Grand Rounds Recap 7.11.18
/Leadership Curriculum with Dr. Stettler
We all have leadership qualities within us, but it is not always easy to find. It is much harder to focus. One way we try to develop this within our department is through our various academies. They meet three to four times per year to focus on leadership traits and challenges within the specific focus area (e.g. operations, education). The academies involve large group sessions (e.g. Grand Rounds lectures), small group sessions, and individual mentoring. To complete an academy, one can complete a mentored project which is a one-on-one, time and labor-intensive project that involves self-exploration and service.
Attitudes of an effective leader:
- Effective communicator
- Collaborative
- Trustworthy
- Effective decision making
- Problem-solver
We then broke into small groups to discuss several areas within our department and residency that have been identified as needing improvement. The goal was to brainstorm ways to improve upon these issues using the qualities and attitudes of leader. Common themes emerged from the solutions, even though the problems were quite variable. Communication was key in nearly every situation, and most proposed solutions involved collaboration with people outside our department. This exercise helped to highlight the practical application of leadership and how honing and developing the qualities of a leader can help facilitate change.
Concussions with Dr. Knight
In the United States, traumatic brain injury (TBI) results in 275,000 hospitalizations and 52,000 deaths annually (1). Nearly 2 million emergency department (ED) visits per year are related to TBI. TBIs are more common in males although females may experience a longer duration and severity of symptoms. TBI is most common in teens and young adults, with athletes being the highest risk population. Falls are the most common cause of TBI followed by motor vehicle accidents.
While sports concussions are often witnessed and recorded, ED patients are often non-athletes with vague complaints which may be concussion-related. It is a difficult diagnosis to make because concussion is difficult to define. It is an image-negative diagnosis with often minimal symptoms at the time of the initial injury.
Concussion is often thought of as a mild TBI, but it frequently is not mild. Injury occurs when an inertial force exceeds the brain’s tolerance. The maximal force amplitude is commonly seen on areas such as the rostral brainstem, corpus callosum, and the gray-white junction of the cortex (2). Why do exertional stresses worsen the symptoms? Metabolic demand increases with exertion, resulting in ATP depletion. This yields further cellular injury with exercise.
In the ED, the diagnosis of TBI is made based on the history. Patients may describe complaints such as headache, dizziness, nausea, concentration difficulties after some sort of preceding trauma to the brain.
The physical exam is often unremarkable, although there are some exam tests that can be useful for diagnosis. For example, the Balance Error Scoring System (BESS) can be used. This can be performed at the bedside in the ED. A patient stands with their eyes closed and feet together for 20 seconds. They then should be asked to stand on their non-dominant foot and lift the other foot up. Finally, they are asked to stand heel-to-toe with the non-dominant foot in back, completing all of these tasks with their eyes closed for 20 seconds each test. The patient is scored based on the number of errors during these tests, and the final score helps to identify patients with concussion.
Vestibular ocular motor screening (VOMS) uses ocular signs to predict concussion. Providers are asked to evaluate smooth pursuit, presence of saccades, convergence, and the vestibular-ocular reflex. The presence of abnormal findings or development of symptoms during this test is indicative of likely concussion.
Following a diagnosis of concussion in the ED, providers should provide return to activity/work instructions. It is not necessary to mandate isolating the patient in a dark room as was previously taught. Generally, minimal physical activity is recommended for the first 24-48 hours with a gradual increase in activity following this. Recovery is guided by the presence of symptoms. In general, 85-90% of patients will have recovery in 7-10 days.
Sleep disturbances are a common complaint following TBI and may lead to return visits to the ED. The presence of sleep disturbance is actually very sensitive for diagnosing concussions. Follow-up is crucial when discharging patients with concussions. In our ED, many patients undergo cognitive evaluation by occupational therapy. The helps to identify patients who warrant further evaluation and treatment.
Long term consequences of brain injury include inner ear injury (dizziness), endocrine dysfunction (depression, suicidality), and cortical spreading depressions (headaches, seizures, stroke). Nonetheless, the evidence regarding this is limited and conflicting. Some sources suggest a possible genetic predilection for this. Other researchers suggest that adjunct therapies such as narcotics may contribute to long term symptoms from concussions. In addition, patients with repetitive sub-concussive injuries are more likely to develop symptoms long term. These may not be evident until 30 years after injury, and it is commonly seen in athletes who develop memory problems and Alzheimer’s down the line. No difference in suicide has been identified, however.
The treatment for concussions is symptomatic. Providers can recommend Tylenol and Ibuprofen for pain. Melatonin can be used for sleep disturbances. Narcotics should be avoided, and follow-up should be arranged from the ED. 10-20% of all concussions will develop persistent concussive symptoms and should be referred to our mild TBI clinic. Again, return to activity is based on the presence of symptoms. All athletes should be required to have physician clearance before returning to sports.
References
1. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. Traumatic brain injury in the United States. 2010, https://www.cdc.gov/traumaticbraininjury/pdf/blue_book.pdf. Accessed 12 July 2018.
2. McAllister T. Neurobiological consequences of traumatic brain injury. Dialogues in Clinical Neuroscience, 2011; 13(3):287-300.
Spinal Cord Emergencies with Dr. Knight
Spinal cord injuries result from a variety of mechanisms. Motor vehicle accidents are the most common cause (33% of cases) followed by falls (22%) and violence (15%) (1). 50% of cases are isolated spinal cord injuries while the other half of cases are patients with other injuries as well. Most commonly, spinal cord injuries result in incomplete tetraplegia (31%). Adolescents have the highest percentage of spinal cord injuries followed by elderly patients.
When evaluating endangered spines in the ED, consider using the high arm technique when rolling a patient to evaluate the back. This is done by flexing one knee up and extending the ipsilateral arm out. This can be used to help provide more stability during the roll.
Syndromes of Spinal Cord Injuries:
- Central cord syndrome: Commonly due to a hyperextension injury, frequently in an elderly patient with cervical stenosis. It results in loss of cervical cord function with relative sparing of the lower extremities.
- Anterior cord syndrome: This results in loss of pain, temperature, and motor function below the level of injury with preservation of light touch and proprioception.
- Brown-sequard syndrome: This is often a result of a penetrating injury to the spine. It results in unilateral hemiplegia and loss of ipsilateral light touch with contralateral loss of pain and temperature.
In patients with spinal cord injuries above C5, be very concerned for their airway. Consider early intubation. Similarly, in any patient with a spinal cord injury who complains of dyspnea or has any increased work of breathing, consider airway intervention. Be very cautious about sending these patients out of the emergency department (e.g. MRI) because they can decompensate. End-tidal can be used to detect changes in ventilation that may help prompt a provider to intervene on a patient’s airway in the setting of spinal cord injury.
There are several uncontrolled studies suggesting a benefit of pushing the mean arterial pressure above 85-90 in patients with spinal cord injury. The thought is that this increases the cord perfusion pressure and may benefit healing. Ultimately, this should be done in consultation with a specialist and should not be the priority in the ED.
Patients with a spinal cord injury above T4 are at high likelihood of developing neurogenic shock because of disruption to the sympathetic chain. This results in unopposed vagal tone which is why these patients commonly have hypotension and relative bradycardia. This should be treated with fluids and vasopressors. This contrasts with spinal shock which is loss of spinal reflexes below level of a spinal cord injury.
The use of steroids remains controversial. There is one study that showed high dose steroids helped patients recover one sensory level following spinal cord injury. In most patients though, the risk of this seems to outweigh benefits, and this application is limited to a very specific patient population (otherwise healthy young patients mainly). The use of high dose steroids for spinal cord injury should be done in conjunction with the consulting service. In the same way, there is limited evidence for hypothermia as well. It is thought to minimize swelling and is often done for patients with incomplete injuries.
References
1. National Spinal Cord Injury Statistical Center. 2014 Annual Report Complete Public Version. https://www.nscisc.uab.edu/PublicDocuments/reports/pdf/2014%20NSCISC%20Annual%20Statistical%20Report%20Complete%20Public%20Version.pdf. Accessed 12 July 2018.
Discharge, Transfer, Admit: ENT and Ophthalmology Cases with Dr. LaFollette
Case 1: 22-year-old female complaining of voice changes. She was recently started on amoxicillin for pharyngitis. She has asymmetric throat swelling on exam but is handling her secretions well. Bedside ultrasound reveals a fluid collection in left peritonsillar region.
Discussion: Ultrasound improves guidance and effectiveness of peritonsillar abscess (PTA) drainage although is not mandated for detection or treatment. Providers can try localizing the maximal amount of pus with ultrasound first and measure the depth in order to cut the needle guard. If the first attempt does not work, try dynamic ultrasound imaging during the procedure to help guide aspiration.
The data shows that needle aspiration of PTA results in a slight increase in the need for repeat aspiration. However, patients report less pain in general. If a large amount of pus is evacuated, the patient may benefit from an incision in order to help facilitate continued drainage from the wound.
Local anesthesia is crucial for PTA drainage. We recommend nebulized lidocaine with or without localized injection of lidocaine to the area. Give the patient the suction during the procedure. It puts them to work and can help with anxiety.
The patient still has voice changes after 5 cc of pus was removed. Now what? If she is able to take PO, can consider discharge if the patient is reliable. Would give intramuscular steroids in the ED and prescribe liquid medications at discharge. At seven days, 50% of these patients still had some component of trismus. Therefore, we likely will not see dramatic improvement quickly, so admission or observation will not necessarily be helpful for these patients.
Case 2: 65-year-old male on warfarin for mitral valve replacement presents with bleeding from an intra-oral biopsy site. He had a biopsy of a buccal-space lesion and began bleeding from it on the morning of presentation. It now has a clot on it. His INR is 2.9. Hgb 12.6. Vitals stable. While in ED, it starts bleeding heavily.
Discussion: Consider using topical TXA (1cc of standard TXA mixed with 9ccs of saline and mix it up). Then soak some gauze in it and hold direct pressure over the area of bleeding. There is also a TXA mouthwash that can be used. Lidocaine with epinephrine injected around the area may help. Can consider silver nitrate, but be careful on mucosal surfaces. Sutures would probably not be helpful.
Discharge is not unreasonable if the patient has a very tight follow-up plan. Instruct patient on how to stop the bleeding themselves if sending home because these commonly re-bleed. It requires a reliable patient though. For patients with more challenging social situations, transfer would be advised if the patient has ongoing bleeding. Consultants have other resources available, e.g. topical thrombin.
Case 3: 55-year-old male with a conjunctival laceration while itching his eye. Normal visual acuity. Fluorescein with triangular shaped defect in conjunctiva. Negative Seidel’s sign.
Discussion: Evaluate for scleral injury by moving conjunctiva around. After topical anesthesia, can evaluate conjunctiva by moving it with a q-tip. Generally, conjunctival lacerations do not require repair. These patients can be discharged with topical antibiotics and follow-up.
Case 4: 45-year-old male was cleaning a toilet bowl when he splashed Clorox cleaner (pH 11-12.5) in his eye. The initial pH of the eye was 10.
Discussion: Irrigate the eye with saline until the pH normalizes. This can be done using the morgan lens or nasal cannula connected to fluids.
On repeat exam for the above patient, his pH is 7. Visual acuity 20/20. Fluorescein exam with diffuse, grainy uptake, and he has unilateral photophobia. Would likely still discharge at this point but would recommend involving ophthalmology (via phone) to arrange for follow-up.
It is important to find out what the patient got in the eye. Powders can leave retained foreign bodies which can lead to delayed changes in the pH. Therefore, consider rechecking the pH 15-30 minutes after a normal pH is obtained in cases of powder exposure to the eye. Patients with opacification of the cornea or limbal ischemia should be transferred to a center with ophthalmology because they may need corneal transplant. Scarring down of the cornea can lead to increased intraocular pressures and need for corneal transplant. If visual acuity is in jeopardy, the patient will likely need to be transferred.
Case 5: 32-year-old male who was punched in the face. There is a mucosal laceration overlying a fracture at the angle of the mandible. Tolerating PO.
Discussion: Would speak with a consultant regarding follow-up for mandibular fractures because they often need surgical repair. Most do not need emergent repair, so discharge is reasonable.
Case 6: 54-year-old female with a history of diabetes who presents with ear pain. She was diagnosed with otitis externa at her primary care provider’s office and has been on ofloxacin for three days. There is a palpable post-auricular lymph node, otherwise no mastoid tenderness or bogginess. She reports hearing loss in the affected ear, but cranial nerves are otherwise intact. Fingerstick is 400.
Discussion: It is important to obtain imaging in these patients to evaluate for mastoiditis from her malignant otitis externa. This is done with a T-bone CT with contrast. This patient will require admission for intravenous antibiotics. 20% of these patients need debridement, and there is a 5% mortality rate from malignant otitis (1) 15% of patients will have cranial nerve abnormalities. CT is adequate for diagnosis.
References
