Grand Rounds Recap 05.29.24
/April mortality & morbidity - quality improvement & patient safety -
r3 Taming the SRU - r1 diagnostics & therapeutics - r2 cPC
Mortality and Morbidity Conference: April cases WITH dr. finney
Manic behavior
Fluoroscopic lumbar spinal injections involve injecting contrast media and anesthetics/steroids into the epidural space with complications including infection, hematoma, and inadvertent injection into the vascular or intrathecal spaces
Intrathecal administration of gadolinium can cause encephalopathy, seizures, increased autonomic drive with CV and respiratory depression and requires astute diagnosis, as contrast deposition will resemble blood on non contrast head CT
Management focuses on supportive care, though steroids and lumbar drainage can be considered in consultation
Motorcycle Collision
Hypertrophic cardiomyopathy is a prevalent disease that can present with ranging including life-threatening arrhythmias, chest pain, syncope, HFpEF
Electrical storm typically occurs in patients with underlying structural heart disease exacerbated by a trigger
Management focuses on use of cardioversion, antiarrhythmics, consultation with EP and discussion of ICD placement
Quick Hit Cases A-D
SREAT typically presents as an encephalopathy and is characterized by high anti-thyroid peroxidase enzymes; treat with high dose steroids and rule out other causes of AMS
Large Benadryl overdose can lead to cardiovascular collapse due to widened QRS; treat with bicarbonate
Sialadenitis can present with facial swelling and can be diagnosed clinically or through radiographic examination by x-ray or CT; consider empiric antibiotics, sialagogues, supportive measures; admit for inability to tolerate PO or concern for airway compromise
Opioid overdose in dogs can be treated with Narcan; keep snout clamped, supply with extra doses and transfer to veterinarian
Airway Exchange Catheters
Catheter-directed airway exchange has complications including failure to pass ETT, esophageal intubation, barotrauma and upper airway injury
Utilizing video via VL or bronchoscopy, patient positioning and ETT tube maneuvers, as well as appropriate sedation and paralysis may help to overcome difficulty
A novel approach is a two-operator technique combining VL and fiberoptic intubation to visualize tube passage through cords and appropriate trajectory down trachea
Flu-like Symptoms
Cervical necrotizing fasciitis is a high morbidity and mortality condition resulting in rapid spread
Descending necrotizing mediastinitis is a feared complication involving progression inferiorly, which is associated with increased mortality
Requires high index of suspicion for diagnosis, as physical exam can be normal and symptoms nonspecific with subcutaneous air not always seen on imaging
Cardiac Arrest
Obstructive CAD remains prevalent in post-arrest patients who suffer from ventricular arrhythmias regardless of post-ROSC EKG findings
Despite this, data does not currently support early coronary cath for post-ROSC patients without STEMI on EKG
A STEMI EKG obtained immediately after ROSC has been associated with a higher false positive rate for clinically significant cardiac cath findings
r3 taming the sru WITH dr. chhabria
Why activate eCPR?
Overall goal is to improve long-term survival and neurological outcome
This is accomplished by maintaining end-organ perfusion while providing more time for diagnosing the pathology and reversing it
eCPR Logistics at UCMC
Ask HUC to activate eCPR
Switch to black Lucas device
Continue ACLS
Obtain IV access
Mix epi ggt
Obtain the following
VBG
Lactate
Type and screen
eCPR Inclusion Criteria at UCMC
Adult 16-65 years
If young appearing, weight > 50kg
Rhythm: VF/ pulseless VT
Persistent after 3 shocks or 10 minutes total of CPR
Witnessed arrest
Bystander or EMS CPR within 5 minutes of arrest
Never in asystole
quality improvement and patient safety: Mindset/self-talk WITH dr. David thompson
Self-talk
refers to the internal dialogue that you have with yourself
think about where your mind goes when you’re on shift
Self-talk is a continuum
The Victim
“they’re doing this to me”
have an external locus of control where circumstances are under control by external forces other than themselves
seek recognition for their victimhood
frequently ruminate about past victimizations
tend to be less likely to take action or accept responsibility
The Pessimist
“I hate this”
tend to have an inclination towards negativity
suspicious when things do go their way
beneficial as they acknowledge and plan for adversity
yet also tends to be associated with anxiety and hostility
The Optimist
“look on the bright side”
opposite of pessimism, where they see the positive side of things
advantageous due to sense of agency over circumstances
yet may fail to plan for potential threats
The Realist
“here we are”
acknowledges what is happening around them to make practical decisions
tend to focus on the present
advantageous as they accept limitations
The Competitor
“Let’s go!”
excited for opportunities for growth
OK with failure if you grow in the process
have an overall goal of becoming the best version of themselves
There are strategies and tactics to help improve your self-talk
First, ask yourself if you’re actually satisfied with your self
If not, try to make adjustments
Are you a victim? Take action, make a plan, and take responsibility for your role.
Are you a pessimist? Zoom out your perspective, which will help you practice mindfulness, gratitude.
Are you an optimist? You can transition to a realist by envisioning and practicing pitfalls.
Are you a realist? You can transition to a competitor by focusing education, seek mastery, and embrace failure.
r1 diagnostics and therapeutics: paracentesis/thoracentesis WITH dr. kotei
Performing a paracentesis in the ED:
Ascites refers to the pathologic buildup of fluid in the peritoneal cavity. It is most often caused by portal hypertension from cirrhosis, and its presence denotes the transition from compensated to decompensated cirrhosis
Patients with cirrhotic ascites have a 3-year mortality rate of approximately 50%, and refractory ascites carries a 1-year survival rate of less than 50%
Complications of ascites include spontaneous bacterial peritonitis, cellulitis, respiratory insufficiency via pleural effusions, reduced functional residual volume and atelectasis, abdominal wall hernias, hepato-renal syndrome, and chronic abdominal discomfort
Fluid can be removed for diagnostics and therapeutic purposes
Ultrasound guidance is the standard of care for identifying an appropriate fluid pocket for performance of a paracentesis.
Early identification and treatment of SBP is imperative. The most commons causative agents include Enterobacter (63%), pneumococcus (15%), enterococci (10%), and anaerobes (<1%)
A 3rd-generation cephalosporin is the standard treatment of SBP
Cefotaxime 2g IV q8hr or Ceftriaxone 1-2g IV q12-24hr is recommended
Performing a thoracentesis in the ED:
Many pleural effusions will be small and have minimal symptoms such as mild shortness of breath on exertion or pleuritic chest pain on the side of the effusion
Diagnosis can be made clinically from decreased lung sounds on auscultation or dullness to percussion, but the most common way to diagnose is via chest x-ray.
Lateral views are important for diagnosing small effusions, as AP views will usually only catch effusions with volumes > 175 mL.
Ultrasound in recent years has become a very helpful tool in diagnosing smaller effusions, and is noted to be almost 100% sensitive for effusions > 100 mL
While consensus guidelines have traditionally considered thrombocytopenia (platelets <50K) and coagulopathy (INR >1.5) as contraindications to thoracentesis, this has not been supported by recent studies
Several prospective studies have not found an association between laboratory parameters (including INR >1.5 or PLT <50K) and bleeding risk, and routine correction of thrombocytopenia or coagulopathy prior to the procedure did not seem to mitigate bleeding risk
r2 clinical pathologic case WITH dr. hajdu & baez
Case involves a previously-healthy 26 year-old male presenting with progressive, unilateral, painless vision loss in his R eye.
Test of choice? MRI brain/orbits with and without contrast
Diagnosis? optic neuritis due to underlying MS
Optic neuritis is an acute inflammatory demyelinating injury to the optic nerve
It can be a clinically isolated syndrome or due to other types of demyelinating disease such as multiple sclerosis, neuromyelitis optica spectrum disorder or myelin oligodendrocyte glycoprotein (MOG) antibody disorder
The disease course is usually characterized by eye pain that is typically worse eye movements, with subsequent loss of vision that progresses over days to weeks
Though central scotoma is the classic description of vision loss, loss of red vision saturation is also very common
Other presentations may include diffuse vision loss, hemianopic defects, arcuate or altitudinal vision loss, and photopsias
MRI of the head and orbits with and without contrast is gold standard to diagnosing optic neuritis
Though optic neuritis will often resolve on it's own, treatment with 3-days of intravenous methylprednisolone followed by an oral steroid taper is recommended because it may hasten resolution of symptoms and prevent recurrence
Optic neuritis is the presenting feature in approximately 15-20% of patients eventually diagnosed with multiple sclerosis
