Grand Rounds Recap 6.23.21
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Morbidity and Mortality Conference with Dr. Hughes
Case 1 + 2
Posterior strokes represent approximately 20-25% of all ischemic strokes. Unfortunately, many evaluations for stroke, including the Cincinnati stroke scale and even the NIH Stroke scale, favor detection of anterior circulation strokes and frequently miss posterior strokes.
Dizziness and Vertigo are the most common symptoms of posterior strokes and occur in about 35% of all posterior strokes. However, posterior strokes may present with a variety of signs and symptoms. Acute infarct of the cerebellum can result in intractable nausea which may make performing a thorough neurological exam challenging and further obscure the diagnosis
Additional clinical pictures of posterior strokes include Locked in syndrome, ipsilateral weakness with gaze palsies, vertigo, and gait ataxia
In patients with intractable nausea and vomiting without obvious etiology on bloodwork (acidemia, uremia, toxins) and abdominal imaging (obstruction, surgical abdomen), always consider an intracranial pathology such as infarcts to the cerebellum or vestibular system.
Case 3
Spinal infections result from hematogenous spread, direct external inoculation (surgery), or dissemination from continuous tissue (like from a retropharyngeal abscess). Patients with suspicion for spinal infections should be evaluated with blood cultures, inflammatory markers (ESR and CRP) and MRI imaging.
Multiple Pulmonary nodules should trigger concern for etiologies like septic pulmonary emboli, kaposi sarcoma, miliary TB, lung abscess, coccidiomycosis, histoplasmosis, amiodarone pulmonary toxicity, silicosis, sarcoidosis, granulomatosis with polyangiitis
Case 4
Orthopedic reductions and arthrocentesis of prosthetic joints are within the scope of ED providers; however, it is appropriate to discuss these with orthopedics prior to performing the procedure. The risk of introducing infection during any sterile arthrocentesis is about 1:3500. If you have a patient with high concern for a septic prosthetic joint and an orthopedic surgeon is not reachable in a timely fashion, ED providers should proceed with arthrocentesis to evaluate for septic joint - an exception to this may be a newly prosthetic joint within several weeks of surgery that can be evaluated by orthopedics within 24 hours.
Note that a PJI (Prosthetic Joint Infection) panel has a sensitivity of 95% and a specificity of 97% for prosthetic joint infection via the Alpha Defense Eliza component of the test. However, at our (and many other) institutions this test is a send-out lab and does not come back in real time, therefore you need to additionally send the standard cell count, gram stain, and culture to assist with appropriate disposition and treatment in the ED.
Case 5
Contrast induced AKI - AKI occurring within 48 hours of IV contrast media administration after exclusion of other nephrotoxic factors
Recent literature co-authored by the American College of Radiology and the National Kidney Foundation (PMID: 31961246), reports that the risk of AKI in patients with baseline eGFR of <30mL/min/1.73m2 is 0-17%, and the risk of AKI is less than 2% in patients with higher eGFR. This data suggests that contrast induced AKI is overstated and should not be withheld for life-threatening diagnosis regardless of kidney function
Acute vs Chronic Right heart failure on bedside echo
Bedside echo in the ED can be used to distinguish between acute right heart failure and chronic right heart failure.
Right Ventricle Hypertrophy - Hypertrophy occurs overtime in response to chronic elevations in afterload and is not typically seen in acute right heart failure. In a parasternal long or subxiphoid view, measure the right ventricular free wall from inside to outside in end-diastole. A measurement greater than > 5 mm is consistent with hypertrophy and suggests a chronic etiology
Pulmonary Artery Systolic Pressure (PASP) - A pulmonary artery systolic pressure less than 35 mmHg is considered normal, 40-60 mm Hg can be suggestive of pulmonary hypertension, and > 60 mmHg is considered highly suggestive of long-standing pulmonary hypertension. To measure PASP, obtain an apical 4 chamber view with good visualization of the tricuspid valve. Place color doppler over the tricuspid valve and the right atrium, looking for tricuspid regurgitation (TR). Use continuous wave (CW) doppler and align it with the regurgitant jet of the tricuspid valve. Press the CW button again to select spectral display in which your x-axis is time, and your y-axis is velocity. Measure the maximum TR velocity (a parabolic appearing tracing with negative inflection along the y-axis indicating flow away from the probe). Typically, the machine will use a modified Bernouli equation to calculate the pressure gradient across the tricuspid valve. The right ventricular systolic pressure (RVSP) can then be obtained by adding the right atrial pressure to the pressure gradient that was calculated. Right atrial pressure is equivalent to central venous pressure which can be estimated by evaluating respiratory variation of the inferior vena cava. Assuming there is no significant pulmonary valve stenosis, the PASP equals the RVSP.
Case 6 + 7
Unless a lung abscess or empyema is present , patients with suspected aspiration pneumonia should not receive empiric anaerobic coverage.
In a study of 95 patients over the age of 65 yo with severe aspiration pneumonia, anaerobic bacteria were isolated in only 16% of patients. Additionally, in those with anaerobic isolates, patients had symptom resolution within 72 hours of presentation even when initial antibiotic choice did not provide anaerobic coverage.
Can consider additionally, anaerobic coverage if the patient is immunocompromised or has received antibiotics within the last 30 days.
When choosing antibiotics for pulmonary anaerobic coverage consider Augmentin, Unasyn, or clindamycin instead of metronidazole.
Case 8
85% of Cefepime is cleared renally. If you are on dialysis, the loading dose is 1 gram.
Antibiotic stewardship in the ED is important and antibiotic choice in the ED can often create therapeutic momentum for a patient’s hospital course.
Use previous culture sensitivities and consider the suspected source before empirically covering with Vancomycin/Cefepime/Flagyl or Vancomycin/Zosyn. Many patients may be appropriately covered with rocephin +/- vancomycin or other alternative antibiotics.
Case 9
COPD exacerbations should always be evaluated with a VBG and a CXR.
In a systematic review of the utility of CXR in COPD exacerbations, a pleural effusion was found 12-27% of the time, pulmonary edema 8-16% of the time, and a new pulmonary in 15-54% of the time.
Case 10
NEDOCS scores can assist with estimating ED crowding. ED crowding strains resources and can be a detriment to patient safety by increasing the rate of left without being seen and return admits in 72 hours.
Why does ED crowding exist → studies have shown that decreased access to primary care in the US puts a large portion of the burden on the ED. Additional studies have demonstrated that overall patient complexity has increased leading to longer duration of stay for patients in general which leads to ED boarding.
As ED docs we can increase throughput and minimize ED overcrowding by minimizing unnecessary testing, assisting with safe arrangement of outpatient follow up, and minimizing ‘soft’ or unnecessary consults which add to ED time even in the most prompt consults.
R3 Taming the SRU with Dr. Wolochatiuk
The Case: Middle aged patient with history of GSWs 1.5 months ago with multiple surgical intra-abdominal injuries and surgical intracranial injuries s/p craniotomy presents with an episode of syncope. Since his penetrating injuries, he has been at home and doing well but today had an episode of syncope when ambulating from the bathroom. He presented tachycardic and dyspneic with clear lungs. He progressed to develop hypotension and increasing hypoxia requiring a non-rebreather. The patient was planned for a CTPA but rapidly became too unstable to transport and lay flat for a CT. During this decompensation a bedside echo was performed which demonstrated a dilated right ventricle with a positive D sign, and a clot in the right atrium in transit through the tricuspid valve. The patient subsequently lost pulses and went into PEA arrest. The patient underwent crash intubation while being coded and ROSC was achieved, however he soon decompensated back into PEA arrest. During the second cardiac arrest TPA was administered, and ROSC was achieved again and maintained.
What is the evidence for thrombolytic therapy in cardiac arrest secondary to massive PE?
One study demonstrated that up to 32% of PEA cardiac arrests are due to pulmonary embolism or coronary artery occlusion
PEAPETT Trial
A single center trial published in 2016 which evaluated the use of tPA during cardiac arrest in 23 patients who had PEA cardiac arrest due to confirmed PE.
All patients were given 50mg of IV tPA, administered over 1 minute. ROSC was achieved in 22/23 patients, and 20/23 patients were still alive at 2-year follow up. Additionally, there was no major or minor bleeding reported in any of the patients during hospitalization. Furthermore, patients were noted to have reduced PA pressures at 48 hours.
Recommendations for Fibrinolytics in Cardiac Arrest
AHA: Fibrinolysis is reasonable for patients with massive acute PE and acceptable risk of bleeding complications (Class 11a, Level B)
ACCP: Thrombolytic therapy is recommended for patients with acute PE who decompensate after starting anticoagulation (Grade 2C)
EHA: Thrombolytic therapy is the first-line treatment in patients with high-risk PE with cardiogenic shock or hypotension, with very few absolute contraindications
ACEP: Administer thrombolytic therapy in unstable patients with confirmed PE for whom the benefits outweigh the risks of life-threatening bleeding (Level B)
Case Follow up: The patient eventually got a CT and was found to have bilateral PEs in addition to a large saddle PE. He underwent targeted temperature management and was admitted to the MICU. Several days later, the patient was awake and following commands and was discharged home.
R4 Capstone with Dr. Skrobut
As a teenager Dr. Skrobut experienced his first significant unexpected loss after a close teenaged friend died in a motor vehicle accident. Initially intent on pursuing a career in dentistry, coping with this loss lead him to switch paths and pursue emergency medicine to ‘give patients back the years that (his) friend had lost’.
As a senior emergency medicine resident, Dr. Skrobut received a tone out on aircare for a patient with the same demographics and mechanism of his childhood friend, a teenager in a single car MVC vs tree after missing their turn at a high speed. In that moment many thoughts, feelings, and fears arise at the similarity. As emergency providers we experience loss frequently, sometimes on a daily basis and at times we feel this more acutely than others. These patients need us to be there for them in their time of need and so, in that moment, you take a breath, calm yourself, and focus.
Countertransference - subconscious pattern recognition that evokes emotions and reactions towards a patient. This can be positive or negative depending on the provider's previous life experiences. Countertransference can be difficult to recognize within ourselves and even more difficult to correct; it requires conscious effort to do so. Do your best to walk into every patient encounter with a clean slate and a clear mind.
After hard cases, always debrief with your team. Just because we see loss frequently does not mean it isn’t hard and doesn’t take a toll on us. We are all human and went into medicine because we care about others. After difficult cases, make sure to check in with all members of the team, especially junior learners who might not have experienced a difficult loss yet.
You Don’t Know What You Don’t Know Part II with Dr. Paulsen
Supervision
Communicate expectations upfront - make sure your supervisee knows what they need to share with you promptly vs what things can be done independently
Trust but verify - trust those you supervise but verify the data they present, the extent of this may look different with the same individual as your relationship and experience together grows
Be collaborative- you don’t need to repeat everything your supervisee has already done, but as mentioned some things you need to verify. The degree of redundancy will likely reflect the level of the supervisee, particularly if they are still a junior learner such as an early M3.
Share your knowledge - both you and your supervisee have different bodies of knowledge that can be shared in both directions allowing for both of you to grow from the interaction.
Close the loop - if you change the plan of your supervisee or learner, remember to close the loop to prevent confusion, delays, or incomplete plans.
Professional Development
Stay current on literature in your field and relevant adjacent fields
Having a younger mentor (yes mentor not mentee) can help keep you in touch with changing attitudes, practices, and social climates relevant to your patients and your career.
Stay up on your procedural skills, even if that means scheduling time on models or in the cadaver lab
QI yourself - review your cases and if possible the departments cases so that you continually learn from your experience and your colleagues
Set and reassess 1-3-5 year goals on a regular basis
Mentorship - Get a mentor and be a mentor.
Burnout
Burnout is multidimensional and includes emotional exhaustion, depersonalization, and loss of a sense of personal accomplishment
Things to consider to mitigate burnout
What can I do differently at work ?
What can I do differently at home ?
Where can I find support ?
What if the changes above are not enough, what is my planned course change if needed ?
