Grand Rounds Recap 7.24.24
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morbidity and mortality WITH dr. moulds
Syncope
Complete heart block is a rare but important cause of syncope
P waves outnumbering QRS complexes should clue to you to high grade heart block
Triage EKGs are often obtained to screen for cardiac ischemia, but bradycardia or tachycardia require a closer look to evaluate for underlying arrhythmias
Checklists can aid in EKG interpretation of rare diagnoses
ED physicians are frequently interrupted on shift but should employ strategies to minimize disruptions to patient care
Mastitis
Mastitis is common in lactating women, caused by pathogen introduction from nipple trauma + milk stasis
Mastitis is a rare cause of septic shock
MRSA and MSSA are the most common pathogens implicated in mastitis
Lactate is a complicated biomarker in sepsis, but levels >4 can predict need for ICU admission
Failure to clear lactate in the first 24h is associated with increased mortality, vasopressor use, and length of stay
Bacteremia
CLABSI and CRBSI are a source of high mortality and burden on the health care system
Risk factors for CLABSI/CRBSI include TPN, chemotherapy, multi-lumen lines, immunocompromised state, and increased catheter duration
Bacteremia does not always equal sepsis
The Shapiro Rule can be used to rule out bacteremia in ED patients
The decision to discharge patients from the ED pending blood cultures is nuanced but can be safe
New HIV Diagnosis
Cytopenias are common in HIV but pancytopenia is rare
The degree of pancytopenia correlates with the CD4+ count
The differential diagnosis of new-onset pancytopenia in adults includes hematologic neoplasm, megaloblastic anemia, drug-induced, and viral, including HIV
Respiratory Distress in ALS
Intubation is high-risk in the setting of ALS
There is no perfect paralytic agent for these patients: they are very sensitive to non-depolarizing NMB, but they are also high-risk for hyperkalemia from depolarizing NMB
Extubation is highly unlikely in patients with ALS, consider pre-existing wishes and code status
Pyelonephritis
WBC >21, chills, urine nitrites, AST >19, and recent urologic instrumentation are all independent predictors of bacteremia in pyelonephritis
Mortality is low in uncomplicated pyelonephritis regardless of the presence of bacteremia, but mortality increases significantly in patients with complicated pyelonephritis + bacteremia
IDSA recommends fluoroquinolones or Bactrim as first-line therapies, but resistance patterns are making these less effective
2nd or 3rd generation cephalosporins are appropriate alternatives, 1st generations are poorly studied
Variceal Hemorrhage
Acute variceal hemorrhage is a highly morbid condition
Medical management of variceal hemorrhage includes blood product resuscitation, antibiotics, and splanchnic vasoconstrictors
Balloon tamponade can be achieved using a Minnesota tube
It is important to know your resources and equipment in high-acuity, low-opportunity situations
faculty case follow up WITH dr. lafollette
Case #1: Don’t trust the foot
Necrotizing Soft Tissue Infections
Type I - polymicrobial
Type II - mono microbial (typically GAS)
doesn’t contain gas, happens in young healthy people
can be triggered by trauma, but not from direct seeding
typically caused by strep
Type III - clostridial
Type IV - fungal
Case #2: MVC 1 Week Prior
Traumatic CSF Hypotension
Rare cause of post-traumatic headache
High association with operative fractures
Trust your physical exam if there is severe positional headaches
r4 capstone WITH dr. brower
Saying the word “quiet” does not make the ED busier or increase acuity. However, believers in this superstition will perceive crazier shifts if the word is uttered so you probably shouldn’t say it, or use cautiously
Full moons have no impact on ED, EMS, or HEMS volumes or acuity.
Nice people are not more likely to get cancer.
Barometric pressure, humidity, and temperature changes may influence stroke and fall incidence (especially in elderly patients with cardiovascular risk factors).
Black clouds don’t exist (but I still sort of think they do).
Pregnant women with GERD are more likely to give birth to babies with more hair.
high risk low prevalence diseases in children WITH dr. chang
Myocarditis
Inflammatory process of the myocardium that effects 1-2 per 100,000 children per year.
Most common cause is viral (coxsackie group B, adenovirus, parvo, EBV, CMV, HHV-6). Other causes include toxic and autoimmune.
Most children have viral prodrome that is usually respiratory or gastrointestinal in nature
Diagnosis of myocarditis carries a very high morbidity and mortality
Most common cause of heart failure in previously healthy children
Myocarditis is a clinical diagnosis
Work up should include labs such as troponin, BNP, ESR/CRP, EKG, CXR, echocardiogram, AST
Treatment:
In the ED will include +/- antibiotics, management of decompensated HF, arrhythmia management, transfer to ECMO/VAD center
Congestive Heart Failure
Clinical syndrome when cardiac output is unable to meet the metabolic demands of the body
1-7 per 100,000 in the US
In the absence of known congenital heart disease, child with CHF almost always has a cardiomyopathy
Children without a congenital heart disease can develop heart failure
Autoimmune Encephalitis
Inflammatory condition of the brain
Antibodies against neuronal cell-surface proteins or antibodies against intracellular neuronal proteins
Incidence rate of 0.8 of 100,000
Rule out other causes of infection, toxic or metabolic disturbances
Intussusception
Invagination of a part of the intestine onto itself
Ileocolic intussusception is the most common form
30 cases per 100,000 children
Causes are largely idiopathic
More common in males than females
Acute Flaccid Myelitis
Acute onset of focal limb weakness + MRI showing spinal cord lesion in gray matter in 1 or more vertebral cases
Risk = 1 in a million
Associated with enterovirus infection
Should suspect with sudden onset of extremity weakness, loss of muscle tone and reflexes, bulbar weakness, slurred speech, loss of bladder function, or unsteady gait
