Grand Rounds Recap 7.31.24
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capacity management WITH Dr. lane
Emergency Department flow can be characterized as Input - Throughput - Output
In the ED, we do not have much control over patient input or output, but we do have control over patient throughput
Simulation modeling was used in our Emergency Department to determine our threshold for “at capacity” or diversion — involves staffing, SRU utilization, ICU bed availability, and patients in the waiting room
More Emergency Department or inpatient beds does not solve ED boarding
Current initiatives to improve boarding and throughput in our system include:
Twice weekly multidisciplinary “Long Length of Stay Workgroup” focusing on currently admitted patients with long length-of-stays
Capacity management teams expediting discharge-dependent processes
Increasing our home health care services to increase the number of patients discharging home
Improving our post-acute care network to reduce delays in patient placement after discharge
sports medicine grand rounds: Admit/Discharge/Transfer WITH dr. gawron
Septic Bursitis
Aspiration typically isn’t recommended for septic olecranon bursitis. The largest retrospective cohort study to date (Beyde et al.) shows that most will improve with empiric antibiotics. None of the patients in this study went on to require operative drainage
Aspiration in the ED can lead be complicated by poor wound healing and/or formation of a fistulous tract
Occult Knee Dislocation
High likelihood of associated vascular injury with knee dislocations
Even if ABI is normal, patient’s with any sign of vascular compromised should undergo CTA of the knee and be admitted for serial neurovascular checks and orthopedic consultation
Achilles Tendon Rupture
Should be splinted in plantar extension, but can usually be discharged home with close outpatient follow-up
introduction with bedside teaching WITH dr. baez
Academic EM physicians spend up to 25% of their time on-shift teaching
Only 36% of teaching is emplicit (direct instruction). The majority of teaching is implicit, which occurs subconsciously and relies on the learner’s ability to make connections and develop practical applications of their knowledge
Emergency Medicine rotations are consistently ranked as one of the most beneficial rotations for learning by medical students, even among students not applying to EM
Students report equal learning from both faculty and residents
Preparation
Prime yourself, your learner, and your colleagues
Goal Setting
Tailoring goals to the learner’s level promotes more effective learning and provides a window into the learner’s mindset for the shift. We discussed some practices to push learners outside of their comfort zone and promote learning, based on their level as well as their goals for the shift.
Differential Diagnosis: For medical students or interns: discuss mnemonics to remember differentials; for R2s/R3s, ask them to consider 5 likely differential diagnosis and how this patient would decompensate based on those differentials
Patient Care: For medical students, encourage them to find at least 3 abnormal physical exam findings throughout the course of their shift; For interns, encourage them to use a new medication they’ve never used before during the course of their shift; For R2s: Find an alternate disposition to admission for at least one patient; For R3s: Avoid at least one CT scan on shift; For R4s: Compete with faculty to identify one exam finding that the other person missed
Efficiency: For medical students, set a time limit for them to obtain their patient history and perform an exam; For R1s: use the new results box in Epic; For R2s: Document the HPI prior to staffing the patient with the attending; For R3s: Utilize ED course for all SRU patients; For R4s: set a goal for # of patients to see on shift, discuss critical care billing for every patient and if they would qualify
Procedures: For medical students: set a goal of two procedures on-shift; R1s: Go with every consultant for procedures being performed in the ED on their patient, practice consenting the faculty or R4 for a procedure; R2s: Perform one new procedure or utilize one new technique on shift; R3s: Ask every consultant how the procedure would be different in a community setting; R4s: teach one new procedure or technique
Teaching: For medical students or interns: choose 1 piece of literature to review and teach on-shift; R2s: Observe 1 HPI performed by a medical student and provide feedback; R3s: Discuss 1 note/MDM with medical students on shift; R4s: Provide a short case discussion applicable to all rotators (medical students, off-service rotators, and EM residents)
Independence: Give the learner criteria for staffing a patient, i.e. staffing with the R4/faculty only after orders are in the chart, the HPI/exam is done, when they have multiple patients to present, or when the patient is ready for disposition. For senior residents, consider prompting them to discuss how a patient’s management would differ in the community compared to an academic setting
Important for the teacher to set their own on-shift goals, as well as the learner
In educational research, pausing for at least 3 seconds when your learner is silent or struggling, before jumping in yourself to speak or provide them the answer, has been shown to increase responses from the learner
Consider asking non-physicians (nursing, pharmacy, respiratory therapy, etc.) to teach you and your learner something new on shift
skin adhesives WITH dr. hill
Dermabond is a polymer (octyl cyanoacrylate) that can be used to repair lacerations in the Emergency Department faster than sutures, allowing the ED physician to be more efficient. Wound healing is faster with Dermabond compared to sutures, and can be useful as a less-painful technique to repair certain wounds
Dermabond differs from non-medicinal superglue because it is sterile, is more flexible, and ultimately less brittle than standard superglue
There have been care reports of non-medicinal glue (superglue, nail glue, etc.) causing full-thickness burns in pediatric patients
Dermabond also has an exothermic reaction but it is decreased compared to non-medicinal forms
This exothermic reaction increases when combined with cotton, so Dermabond should not be applied directly to cotton materials
Dermabond typically lasts 7-10 days before naturally breaking down and falling off
Moisture, friction, and topical antibiotic ointments cause Dermabond to breakdown faster
To apply Dermabond:
Hold the applicatorvertically and crack the ampule inside only once (squeezing the tube multiple times can cause tiny glass shards to enter the wound)
Dry the skin as much as possible prior to applying possible
Moisure “activates” Dermabond, so if Dermabond is activated by blood on/within the wound, it will never reach the skin surface and will not actually secure the wound
The wound should be approximated prior to applying Dermabond
Steri-Strips can be used to approximate the wound, and Dermabond can be applied directly on top of the Steri-Strips
A burning/stinging sensation may occur if Dermabond enters the wound itself
Drying the Dermabond with oxygen or by fanning it does not make the Dermabond set any quicker
We then discussed ‘tricks of the trade’ for certain wounds for which Dermabond can be helpful:
Fingertip Avulsions
Soak the fingertip in lidocaine with epinephrine or apply a finger tourniquet to make the wound hemostatic, then apply Dermabond to the avulsed portion of the skin after the wound is dry and hemostatic
Nailbed Lacerations
Soaking the wound in lidocaine with epi and applying a finger tourniquet can also be helpful in these scenarios
Dermabond can be used to close the nailbed laceration
The eponychial fold still needs to be elevated using a piece of suture foil, the nail itself, etc.
Scalp Lacerations
Hair apposition technique can be effective to close scalp lacerations
Take several strands of hair on either side of the wound, twist them together over the wound, and then secure the knot with Dermabond and apply Dermabond to the laceration itself
Lacerations Near the Eye
Dermabond can be used to close lacerations near the eye, but caution should be exercised to avoid getting Dermabond in the eye itself
Bacitracin ointment can be used to create a “barrier” to prevent Dermabond from entering the eye; a tegaderm can also be applied over the eye
If Dermabond inadvertently enters the eye, the eye should be irrigated and then Polysporin ophthalmic ointment can be used to remove the Dermabond
Tongue Lacerations
Dermabond can be used successfully for superficial tongue lacerations, though may break down prematurely from moisture in the mouth or consumed warm liquids
Dermabond can also be utilized in persistent ascites leakage after paracentesis, venous oozing from a dialysis fistula, or bleeding varicose veins
Securing peripheral IVs
Place a drop of Dermabond between the skin and the angiocath after the IV is properly inserted, and then place Dermabond over the skin at the site of the entrance of the angiocath
Using Dermabond to secure peripheral IVs reduces IV failure rate
hypertensive emergency WITH dr. irankunda
Definitions
A hypertensive emergency is an acute, marked elevation in BP associated with signs of target organ damage
Hypertensive urgency is a misnomer, and this term is falling out of favor
Treatment Classes
Calcium Channel Blockers
Nicardipine has an onset of 10-20 minutes, peaks at 30 minutes, and has a half-life of 2-4 hours
Dose may need to be adjusted in patients with kidney failure
Clevidipine has a rapid onset of 2 minutes with a half-life of 1 minute
Helpful in patients with liver and/or kidney failure, as it is broken down via a separate mechanism and does not require hepatic or renal clearance
Beta Blockers
Esmolol
“Fast on, fast off”: Onset is 1 minute with a short half-life of 9 minutes
Labetalol
Onset of 2-5 minutes with a longer half-life of 5.5 hours
Nitroglycerin
Fast onset of 1-3 minutes and a fast half-life of 2-3 minutes
Hydralazine
Has rapid onset within 5-20 minutes but has variable peak of 10-80 minutes and a variable, though long, half-life of 2-8 hours
Clinical effects are less predictable and vary from patient to patient
Clinical Presentations of Hypertensive Emergency
Neurologic Emergencies
A typical BP goal for ICH/IVH in the setting of hypertensive emergency is an SBP <160
For SAH, the SBP goal is slightly lower, goal SBP <140
For patients with an ischemic stroke who are TNK candidates, their BP should be lowered gentyl to SBP <185 and DBP <110
Labetalol or nicardipine are the preferred agents in this situation
After receiving TNK (regardless if initial BP control was necessary), BP should be maintained to SBP <180 and DBP <105
PRES/RCVS
Caused by a failure of autoregulation and endothelial dysfunction, characterized by a rapid increase in blood pressure
Goal: MAP reduction by 25% within 1-2 hours
CCB or BB can be used, there is some thought that calcium channel blockers help more with the vasospasm component in these patients
Aortic Dissection
Goals: HR <60, SBP <110-120
Pain control to reduce physiologic stimulation of increased HR/BP
HR control, usually with esmolol
BP control with CCB or labetalol
SCAPE (Sympathetic Crashing Acute Pulmonary Edema)
Mainstays of treatment are non-invasive ventilation to support their respiratory status and nitroglycerin to reduce preload and optimize the fluid shifts that lead to SCAPE in the first place
CCB and diuretics are adjuncts that can be used to reduce BP
Beta blockers should be avoided, as many of these patients may have acutely decompensated heart failure
Pre-Eclampsia/Eclampsia
Consider in pregnant patients >20 weeks gestation with blood pressures >140/90
Can present up to 6 weeks post-partum
Labetalol, hydralazine, and nifedipine are all safe in pregnancy
High-dose magnesium is indicated in these patients
Acute Coronary Syndrome
Nitroglycerin and beta blockers can be used to to reduce LV preload and afterload and decrease HR in patients with ACS caused by hypertensive emergency
Asymptomatic Hypertension
For ED patient’s with asymptomatic hypertension, routine screening for acute target organ injury (EKG, troponin, BMP, UA) is not required. In select patient populations (such as those with poor outpatient follow-up), screening with a BMP to evaluate their serum creatinine may be beneficial
Patients with asymptomatic hypertension should be referred to their PCP for outpatient follow-up. ED physicians can consider starting an anti-hypertensive at the time of ED discharge for patients with poor follow-up
ultrasound qa review WITH dr. broadstock
Portal Venous Gas
Mortality is significantly elevated, 56-90%
Often associated with bowel ischemia or necrosis, IBD, and intra-abdominal abscesses
Pneumobilia: Air Within the Gallbladder
Characterized by “champagne bottle sign”, with hyperechoic foci with posterior shadowing along the GB wall
Can be benign, depends on patient’s clinical presentation and past medical history
Causes
Iatrogenic (stenting, previous anastamosis)
Biliary-enteric fistula
Infectious: emphysematous cholecystitis, acute cholangitis, liver abscess
Mimics
Adenomyomatosis
Cholesterol accumulation within the wall of the GB, usually an incidental finding
Presents with “comet-tail” shadowing
Wall-Echo-Shadow Sign
A GB completely full of gallstones can present with dense shadowing from the stones itself and can mimic pneumobilia
Porcelain Gallbladder
Calcifications within the GB wall can cause posterior shadowing, can be very difficulty to distinguish from pneumobilia
Abdominal Ectopic Pregnancy
Makes up 1% of all ectopic pregnancies
High morbidity and mortality: maternal mortality is 12%, up to 80% require blood transfusions
Cardiac Tamponade
Rare case of cardiac tamponade from right ventricular rupture secondary to pacemaker wire migration, where the pacemaker wire was seen on POCUS
Rare: occurs in 0.14% of all pacemaker placements, but carries an in-hospital mortality of 5.6%
Can present in a delayed fashion, does not always occur immediately after pacemaker placement
Delayed presentations present with signs and symptoms of cardiac tamponade in two-thirds of cases
Abdominal Aortic Aneurysm
Repair is usually indicated when aortic diameter is >5.5 cm (males) and >5 cm (females)
Risk of rupture increases as the diameter of the aorta increases
6 cm: 10-20% annual risk of rupture
7 cm: 20-40% annual risk of rupture
8 cm: 30-50% annual risk of rupture
Cholelithiasis and Cholecystitis
If gallbladder distension is present, it increases the specificity of POCUS for diagnosing acute cholecystitis
Gallstones can hide within the GB neck and can be difficult to appreciate
Acute Right Heart Failure Secondary to Massive Pulmonary Embolism
RV failure is characterized on ultrasound by: RV dilation; hypokinesis of the RV free wall relative to the apex, which is hyperkinetic due to the systolic function of the LV
Pulmonary emboli can very rarely been seen on POCUS by getting a view of the base of the heart and RVOT in patients with appropriate anatomy and very large emboli
How to give a presentation WITH Dr. knight
Effective presentations blend text and visual media effectively with the presentation itself
Slides should be used to emphasize your points, not to collectively list all of the information you want to convey to the audience
Record yourself practicing your presentation and watch it back to review your mannerisms and identify any speech fillers you tend to use (umm, like, etc.)
Know your audience, and tailor your presentation to them in terms of humor, pop culture references, and dress code
Err on the side of making your presentation slightly shorter than the alloted time to allow room for questions. It is better to finish early than rushing through your presentation
