
Patients under arrest are protected from unreasonable search and seizure
They have the right to refuse medical examinations and performing invasive exams or procedures without consent can be viewed as assault even when the patient is in police custody.
Search warrants are judicial tools that facilitate police to perform search and seizure, but have no bearing on medical providers to perform exams or procedures without consent.
What about court ordered exams and procedures?
Although uncommon and heavy-handed, providers can be arrested and held in contempt of court for not following the order if specifically named in the order.
When faced with a “lose-lose” situation, protect and do what’s best for your patient, but also protect yourself by documenting well and engage your legal consultants.
RUSH Exam
The RUSH exam rapidly categorizes undifferentiated shock into a specific type.
The protocol developed about 16 years ago
1 - Evaluate the heart for effusion, LV dysfunction, and RV dilation.
2 - Assess the IVC diameter and collapsibility for volume status.
3 - Look at the RUQ for Morrison’s pouch and right pleural effusion.
4 - Complete the remainder of the E-FAST exam (LUQ, pelvis, and lung) for any abnormal findings.
5 - Finally, check the abdominal aorta for aneurysm, and add femoral and popliteal veins to assess for DVT.
How common are the different types of shock identified by the RUSH protocol?
Cardiogenic is the most common at 28%.
Hypovolemic, obstructive, and distributive are all similarly common with percentages in the mid teens.
Importantly, 22% of patients have multiple etiologies, or “mixed shock,” identified. This is important to realize and to be sure to complete the entire protocol even if in the first step you find a cardiogenic cause.
Organophosphate Poisoning
Organophosphate poisoning has other presentations besides the classic SLUDGE syndrome.
The “intermediate syndrome” occurs 1-4 days after exposure and is seen in about 25% of patients.
Characteristics include proximal muscle weakness and diaphragmatic weakness that may require mechanical ventilation.
Delayed neuropathy can also occurs weeks after exposure and is characterized by progressive, irreversible distal motor weakness and sensory loss. It can happen even in minor poisonings.
When faced with an unclear diagnosis, what should you do? We often rely on our fast-twitch type-1 thinking, but these situations are where methodical type-2 processes shine.
Take a step back
Look for incongruence
Try to identify your bias: anchoring, premature closure, etc
Recreate your Ddx if you’re still unsure
Decide if you need additional diagnostics/therapies
Phone a friend if you need to
R3 Small Groups - Envenomations WITH Drs. Hall, Modi, and Shaw
Marine envenomations
Stonefish
Bury themselves in the sand in shallow water and are easy to miss due to their camouflage.
Equipped with venomous spines that pierce tissues and cause intense pain at the wound site; sometimes nausea, vomiting, dyspnea, dizziness; rarely hypotension, bradycardia, pulmonary edema
Treatment
Hot water immersion - venom is heat-labile
Analgesia with IV opioids or a regional block
Consider abx ppx
Antivenom exists, but is derived from horse serum and there is risk for anaphylaxis and serum sickness. Should be reserved for patients whose pain is completely refractory to all other interventions or who are experiencing systemic symptoms.
Blue-ringed octopus
Found in tide pools and coral reefs in the indian and pacific oceans
One of the most venomous animals - carry enough venom to kill 26 people; envenomation occurs from a direct bite from the animal’s beak, not contact with the tentacles.
Produces tetrodotoxin - sodium channel blocker that produces descending flaccid paralysis with respiratory failure
Victims may die in the water, but if they make it to the ED, intubate early for any signs of paralysis
Sting rays
Most common cause of fish-related injury due to contact with the caudal barb.
Envenoming syndrome causes local myonecrosis and pain.
Venom is heat-labile, so like the stone fish it can be treated with hot water immersion.
Treat penetrating injuries appropriately and consider antibiotic prophylaxis.
Reptile envenomations
Coral snake envenomation
Elapids produce neurotoxins that cause greater systemic effects than crotalids, which are more likely to cause local effects
Patients may require intubation for diaphragmatic paralysis.
Water moccasin
Crotalid venom produces myonecrosis and coagulopathy.
Cro-Fab is a sheep-derived antivenin that can cause an anaphylactic reaction. If patient has an allergy to sheep then they can be pre-treated with benadryl, solumedrol, and subQ epi, and antivenin can also be diluted.
Gila monster
Venom produces excruciating pain and can lead to hemodynamic instability, but in a delayed onset of 6 or more hours.
Arthropod envenomations
Hymenoptera (bees and wasps)
Commonly cause anaphylactic reactions.
Use antihistamines and NSAIDs for symptom control.
Subcutaneous epinephrine is the mainstay of treatment.
Brown recluse spiders
Loxoscelism
Cytotoxic venom causes a necrotic wound spreading from the bite site.
Treatment centers on analgesia and wound care.
Dapsone is an anti-leukocyte aggregator that reduces necrosis, but is only used if the spider is directly identifiable because of side effects from the medication.
Pediatric patients are more prone to hemolysis.
Black Widow Spiders
Produce neurotoxic venom that prompts presynaptic release of acetylcholine. This produces muscle rigidity, pain, vomiting, and diaphoresis.
Mainstay of treatment is analgesia and benzos.
Antivenom used for adult patients who respond with severe hypertension and for any symptomatic pediatric patient.
Funnel web spiders
Native to Australia, most deadly spiders in the world.
Their neurotoxic venom produces a biphasic syndrome: cholinergic crisis followed by sympathomimetic toxidrome that leads to cardiovascular collapse and death.
Deaths are rare since the development of antivenin.
Bark scorpions
Neurotoxic venom similar to black widows, causes release of acetylcholine
Classic symptoms include bulbar dysfunction that may require definitive airway management.
The antivenin is reserved for adults with severe symptoms or pediatric patients with any symptoms at all.
Gun Violence and Public Health WITH Guest Lecturer Dr. Megan Ranney
Firearm statistics
Ownership varies by state, but we don’t have great data.
There are about 12 per 100k deaths from firearms per year.
40k death and 140k injuries in 2017
In context, deaths from example medical problems are as follows (x per 100k)
Diabetes 21.5
Influenza 14.3
Sepsis 10.6
Parkinson’s 8.4
The takeaway is that firearms have comparable death rates to other conditions like sepsis, and we spend a lot of time talking about how to improve sepsis care, but proportionally barely any time or resources are spent on gun violence and deaths.
Where we overlap with the problem
Patient care
Hospital and clinic safety
Security
Active shooter drills
Legal questions
Reportable injuries, but there are things that we can and can’t say to police
There are other aspects to be revealed later in the presentation
We are a part of the solution
We have a voice and a role to play
Overview
Who dies?
Males comprise 86% of deaths with spike in teens to 30s and then plateaus.
Women die mainly from intimate partner violence.
Non-hispanic whites have a biphasic distribution with peaks in the 20s and then later in the 50s-60s.
Non-hispanic blacks and hispanics have a disproportionate peak in teens-20s
Why do people die?
2017 saw 40k deaths
1.2% were “accidental:” child finds gun, shoots someone.
0.3% were in mass shootings.
38% homicide and legal intervention.
60% suicides (largely white men in rural areas).
Overall only about 10% of people with suicidal thoughts or actions die.
However, 90% of people who use a gun die.
The decision is often impulsive - access to a gun increases the death rate immensely.
Children and guns
2:1 ratio of injuries to deaths, much higher than other entities.
School shootings are the minority of incidents despite the disproportionate amount of media coverage.
Framework for action
Surveillance - what is the scope of the problem?
Identify risks and protective factors
Develop and evaluate interventions
For example, extrapolating from what we know about traffic deaths and effective interventions:
Education (seatbelts, car seats)
Enforcement and enactment (speed limits)
Engineering (air bags, crumple zones, graded roads)
Implement and scale up effective interventions
Comparison to other epidemics
Again, to extract from traffic death data
There has been a large decrease in proportionate deaths from traffic incidents despite a greater number of cas on the road
But traffic deaths are usually accidental and not politicized.
What about HIV/AIDS? Early in it’s history this was a highly politicized topic.
Education, destigmatization, harm reduction have all decreased transmission without banning sex.
Gun violence has been constant, if not slightly increasing.
Funding is lacking - in comparing mortality vs funding wiht other entities such as sepsis, gun violence has received only 1.6% of predicted funding.
This dates back to the 1996 Dickey amendment - prevented funding for the CDC to advocate for gun control. However, Rep. Dickey later regretted this legislation and recanted.
$25 million was granted this past year, but this is still far less than what we need.
Action in the ED
Currently our approach focuses on resuscitation of gun violence victims.
Gunshot wounds are the only type of traumatic injury with increasing case-fatality rates, suggesting that this approach is flawed.
Focus on resuscitation is therefore not the most effective strategy, we should focus on prevention (i.e. preventing escalation of risk factors)
How to prevent escalation
Identify who is at risk - suicidal patients; victims or domestic violence; victims of physical altercations (alcohol/SUD, elderly, young are also at-risk groups, although not as high as the first three mentioned).
Access to firearms among at-risk groups is high.
Screen, intervene, refer
Much like other behavioral risk factors such as smoking.
The message is about harm reduction, not judgement - language should focus on temporary nature of both the risk and relocation of the guns (e.g. “what do you think about storing your guns off-site until the situation improves?” not “give up, relinquish, dispose of, etc.”)
Examples of interventions shown to work: brief counseling + a trigger lock; ED and trauma service interventions to decrease fights and weapon carriage; and counseling of locking up guns for families of suicidal teens.
We don’t do this very well:
Studies have shown that only about 50% of suicidal patients had a lethal means assessment conducted in the ED prior to discharge.
The truth is that there are no laws that ban us to prevent us from having these conversations (despite urban myths to the contrary).
Action outside the ED
Ownership patterns vary place to place and views on ownership may vary, but collaboration is possible. For example:
Suicide prevention partnerships with gun ownership groups
HAVI - health alliance for violence intervention - links high-risk people with resources
Physicians’ questions about the law
What are the laws about gun ownership?
What must I report?
What practical advice can I give?
What can I ask and record?
What may I report?
How do I start the conversation?
Creation of community partnerships
Technology and social media outreach
Change the conversation
Take this out of the partisan political debate - prevention doesn’t have to be tied to bans.
What can be done today?
Create a standard of care
At minimum ask everyone who is suicidal and all victims of partner violence or street violence if they have access to firearms.
Develop guidance for your colleagues.
Collaborate across the political spectrum.
Be part of the movement towards research funding.
Share your stories.
Question and answer
How can we be more involved with policy?
Check out the RAND corporation for the evidence around particular interventions
Restricting ownership for domestic violence.
Extreme risk protection orders - people who are very high risk for harming themselves or others. This has to be enacted by a family member or law enforcement, not us. However, we can call a family member or the police when we deem someone at very high risk (much like calling collateral information in other situations).
“Assault rifle” bans actually have little evidence for benefit.
Create relationships with policy advocates
What are some Interventions for GSW victims discharged from the ED?
With consent, contact ISPN
Conversations about safe handling
Child and family services if children are involved
How do you address the association of gun violence with socioeconomic disparity in your short ED visit?
Probably not feasible in the limited face time you have with a patient in the ED.
Community partnerships are key.
Violence intervention programs.
Technology - remote intervention/follow up via technology may be acceptable for patients not open to face to face intervention in the ED.
Police-community partnerships are very effective when they are possible.
How do you train your residents and faculty?
Lectures, simulation, and shadowing
Social media advocacy
Share your stories and change the national conversation (obviously pay attention to HIPAA concerns)
Make sure that the data you present are based in fact as much as possible
Invite and share collaborations
Create or become part of a professional community. SAEM and ACEP have groups of like-minded individuals.
