Grand Rounds Recap 7.10.24

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Femoral nerve Block Case Review WITH dr. stolz

Why do we care about regional anesthesia, specifically femoral nerve blocks?

  • More efficacious than parenteral opioids alone

  • Safer than opioids

  • Decreased delirium

  • Patients have been shown to have improved functional outcomes at 30 days

  • Early pain control matters!

Indication - skeletally mature patients with a radiographically documented femur fracture (hip to knee)

Contraindications:

  • Patient refusal

  • Allergy to local anesthetic

  • Infection over site of planned injection

  • Obtunded/uncooperative patient

  • Crush injury

  • No available provider or space

Medication: 0.5% Ropivacaine (5mg/ml)

  • 30 milliliters is the recommended volume

  • 3 mg/kg is the maximum allowed dose

  • A 50 kg patient will be at max dose with recommended volume

Lateral Displacement of the Nerve

  • Sometimes, with hip fractures, the external rotator muscles are unopposed

  • This can lead to lateral displacement of the femoral nerve

  • Be aware of this if femoral nerve is easily located directly lateral to the femoral artery

Morbidity & Mortality - Community Practice WITH dr. hughes

Case #1: Cough / Case #2: Flu Exposure

  • Pneumonia Predictors

    • CURB-65

      • Equal sensitivity of mortality prediction

      • Easier to use

      • Higher specificity (74%)

      • Higher Sensitivity for ICU predictions

    • Pneumonia Severity Index (PSI)/PORT Score

      • Equal sensitivity of mortality prediction

      • Validated for COVID pneumonia

      • Better at identifying patients who can safely be discharged

  • Utilization of a clinical prediction rule in addition to clinical judgement for determining disposition of patients with community-acquired pneumonia (CAP) outperforms clinical judgement alone

  • Official guidelines by the American Thoracic Society and IDSA recommend use of the Pneumonia Severity Index Score over CURB-65 based on more robust evidence

  • Patients with comorbidities and/or risk factors (i.e. MRSA, Pseudomonas, IV antibiotics within 90 days) need more than single agent therapy as an outpatient.

Case #3: Shortness of Breath

  • In patients with chronic atrial fibrillation, rapid ventricular response (RVR) is their equivalent of sinus tachycardia. Look for the cause!

  • Amiodarone IV is treatment of choice for stable atrial fibrillation with RVR and decompensated heart failure.

  • Magnesium IV can be added to standard rate control agents to improve efficacy.

    • A meta-analysis of 6 randomized control trials (N=745 patients) compared IV magnesium + standard rate-control measures vs placebo + standard rate-control measures in patients with A-fib with RVR.

    • Rate control was achieved in 63% vs 40% of patients who received IV magnesium + standard rate-control measures vs placebo + standard rate-control measures.

    • Conversion to sinus rhythm occurred in 21% vs 14% in the group who received IV magnesium + standard rate-control

  • There may be a role for PO rate control in the ED but more research is needed

Case #4: Dog bite

  • Untreated dog bites rarely get infected (5%) as compared to cat bites (80%)

  • Prophylactic treatment should be administered to high risk patients and high risk injuries

    • Immunocompromised, asplenic, liver disease, edema, moderate to severe injuries, or periosteum or joint capsule penetration

  • Most common organisms: Streptococcus spp., Staphylococcus spp., and Pasteurella spp.

Case #5: Shortness of Breath/Cough

  • EKG’s should only be handed to direct supervisors & interpreted the same way every time, looking for more than just STEMIs

  • Dyspnea is an anginal equivalent

    • Nakanishi et al. Atheroslerosis (2013) found that dyspnea had OR 1.9 for obstructive CAD, OR 1.8 for proximal vessel occlusion.

  • Checklists improve efficiency and reduce errors

    • The Checklist Manifesto: How to Get Things Right by Atul Gawande

Case #6: Finger Pain & Swelling / Case #7: Foot Pain

  • While a VBG can add additional information, a low bicarb is sufficient for finding the acidosis of DKA

  • The gold standard for ketone measurement in DKA is serum ketones, measuring beta hydroxybutyrate directly

  • SGLT2i stimulate a small amount of ketosis at baseline, worsened by conditions that induce lipolysis

Case #8: Right Lower Extremity Pain

  • Aortoiliac occlusion (“Leriche Syndrome”) is a form of peripheral artery disease, often presenting to the ED once critical stenosis or embolic event(s) occur.

    • Triad:

      • Claudication

      • Impotence

      • Decreased peripheral pulses

  • The overall risk of spontaneous intracranial hemorrhage with mechanical thrombectomy is 4.4% for all patients, high for those on Vit K antagonists, but not DOACs

r2 clinical pathologic case WITH drs. boyer and benoit

  • Disseminated gonococcal infection is one of the most common causes of monomicrobial septic arthritis for sexually-active patients.

  • Patients will typically present with a constellation of asymmetric polyarthralgia, tenosynovitis, and dermatitis.

  • Polyarthralgia and tenosynovitis caused by gonococcal infection is believed to be caused by an inflammatory response to gonococcal cell walls, and not to microbial seeding of affected structures.

  • Treatment for disseminated gonococcal infection includes 7-14 days of an intravenous third generation cephalosporin. Depending on clinical severity, antibiotics for likely coinfection with chlamydia and other sexually-transmitted illnesses may be necessary.

visual diagnosis WITH dr. moulds

  • Ciliary flush is conjunctival infection focused around the limbus/iris (as opposed to conjunctivitis which tends to be limbal sparing) and is indicative of more severe underlying inflammation.

  • A hyphema is a collection of blood within the anterior chamber. Most resolve on their own with time but still require close ophthalmology follow-up. High-risk features include elevated IOP, a history of sickle cell anemia or coagulopathy, an "8-ball" appearance to the hyphema where the blood has darkened (indicative of poor oxygen concentration and at high risk of progressing to secondary angle closure glaucoma), and a hyphema that occupies >50% of the chamber. 

  • A hypopyon is a collection of pus/inflammatory cells within the anterior chamber and is a symptom of a severe underlying inflammatory disorder such as endophthalmitis, severe corneal ulceration, anterior uveitis, or infected ocular foreign body. 

  • "Munson's Sign", or a 'v'-shaped indentation of the lower lid during downward gaze, can be seen in acute corneal hydrops in patients with keratoconus. This can present as sudden onset painful unilateral vision loss due to rupture of Descemet's membrane. 

when time matters WITH dr. baxter

  • If a patient presents with symptoms that are both sudden and severe, think vascular.

    • However, not all vascular presentations are sudden, especially if there is stenosis that causes the patient to have some symptoms prior to complete occlusion

  • Aortic Dissection

    • In one study, thoracic aortic dissection requiring surgery carried a mortality rate of 21.3%.

    • In the subgroup with time between radiographic diagnosis and surgical intervention mortality was 66.7%.

    • Clinical tools to help guide when we should pursue this diagnosis:

      • Aortic Dissection Detection Risk Score (ADD-RS) plus D-dimer

        • ADvISED trial (2017)

        • ADD-RS of 0 or less than or equal to 1 and D-dimer <500 ng/ml

        • Missed 0.3% of dissections

  • Mesenteric Ischemia

    • No lab tests that have great sensitivity or specificity

    • Consider WBC, pH, lactate, d-dimer, although the consensus group guidelines state they are not conclusive

operational aspects of stroke care WITH drs. richards and demel

  • “Time is Brain”

    • Death occurs to approximately 2 million brain cells per minute of ischemic stroke

    • For every 15 minute increment reduced treatment time patients have:

  • Expanding the Treatment Window for Thrombolysis

    • In 1995 alteplase was FDA approved for use in treatment of acute ischemic stroke <3 hours from last known normal.

    • Initially, stroke treatment rates with alteplase were low. Throughout the early 2000s, only 1-2% of patients were being treated with alteplase.

    • Tenecteplase is the new thrombolytic on the block. Not yet FDA approved, but clinical trials have been promising.

  • Endovascular Therapy for Acute Ischemic Stroke

    • Early thrombectomy trials (IMS, MR Rescue, SYNTHESIS published in 2015) - all had neutral outcomes, criticized for poor patient selection and outdated technology

    • Successful thrombectomy trials (MR CLEAN, REVASCAT, ESCAPE) - a treatment effect favoring thrombectomy was seen across all clinical outcomes (NNT=4)

    • Two pivotal trials DIFFUSE 3 and DAWN extended the endovascular therapy time window from 6 hours to 16 and 24 hours.

    • Currently EVT for large core is being looked at and so far the outcomes seem to be favorable