Grand Rounds Recap 8.2.17

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Ultrasound-guided resuscitation with dr. stolz

RUSH Exam (HI-MAP: Heart, IVC, Morrisons, Aorta, Pulmonary) vs SHoC  Exam (Heart, IVC and Lungs only)

  • Heart
    • Visually estimating EF: Percent change between the heart at the end of systole and the end of diastole = EF%
    • Start with short axis to help determine % change however always look at a second view
    • EM physicians are about 94% sensitive for picking up low EF
    • Limited by wall motion abnormality and number of scans
    • E-point septal separation (EPSS)
      • Obtain parasternal long, place M mode line over the anterior leaflet of the mitral valve
      • Measure the distance between the tip of the e-wave and the septum
      • <7mm Normal, 7-10mm mild to moderate decrease in EF, >10mm severely depressed EF
      • Pitfalls: sensitive to angle, cannot be used in mitral disease, diastolic failure or a. fib
  • IVC
    • Prevailing idea being that a low IVC volume with respiratory variation indicates a need for volume 
    • To differentiate between IVC and aorta, look for hepatic veins draining to IVC and IVC draining to RA
    • Measure in longitudinal with probe subxiphoid
    • Predictor of fluid responsiveness: Sn 63%, Sp 73%
    • Cannot rely upon this however you can use this in the broad clinical picture to give you more information
    • Can think of this as more of a binary thought process (i.e. is it big [>2.5cm] or is it small [<1.5cm]?)
    • Caval index = (Max size- Minimum Size)/ Maximum size (% collapse using 50% as a cutoff)
    • Likely more reliable in mechanically ventilated patients

Benefits of POCUS in Resuscitation

  • Implementation of ultrasound in the first fifteen minutes in a patient with shock has been shown in some studies to increase diagnostic accuracy but almost 30%
  • Clinical Impression Sn 28% and Sp 86% vs Impression + POCUS Sn 73% and Sp 95% 
  • Improved time to disposition

Case One: 50 y/o M with syncope at a homeless shelter, 1 week s/p CABG. Eventually found to have RV collapse and large effusion on US.
Case Two: 45 y/o F s/p single vehicle MVC with pills in car, low mechanism. Arrests on scene --> gets shocked once and ROSC achieved. FAST shows poor LV squeeze with dilatation. Dx: cardiomyopathy --> V. tach --> MVC.
Case Three: 66 y/o M with no PMH and dyspnea. US shows poor LV squeeze with B-Lines which resolved with one hour of Bi-Level. Dx - CHF
Case Four: 22 y/o F, pregnant who presents with abdominal pain. Negative RUQ FAST view with + IUP on US. Hyperdynamic LV with small IVC. Dx shifted from ruptured ectopic to sepsis.
Case Five: 74 y/o M with dyspnea and recent dx of pneumonia. D sign (septal flattening) with dilated RV on US. PNA on CXR likely pulmonary infarct. DVT study positive and patient had a PE
Case Six: 75 y/o M with dyspnea and recent dx of pneumonia. Effusion seen on ultrasound. Final dx empyema. 
Case Seven: 22 y/o F with syncope after MVC. FAST showed LUQ free fluid, pelvic view showed ectopic. 
Case Eight: 65 y/o M with fatigue and left sided diabetic foot ulcer. Diffuse hypokinesis seen on ultrasound. IVC adequate. Foot ultrasound showed subcutaneous gas. This technique is often times more sensitive than x-ray alone for necrotizing fasciitis.

Emergency medicine procedural complications with dr. Knight

Interruptions

  • As EM providers we get interrupted on average once every three minutes
  • Every two out of three of these interruptions is a complete change of your focus
  • This leads to disruption of our normal workflow and can lead to complications
  • The concept of sterile cockpit during critical procedures (ie intubations, chest tubes, central lines, etc) may help to counteract this

Sterile Technique

  • Biggest way to prevent empyema during chest tubes is sterile technique
  • Things that are known to decrease infection: CLABSI bundle, hand hygiene, avoiding femoral lines, chlorhexidine scrub

Central Lines

  • Know your anatomy and equipment before you ever need to do the procedure
  • Site selection is key to preventing complication
  • Always have the patient on telemetry during procedure to prevent misplacement
  • Types of complications: mechanical, infectious, thrombotic, occlusive
  • Check the history (IVC filters, coags, platelets, etc)
  • 3 attempts = new approach or new proceduralist

Pro Tips for Vein vs Artery

  • Can push agitated saline under ultrasound guidance
  • Wiring through an angiocath (especially for thin, dry or agitated patients)
  • Can traduce the pressure using the wire holder or clear tubing in the kit (think LP opening pressure), if it overflows - it's time to hold pressure
  • Send a blood gas
  • If ever any doubt don't dilate

how to give a lecture with Dr. Knight

Become a content expert
Do not apologize for your topic, think about why you are presenting and own it
Prior to starting "get your ingredients out"

  • Map out your talk before you start putting slides together, otherwise it can turn into 'sorting slides'

The more words/data on the slide, the less your learner's process the information and the less of an expert you appear

  • The audience will always read over listening
  • One main idea per slide

Know your audience and venue

  • Consider this when you decide your dress, intonation and verbage
  • Use humor appropriately but don't let it dominate your talk 
  • Use filler (ie pictures from your recent vacation) tactfully. It can help break up and give learners a cognitive break but can also bore the viewer.

Think about alternate ways to present large amounts of data (ie multiple trial results in a chart)

  • Instead of showing the chart you can consider breaking it down into "There have been 8 trials covering xyz since 1989"
  • Walk your audience through the data using verbal explanations, not slides 

If you present a list, all things appear to be equal in importance
Consider your color schemes (are you excluding color blind learners)
Make eye contact
Consider tactful wandering (rehearse/get feedback on your wandering if this is your style)
Don't memorize the material, know the material - it will make you flexible and spontaneous

  • Be ready to go without your media

Consider using QR codes to link to resources
End with your message
Three good pieces to be conscious of while making your presentation

  • Message
  • Media
  • Delivery

r4 case follow up with dr. Lagasse

CC: AMS (presents 30 minutes prior to turnover)

Elderly female with PMH of hypertension. Patient unable to provide history. Family states patient has had 3 days of nausea and vomiting and just "not acting right."

  • Febrile to 101 with otherwise normal vitals
  • Cachectic female with diffuse abdominal tender to palpation, no focal deficits, no dysarthria, inappropriate answers but not obtunded
  • BG normal, CXR normal, EKG normal

TURNOVER OCCURS (at turnover patient was presented as sick and requiring some honest thought)

Labs significant for elevated LFTs, lactate of 8 and leukocytosis. On reassessment pills found in mouth and MJ in pocket. The patient undergoes crystalloid administration, gets blood cultures and broad spectrum antibiotics
Repeat temp = 104.5
On reassessment again patient is completely lucid and appropriate and gets CT Abdomen/Pelvis concerning for cholangitis
Blood cultures rapidly grew E. Coli, Klebsiella and Proteus
On third reassessment BP is 86/44, Lactate increasing at 8.2 so a central line is placed and norepinephrine gtt is started

Why are marker's not improving despite antibiotics and fluid resuscitation? 

  • Consider source control 

Acute Cholangitis

Mortality 2.7-10%, before 1980 >50% likely 2/2 improve recognition
Caused by obstruction (stone, stricture or malignancy) and subsequent infection of the biliary tree

  • Often polymicrobial and gram negative

Diagnosis
Charcot's triad: fever, jaundice and RUQ pain
Reynold's Pentad: Triad + shock and AMS

CT scan is preferred even over ultrasound to help aid you in finding the etiology of the obstruction 

Management

  1. ERCP: gold standard, more versatile depending on etiology, timing is important 
  2. Percutaneous drainage
  3. Surgery: associated with higher complications

The 2013 Tokyo Criteria can help you classify severity
Mild: Supportive therapy, discuss treatment with GI, can occur as an outpatient
Moderate: recommend drainage within 48 hours with resuscitation therapy
Severe: recommend early biliary drainage (100% within first 24 hours) 

Geriatric Small groups with drs. Colmer, Soria and Continenza

1. Geriatric Pharmacy

  • Absorption
    • Decreased small bowel surface area
    • Decreased gut motility
    • Decreased gastric emptying
  • Distribution
    • Total fat increased, total body water decreased, albumin decreases
    • Affects volume of distribution of lipophilic drugs
  • Hepatic Metabolism
    • Cytochrome P 450 decreases, first pass metabolism decreased by 1% every year after 40 years old
  • Renal Metabolism
    • GFR is more reliable than GFR due to changes in muscle mass

High Risk Medications: benzodiazapines, anticholinergics, pain medications, anti-arrhythmics, Nitrofurantoin, PPis, and Cyclobenzaprine to name a few
Consider using the Beer's List to guide prescription practices

2. Case Study

HPI: 86 y/p F with PMH significant for mild dementia, HTN, DM2, CAD s/p stents, GERD, CKD stage 2, CHF with EF 40-50%, a. fib on warfarin, depression, hypothyroidism and osteoarthritis who presents with 2-3 days of generalized weakness. Has mild nausea and constipation with last BM 2 days ago and decreased appetite. Intermittent abdominal cramping and DOE.

Vitals: HR 90, T 96.5, BP 103/60, RR 20, SpO2 95% on RA, BG 134
Exam: Mild diffuse abdominal tenderness
Labs: WBC 11.9, baseline anemia, BMP baseline, INR 2.1, Lactate 1.9

How do you handle this patient in the setting of a busy ED?
Low suspicion to scan. Broaden differential to cardiac and hypothyroidism.

CT scan shows appendicitis

  • In patients >80 with abdominal symptoms the CT changes our management 43% of the time, 55% of scans have a positive finding
  • Appendicitis it the 3rd most common indication for abdominal surgery in the elderly, mortality is 4-8 times higher
  • Misdiagnosed 54% of the time and diagnosis frequently delayed
  • Less than 20% with classic symptoms, fever present less than 50% of the time
  • Higher risk of perforation in octogenarians compared to younger elderly (65.5% vs 49.5%)

3. Geriatric Trauma

Case 1: 80 y/o M with witnessed backwards fall form standing, hitting left posterior flank leading to left sided rib fractures (#6-11) with displacement of #8-11 and a left sided moderate hemopneumothroax.

  • >65 increased risks of morbidity and mortality after rib fractures
  • For patients <65 pneumonia occurs in 11-17%, patients >65 rates up to 34% have reported
  • Mortality: for every rib over 4 the risk increases by 19%

Management

  • Multimodal control with NSAIDS, lidocaine patches, acetaminophen and consider an epidural early
  • Positioning (sit up)
  • Be judicious with fluids to account for possible pulmonary contusion
  • Aggressive pulmonary toilet with IS, couching, deep breathing and early ambulation

Case 2: 85 y/o M s/p MVC. Confused and amnestic. Pain from the backboard. HR 70 and irregular, BP 110/65, O2 sat 94%. GCS 14

  • With irregular heart rate consider that the patient may be on anticoagulation or beta blocks/calcium channel blockers
  • Consider reversal (Dabigatran and Rivaroxaban/Epixaban pathways here)

Case 3: 78 y/o F s/p fall over rug leading to unstable right femur intertrochanteric fracture.

  • Mortality rate is 20% in a patient with no other medical problems
  • Sooner is better for fixation however consider the baseline functional status of the patient. It may be better to delay treatment in order to control co-morbidities first. 

Mastering minor care - eyes on the community with dr. toth

Case 1: 28 y/o M construction worker with FB in the left eye. On physical exam has OS conjunctival erythema. Fluorescein stain is negative. On exam you see a small punctate FB over the iris.

Removal of FB

  • Evert and sweep lids after tetracaine administration
  • Consider use of 27g needle or TB syringe
  • Come at the eye parallel to the plane not perpendicular 
  • Abx recommended however evidence not robust
  • 24-48 hour follow up especially if there is a rust ring

Case 2: 69 y/o F sent in from NH for dilated R pupil with blurry vision and pain. Only light perception OD. Dilated pupil, poorly reactive, fluorescein negative, IOP > 60

Dx: Acute Angle Glaucoma Management

  • Elevate HOB
  • Consider 500mg of acetazolamide IV and Topical timolol 

Case 3: 30y M s/p blunt trauma to the eye several days ago presents with OD perilimbal conjunctival erythema, photophobia (direct and consensual), reactive pupil, IOP 18 and decreased visual acuity OD

Dx: Traumatic Iritis

  • Cycloplegics and steroids
  • 10-15% develop some form of glaucoma
  • F/u in 5-7 days from trauma (not from presentation)
  • Ensure follow up with a specialist

Case 4: Young girl with FB sensation OS, conjunctiva is injected, normal visual acuity and otherwise normal exam until fluorescein 

Dx: Corneal Abrasion 

  • Heals in 1-4 days
  • Topical antibiotics are unproven but standard of care
  • Cycloplegics are also unproven but my help with discomfort
  • Remember psuedomonal coverage for contact lens wearers
  • No need for eye patch

Tips for the Dilated Eye Exam

  • Only 33 out of 600,000 cases of a dilated eye exam precipitated acute angle closure glaucoma - it is safe to do
  • Tropicamide (Mydriacyl) potentially has the safest profile
  • Document presence of afferent pupillary defect first

Cincinnati opioid epidemic with Dr. Shaw

1. The problem
1 in 9 heroin deaths in the US happen in Ohio
1 in 14 synthetics opioid deaths in the US happen in Ohio
UCMC sees more of these proportionately than any other hospital in the Cincinnati area

2. The ideal solution
New Haven Study: RCT using buprenorphine prescriptions from the ED
Six months later, half of the patients (despite pharmacologic treatment) were in active treatment programs
Increased likelihood if they were discharged with buprenorphine

3. Where we are now
New algorithm here
Disposition at two hours after an uncomplicated overdose with a single time reversal with Naloxone is safe

4. Future developments
Potentially prescribing buprenorphine from the ED
Ability to dispense physical Naloxone from ED rather than just prescriptions