Grand Rounds Recap 06.24.20
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MORBIDITY & MORTALITY CONFERENCE WITH DR. GOLDEN
Case 1: Occult (Afebrile) Bacteremia
Be aware of cognitive biases including diagnostic momentum, anchoring, and premature closure
Afebrile bacteremia accounts for ~15% of cases of bacteremia and is more common in (1) patients >85 years, (2) non-hematologic malignancies, such as S bovis in GI cancers, and (3) specific infections including SBP, necrotizing fasciitis, and pneumonia
As compared to febrile patients, afebrile bacteremia has a higher mortality rate at >40% compared to 17%
Case 2: MVCs - Mechanism & Observation Period
Injury severity scores correlate with mechanism of injury, with higher scores seen with lack of seatbelt use, posted speed limit >55 mph, and head-on injuries. While often asked, seat position has little correlation to injury severity
Blunt abdominal trauma was evident in 91% of cases within 60 minutes of presentation. While the mean observation time for injury was 74 minutes in one study, the range was wide with the longest observation period being 8.25 hours
Case 3: Pancreatic Pseudocyst Complications
Pseudocysts are a common complication from pancreatitis, which can then cause further complications via obstruction and/or mass effect. Complications include:
Pseudocyst infection
Pseudocyst rupture, ranging from asymptomatic to symptoms of upper GI bleed, peritonitis, and even hemorrhagic shock
Splenic infarct & splenic vein thrombosis
Splenic pseudocyst from a pancreatic tail pseudocyst that locally invades the spleen, albeit rare
Hemorrhage from pseudoaneurysm, created via direct pressure on a vessel or enzymes breaking down the arterial wall
Obstruction, including gastric outlet obstruction and biliary obstruction
Portal hypertension
Case 4: Incidental Findings
One third of general ED patients have incidental findings on imaging but less than 10% get reported, which can lead to late-stage disease processes that otherwise may have been preventable.
Be sure to review both the body and impression of radiologic readings and communicate these findings to patients. (At UCMC, you can use the dot phrase “.edradincidental” to standardize this communication in discharge instructions.)
Insurance status was not a factor when looking at populations less likely to follow up incidental findings.
Case 5: CT Negative Cervical Spinal Cord Lesion
In trauma patients, have a high index of suspicion for cervical injury in patients who are altered, complain of persistent pain, and/or have neurologic deficits
Prevalence of cervical spine injuries found on MRI:
43% - Upper extremity neurologic deficit
38% - Equivocal CT C-spine findings
34% - Presence of extra-cervical injuries
20% - Midline cervical tenderness
0% - Isolated lower extremity neurologic deficits
Case 6: Non-Convulsive Status Epilepticus (NCSE)
Convulsive status epilepticus is defined as seizure >5 minutes or recurrent seizure without return to baseline
NCSE is more common than likely anticipated (14-33% prevalence) with a higher mortality than convulsive status (18%, up to 27% in medical etiologies)
Consider getting cEEG for patients in the ED with:
Recurrent seizures
Prolonged postictal state
Heavy sedation
Acute supratentorial brain injury with AMS
Unexplained AMS without known brain injury
Abnormal routine EEG
Pharmacologic paralysis
Clinical paroxysmal activity concerning for seizure
R3 TAMING THE SRU WITH DR. SHAW
Massive hemoptysis has several definitions, the most relevant to our practice being life threatening bleeding that occludes the airway
The conducting airways can only hold 150 mL of blood, after which leads to asphyxiation from lack of gas exchange
Most common etiologies include: TB, malignancy, bronchiectasis (i.e. CF, ILD), vasculitides, and infectious processes (esp. aspergillus)
Localize:
CXR only identified the side of bleeding in 46% of cases
Bronchoscopy identified source of bleeding in 49% of cases
CTA Chest can localize bronchial bleeding in 70% of cases
The combination of CT and bronchoscopy increases localization to 84% of cases
Temporize:
Lie the patient in a lateral position with the bleeding side down, if known, to allow for the remaining lung to be aerated
Avoid intubation if possible, as the cough reflex is stronger and more effective at airway clearance than the ability to provide suction down an ETT
If intubation is unavoidable, use the largest ETT possible (8.0 or 8.5) and consider single lung ventilation (likely via bronchoscopy) if the bleeding side is known
Reverse coagulopathy with systemic blood products and TXA. Inhaled TXA can be considered, demonstrating decreased LOS, decreased bleeding volume, and decreased procedural needs in an RCT, though this was in non-life threatening bleeding
Proceduralize:
Call to IR early for possible bronchial artery embolization can be life saving
R4 CAPSTONE WITH DR. MURPHY-CREWS
NNT - ED Thoracotomies
Much of what we do in emergency medicine is defined by the number needed to treat (NNT) to decrease all-cause mortality
Thoracotomies have surprisingly low NNT for their indications, especially as compared to classic treatments for STEMIs such as ASA and PCI in STEMI (~50)
NNT 5: Thoracotomy for penetrating thoracic trauma (with signs of life during care)
NNT 6.4: Thoracotomy for penetrating extra-thoracic trauma (with signs of life during care)
NNT 37.5: Thoracotomy for blunt trauma (with signs of life during care)
Moral Injury
Burnout and physician suicide go hand-in-hand, with suicide rates twice as high for physicians as the general population
While there is evidence for mediation, etc. burnout is not a resilience issue. Attributing it to such is a form of victim shaming, as if the individual didn’t do enough to protect one’s self.
Burnout is about systemic issues within an inhospitable environment and would be more aptly referred to as “moral injury'“
