Grand Rounds Recap 7.31.19
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Morbidity and mortality conference WITH DR. Banning
Cardio-cerebral infarction
Describes a syndrome of concomitant stroke and myocardial infarction.
This is a rare syndrome that has been reported in up to 0.9% of patients undergoing PCI for AMI.
There is higher association with STEMI than NSTEMI and reduced ejection fraction <30% is the only known independent risk factor.
The exact mechanism is not well understood. Possibilities include thromboemboli from hypokinetic myocardium, watershed infarction in the setting of hemodynamic compromise, or extension of aortic dissection.
Emergency physicians are uniquely positioned at the point of overlap between numerous specialties responsible for acute care of critically ill patients and should use this position to summon resources when placed in seemingly impossible situations.
Trauma and the intoxicated patient
Diagnostic momentum is dangerous because it leads us to anchor on a diagnosis when we should keep our differential broad.
Keep an open dialogue with admitting teams when you are co-managing a boarding inpatient in the ED.
Clinical decision support tools such as the Canadian or New Orleans head CT rules are useful, but be aware of the patient populations in which they were validated and be sure that your patient is an appropriate subject when you use them.
Intoxicated patients are challenging because they often cannot provide reliable history. In these situations you must obtain collateral information where it is available - EMS, family, and caregivers who know the patient. A thorough physical exam is also vital as well as serial assessments that may garner more information that was unavailable initially.
HEART Score
Take care when there is discrepancy between a decision support tool such as the HEART score and your own gestalt. Use your own critical thinking to determine if you need to look further or in another direction.
Don’t rely on a single-troponin rule out in the setting of intermittent chest pain. Obtain serial values.
The historical element of the HEART score system is subjective and studies have shown large variances in inter-rater reliability. Other studies have shown that the historical elements that have the highest association with true coronary ischemia are 1) radiation to both arms, 2) pain similar to prior MI, and 3) change in quality over the previous 24 hours.
Resuscitative Hysterotomy
ACOG has no clearly defined guidelines on when this procedure is indicated.
Pregnancy produces changes in maternal physiology that have important implications for resuscitation.
IVC compression begins as early as 12 weeks and so chest compressions may only increase CO by 10% if mother is not ramped into a left lateral tilt to alleviate this.
FRC decreased by as much as 20% due to elevation of diaphragm and so ventilation is less effective.
Important points to keep in mind when considering whether to perform resuscitative hysterotomy include:
Is this for mother or fetus? Most research is low-quality and based on case reports, but maternal survivability is up to 34%. On the other hand, fetal survivability is extremely variable between 25-70%.
When thinking about total downtime, how long is too long? The traditional teaching is within 4 minutes or two rounds of CPR but there are significant numbers of cases that were reported to occur after 15 minutes (usually due to transport time). However, earlier is better for the fetus if that is the focus.
At what gestational age should we be considering this? It is not recommended to delay for ultrasound dating even if you have a provider on hand who is capable of doing so. Instead rely on your physical exam, but note that the traditional teaching of “fundus at the umbilicus” indicating gestational of of 20 weeks may be inaccurate. In reality this is variable, usually from 15-19 weeks due to anatomic features such as a retroverted uterus or multiple gestation.
For more information see Dr. Gottula’s in-depth post on the topic
DKA and ACS
Diabetics are naturally at higher risk for ACS for several reasons including accelerated atherosclerosis, impaired glucose metabolism making tissues at higher risk for ischemia, and the well-known fact that they are less likely to experience typical symptoms of coronary ischemia.
DKA and ACS are a “chicken and egg” phenomenon. They each may be the proximate cause of the other and sorting this out can be difficult, but ultimately the true learning point is to consider both and not miss one.
We are all aware that there exists a population of patients who have a small elevation in troponin at their baseline. The “chronic troponin leak” is not a well defined entity, but you should be concerned for an acute process when there is at least a two-fold increase from a patient’s baseline.
When does troponin return to baseline? TnI returns to baseline in 5-7 days, so if you have a patient with chest pain who recently had a significant troponinemia be concerned for new ischemia if it does not follow an appropriate downwards trend.
What is the significance of lead aVR in ACS? According to the American College of Cardiology’s Fourth Universal Definition of Myocardial Infarction (2018) it is a STEMI equivalent when:
There is STE > 1mm
There are > 6 leads of reciprocal depression
The patient appears in extremis
Hypertriglyceridemia-induced Pancreatitis
Hypertriglyceride-induced pancreatitis is the third most common cause of pancreatitis after alcohol and gallstones.
Consider this diagnosis when you have a patient with pancreatitis and serum triglyceride > 1000, with chronic hyperlipidemia, pregnancy, obesity, or diabetes.
Although we don’t often check serum triglycerides in the emergency department, this test actually has a rapid turnaround in the lab of 20-40 minutes and so is a reasonable lab to run.
Unlike most other causes of pancreatitis that are managed only with supportive care, there are specific treatments for this etiology. These include plasmapheresis and continuous insulin infusion.
Furthermore, pancreatitis due to hypertriglyceridemia is associated with higher rates of ICU admission, mortality, organ failure, and infection. Catching this diagnosis not only affects treatment but also potentially level of care.
The Well Oiled Machine
We consistently provide excellent care to patients, exemplified by cases such as this one in which a patient with penetrating thoracic trauma had an arrival-to-OR time of 8 minutes. In that short 8 minute span we activated the trauma team, established two points of large-bore IV access, started whole blood, sent labs, completed a FAST exam and chest xray, activated the massive transfusion protocol, and got the patient to the operating room alive.
We should feel pride in what we do and strive to make every encounter as exemplary as this one.
Air care grand rounds WITH DRs. hinckley, Humphries, and spigner
Stress inoculation
Performance decreases as arousal increases but this response can be conditioned by exposure to a stressor in a controlled environment.
Acquiring knowledge, practicing skills, and honing techniques such as box-breathing are all important elements of this type of training.
Cognitive control techniques are an extension of mindfulness training and designed to replace negative thoughts with goal-directed thoughts.
Physiologic control techniques are designed to regulate the physiologic parameters that are known to worsen the stress response. Box-breathing is an example.
Mental practice and rehearsal activates the same neural pathways as actually performing a task and can enhance performance when the chips are down.
Air craft operations and logistics
Numerous topics were discussed in engaging formats with flight physicians, flight nurses, and pilots.
