Grand Rounds Recap 8.4.21
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POISONOUS PLANTS WITH DR. OTTEN
Plant poisoning is more of an accident if anything since their toxins are secondary metabolites and designed to protect plants from herbivores.
Populations of often experience plant poisoning:
Mostly children, but they rarely have bad outcomes
Foragers who collect plants for food and misidentify (ex, mushrooms)
Herbalists who use plants as medicines
Abusers who use plants for their psychotropic effects
Plant toxins
Plant toxins may precipitate a wide spectrum of clinical presentations that may differ across species.
Plant toxins demonstrate ecotypic variations with phenotypic plasticity. Basically, the toxicity of the plant can vary depending on growth stage, time of year, soil conditions
“Dose makes the poison” - toxin concentration varies as it progresses through the food chain.
Additional or primary toxicity may arise from exogenous chemicals (eg, fertilizers, herbicides, insecticides)
Individuals could be exposed to toxins through absorption of metallic compounds.
Classes of plant toxins:
Alkaloids
Most common, found throughout all parts of the plant
Examples include nicotine, poison hemlock, Belladonna, Atropine, Scopolamine, Jimson Weed, deadly nightshade, Opium, Quinine, Ipecac, Poppy, among others
Among these, Jimson Weed is found as a weed throughout the US in both rural and urban environments and is commonly abused by teenagers, precipitating an anticholinergic toxidrome.
Glycosides
Cyanogenic glycosides are typically only a problem if ingested. Their enzymatic breakdown can precipitate GI bleeds, respiratory distress, syncope, coma, seizures. Typical onset within 30 minutes up to 2 hours.
Examples include digitalis, foxglove, oleander, lily-of-the-valley, henbane, frangipani, squill, amygdaline, cassava, almond, ginseng, senna, aloe,
Oxalates
Includes calcium and soluble oxalates
Precipitates needle like crystals, leading to multiorgan failure or damage
Resins
Examples include Water hemlock, chinaberry
Phytotoxins
Examples include Ricin, Curcin, Castor Bean
Castor bean toxicity causes GI effects in 6 hours, and cytotoxic effects to the brain, kidneys, and liver 2-5 days later.
Oils
Examples include Methyl salicylate, Wintergreen, Eucalyptus, Horseradish
Miscellaneous toxins
Hypoglycemic agents such as the Ackee fruit
Metals concentrated in vegetables
Nitrates that lead to methemoglobinemia
Coumarins causing coagulopathy
Fava beans causing hemolysis
FINANCES FOR PHYSICIANS AND GETTING A JOB WITH DR. DOERNING
Part 1: Financial planning
Why are doctors bad with money?
We don’t talk about it.
Careers start late, so we don’t start saving till late.
We don’t necessarily take training debt seriously.
We’re good at calling consults, so we often farm out our work to financial advisors.
Lifestyle creep
Investment basics and terminology
Stocks - buying a share in a company
Bonds - a unit of debt, an IOU; lower return but generally safe
Funds - mutual funds and exchange traded funds (ETFs); mix of different asset classes
Within funds, you should:
Diversify
Focus on options that you can “set it and forget it” (eg, index funds, life cycle funds)
Prioritize funds that rely on passive management
Understand what an expense ratio is
Saving for retirement
If nothing else, save more than you spend, make saving automatic and intentional, make your money work for you.
Mistake # 1: Not starting early
Mistake # 2: Pay attention to and reduce fees! A difference of 2.5% in fees can result in the loss of 70% of the value of a retirement account. Examples of good management firms: Betterment
Mistake # 3: “Timing” the Market - you cannot time or beat the Market. Remember, set it and forget it with small tweaks over time
Mistake #4: Ignoring taxes - prioritize tax advantaged accounts (i.e 401(k), 403(b), 457, IRAs, HSA) and stop buying individual stocks before maxing your tax advantaged accounts
Bob’s Personal Philosophy for Financial Health
Step 1: Pay off high interest debt - make a budget and stick to it; credit card debt is a killer (avg interest rate is 17.3%); consider refinancing high interest debt; not all debt it bad (if the interest rate is lower than an expected yield on an investment, it makes sense to not rush to pay off the debt)
Step 2: Build an emergency fund - Conservative recommendation is to have 3-6 months of living expenses and cultivate a high yield savings accounts around 0.09%-0.5% (Example: Ally, AmEx, Betterment)
Step 3: Save for your retirement
3a - Consider ROTH/Traditional IRA
Traditional IRA - you pay no taxes on the money you put until you withdraw it
ROTH IRA - you pay taxes upfront but you pay no taxes on earnings and when you make a withdrawals after age 59.5,
The benefit of the 401k is it comes out of pretax dollars so it can decrease your end of year tax burden since you have a lower “income”
3b - Invest with your HSA
If your health situation allows, you should secure a high deductible plan with an HSA. This allows you to deposit pre-tax money for medical expenses and is not taxed
You can contribute $3550 a year, and rolls over every year so you never lose it
Step 4: Taxable account investing
If you have maxed out your tax free/tax deferred funds, consider a taxable account
Examples of this include invest in index funds, ETFs
Consider a robo-advisor or traditional broker (eg, Betterment, Wealthfront) with low management fees around 0.25% to help arrange this
Open a fee free trading account (Robinhood, Schwab)
Take Home Points:
Save more than you spend
Make saving automatic and intentional
Make your money work for you.
Know what your money is being spent on
Part 2: Getting a Job
State of the Job Market
Unsurprisingly, COVID had a tremendous effect on hiring, but now that volumes are returning, so too are the jobs. Job market also affected by supply given growth of training programs and new Contract Management Groups (like USACs, TeamHealth)
Lots of challenges, but lots of opportunities! We may not be able to change the market, but we can change our response to it and adapt, as we always do.
Find your niche
Get involved: ACEP, SAEM, other professional organizations
Develop a professional plan
Applying for jobs
Many jobs are not publicly advertised. Use word of mouth, networking, conferences, etc.
Create and maintain a CV. Have versions that you tailor based on the type of job (academic v. community). Have friends, family, colleagues edit it.
The Interview:
Zoom interview is the new normal
You are interviewing them as much as they are you
Know what is negotiable and what is not
Ask for a job
The contract
Consider having an employment lawyer look at it
Bring it to your mentors or any faculty
Don’t feel pressured to sign anything
Take Away Points:
Remember why you got into EM
You have a long career ahead of you and the best network in the world
Develop your niche! If it doesn’t exist, create it.
SOCIAL EMERGENCY MEDICINE WITH DR. JARRELL
Social EM Fellowship at UC: The Rundown
2 year with MPH (about 12 hours a week); serve as a clinical instructor and work clinically at WCMC and UCMC; focus on education (oversee Social EM elective, interest group, journal clubs, and designed Public Health Leadership Academy / PLA) as well as public health operations (EIP, TaP)
What is social EM?
SEM recognizes the unique position of the emergency department in the community and within the healthcare system. Emergency Departments are the safety net for the healthcare system and are a safe haven for the community. SEM uses the perspective of the ED to investigate societal patterns of health inequity, identify social needs contributing to disease, and develop solutions to decrease health disparities for vulnerable populations.” - Stanford Emergency Medicine
The Epidemiologists’ Bathtub conceptualizes the following terms:
Prevalence - proportion of individuals in a population that have a disease at a particular time
Incidence - number of new cases that develop or are recorded within a given time period
Death, Recovery, and Recurrence are pretty self-explanatory.
Spectrum of prevention exists on several different levels - influencing policy and legislations, arranging organizational practices, fostering coalitions and networks, educating providers, promoting community education, strengthening individual knowledge and skills
Primary - intervention before the health effects occur (Example: D.A.R.E)
Secondary - identifying the disease in the early stages Example: National alcohol screening day)
Tertiary - treatment or managing a disease after diagnosis (Example: Medication for Opioid Use Disorder)
Harm reduction aims to reduce negative consequences of drug use and accept that licit and illicit drug use is part of our world.
Addiction is a disease. It is a product of intersections of biology (genetics, gender, mental health issues), environment (home, abuse, parent use, attitudes, peer influences, community attributes), and drug (effect of drug, early use, availability, cost, leading to certain changes in brain mechanisms (adjustments to excitatory and inhibitory neuronal pathways that link to pleasure), which create pathways that help contribute to addiction.
Social Ecologic Model of Substance Use and Overdose relies on idea that there are overlapping spheres of influence that influence individuals likelihood of continued use and recovery (individuals, interpersonal, community, and societal). As ED providers, we have the opportunity to intervene at several of these levels of influence.
R3 TAMING THE SRU: CALCIUM CHANNEL BLOCKER OVERDOSE WITH DR. COMISKEY
The Case: Teenage male presents after an intentional overdose of unknown quantity of Amlodipine (later confirmed: 15 tablets of 10 mg dosage), Aleve, Melatonin, and possible other substances, including Levothyroxine, Sertraline, hydrochlorothiazide, Tizanidine, Aspirin, and Atorvastatin. On exam, patient is lethargic, but responds to verbal stimuli and follows commands. Initially, HDS, but then patient becomes more obtunded, bradycardic, and blood pressure decreases.
Calcium Channel Blocker Overdose
MOA: Inhibits calcium influx through the L-type calcium channel, reducing contraction of arteries through action on vascular smooth muscle peripherally and precipitating vasodilation and reducing force of contraction and precipitating negative inotropy centrally. It also actives a negative chronotrope and lowers blood pressure via reduced aldosterone production.
Two types:
1. Dihydropyridines (Ex: Nifedipine, Amlodipine) – Greater impact peripherally > centrally; cause peripheral vasodilation; indicated for HTN, vasospasm, migraines.
2. Non-Dihydropyridines (Ex: Diltiazem, Verapamil) – Greater impact centrally > peripherall; decrease cardiac conduction and contractility; indicated for management of tachydysrhythmias, HTN, angina
Pearl: In patients who present with overdose, you may NOT the observe classic effects associated with each class of CCB because at high doses, the selectivity of the CCB is lost and acts on both vasculature and myocardium. Patients can subsequently develop a reflex, relative tachycardia with more refractory hypotension in contrast to the classic teaching of hypotension and bradycardia.
Treatment options:
“Most of what we do is magic, the rest is case reports.” - Dr. Otten
1. Intubation is not uncommon for anticipated clinical course and, in this case, for airway protection
2. Initial resuscitation with IVF for hypotension, though are not likely to be fluid responsive. Use with caution especially in patients with CHF, findings concerning for pulmonary edema, CKD.
3. Pressor support (Norepinephrine > Epinephrine > Vasopressin) is important to maintain adequate perfusion and titrated to mean arterial pressure for patient.
4. IV Calcium Chloride (central) administered to help overcome calcium channel blockade and increase cardiac contractility.
5. High-dose Insulin/Euglycemic Therapy is the ONLY treatment proven to have a survival benefit!
a. It address the insulin resistance induced in the myocardium and pancreas by CCB and thus improves cardiac contractility and supports the heart metabolically.
b. Expect to start at “scary” high doses (1.0 Unit/kg/hour bolus followed by a 0.5-1.0 Unit/kg/hr infusion, though can go as high as 10 Unit/kg/hr).
c. Target euglycemia (FSBS 100-200) with supplementary dextrose infusion. Plan for frequent FSBS checks every 15-30 minutes initially and monitor potassium.
6. Methylene Blue is occasionally used for refractory vasodilatory shock. Two MOA (NO scavenger and prevent smooth muscle relaxation via decreased cGMP production). Use less than 2 mg/kg dose. Caution in patients with concomitant SSRI or MAOI ingestions given concern for Serotonin Syndrome.
7. Intralipid is indicated for patients with lipophilic drug ingestions like Amlodipine, but still not routinely recommended by toxicologists. Adverse effects include hypoxemia, acidemia, hypertriglyceridemia.
8. PLEX (ie. Plasmapheresis) effectively filters whole blood and removes highly protein bound components like Amlodipine and returns blood to patient. This is functionally good for certain ingestion pathologies and appeared to be favored at UC.
9. V-A ECMO is unconventional and not typically used for Dihydropyridines OD, but may have more use for Non-Dihydropyridine ODs. Case reports of its use for patients with refractory shock after more conventional methods like HIET, Calcium, and pressors have failed.
Case Resolution: Given amount of Amlodipine, patient lost peripheral selectivity. He was intubated for airway protection given somnolence, underwent PLEX on day 1, was initiated on a levophed gtt, calcium, HIT/D70 therapy. On day 2, extubated, and A-line and CVC removed. Ultimately, he was ultimately discharged to an outpatient psychiatric hospital.
R4 CAPSTONE: THE BIRDER’S FIELD GUIDE TO EMERGENCY MEDICINE WITH DR. BERGER
In the ED, we are asked to take very similar presentations and, with high fidelity, determine a diagnosis. This is very similar to bird watching and identification.
Diagnosis, bird identification, and dual process theory
Dual Process Theory
Type 1 - intuitive, fast, pattern recognition, experience-based, difficult to reproduce (Example: Cardinals, Bald Eagles, Torsades, Unstable)
Type 2 - reasoned, slow, algorithm application, learning-based, accountable (Example: warblers, LBBB with Sgarbossa Criteria, PERC rules)
Calibration is a way in which we balance the two systems level thinking.
Pattern recognition sets us on a path towards one or the other of these systems of thinking. Experience gradually favors system 1 thinking by adding to recognized processes, and our thinking undergoes calibration by the tests we order.
Cognitive forcing is a way of pushing us to think about this balance and check ourselves.
Example: seeing a rarer Cackling Goose amidst a flock of Canadian geese because you forced yourself to look.
In medicine, questioning the triage bias and diagnosis, avoiding anchoring. Example: patient triaged as a “drunk guy” but actually with severe myxedema coma.
Beauty in unlovely places.
Sometimes you find beauty in unexpected places… snow owls on port-a-potties outside Chicago… beauty amidst the chaos, smells, stress of the Emergency Department
Emergency physicians treat people in unlovely places because we are motivated by passion to help those individuals and the challenges of caring for them. We need to remember this and how lucky we are to do so.
Further experience led to deeper appreciation. It is up to us to understand why such a place has tremendous potential and beauty for both ourselves and our patients.
Take Away Points:
Type 1 thinking is intuitive. Type 2 is logical. We do both in emergency medicine
Slow your brain at least once for every patient
Beauty and meaning can exist in unlovely places
PHARMACY UPDATES WITH JESSIE WINTERS, MADDIE FOERTSCH, AND NICOLE HARGER
Anti-Xa Inhibitor Reversal with Jessie Winters
Direct Xa Inhibitors (Examples: Apixaban, Edoxaban, Rivaroxaban)
Recommended reversal method varies depending on institution, organizational recommendations (Western Trauma Association v. ESO v. ACC, etc), but include:
Andexanet alpha acts as a decoy protein, binding and sequestering Factor Xa Inhibitors and inhibiting tissue factor pathway inhibitor
FFP/PCC
Important to know the last dose of Factor Xa inhibitor. Useful to get an anti-Xa level as well to determine drug concentration of factor Xa.
Andexanet alpha administered by either high or low dose regimen based on time since last dose of medication and amount of last dose
Low dose: 400 mg, target 30 mg/min (initial IV bolus) followed by 4 mg/min, up to 120/min (follow-up IV infusion)
High dose: 800 mg, target 30 mg/min (initial IV bolus) follow by 8 mg/min, up to 120/min (follow-up IV infusion)
Evidence base
ANNEXA-4 Trial evaluated safety, efficacy, outcomes for patients with acute major bleeding and a baseline anti-factor Xa activity > or equal to 75 ng/mL. Found similar activity with respect to Enoxaparin, excellent efficacy in ICH hematoma reduction and good efficacy in GI bleeds with respect to hemagloin correction.
Prothrombin Complex Concentrate (PCC) have robust data in Warfarin reversal (faster INR correction, less volume, superior for ICH). In UPRATE, PANOS, et al trials evaluating efficacy of 4-Factor PCC for patients on Factor Xa inhibitors in patients with ICH and non-ICH, could argue that there are some equivalent results across trials.
Take Away Points:
Andexanet alfa and PCC have similar rates of efficacy in both ICH and non-ICH bleeding events
Further data and comparative trials needed to elucidate thrombotic event rates between agents
Andexanet alpha is the only FDA-approved reversal agent for factor Xa inhibitors
Paralytic Reversal with Maddie Foertsch
Depolarizing and Non-Depolarizing
Succinylcholine is an example of a depolarizing NMBA and is an acetylcholine receptor agonist with persistent depolarization.
Rocuronium is an example of a non-depolarizing NMBA and is a competitive acetylcholine receptor antagonist, which binds to the receptor but does not cause action potential.
Rocuronium v. Succinylcholine for RSI intubation
Cochrane Review published in 2015 found that Succinylcholine was superior to Rocuronium for achieving excellent intubating conditions, but no statistical difference in intubation conditions when succinylcholine was compared to 1.2 mg/kg of Rocuronium. Succinylcholine was superior given its shorter duration of action though.
Additional study from Annals of Emergency Medicine in 2018 found that first pass intubation success was comparable between succinylcholine and rocuronium (87% with Succinylcholine v. 87.5% with Rocuronium, aOR 0.9, 95% CI 0.6-1.3).
What about higher dose Rocuronium? Typical dosing of Rocuronium for RSI is 1 mg/kg. Levin et al (Canadian Journal of Emergency Medicine, 2021) found that overall first attempt success was 88.4% for < 1.0 mg/kg, 88.1% for 1.0-1.1 mg/kg, and 89.7% for 1.2-1.3 mg/kg, and 92.2% for greater than or equal to 1.4 mg/kg. The adjusted odds of a first attempt success was significantly higher in ≥1.4 mg/kg group at 1.9 (95% CI 1.3–2.7) relative to the other dosing ranges.
Dosing:
Rocuronium is dosed based on ideal body weight (hydrophilic, low distribution in adipose tissue).
Succinylcholine is dosed based on actual body weight (large volume of distribution)
Sugammadex Use in ED/ICU
Increased sugammadex use for emergent neurologic assessment in ED/ICU after rocuronium or vecuronium administration
Unknown optimal sugammadex dose without train-of-four (TOF) and at various times after rocuronium administration
Takes Away Points:
Consider body weight when dosing Rocuronium
Get a good neurologic exam before using Rocuronium
Sugaamadex restricted to use outside the perioperative setting for reversal of NMBA to facilitate neurologic exam. Restricted to perioperative patients with at least one of the following: inadequate response to neostigmine reversal, reversal for brief procedures when succinylcholine is contraindicated, high risk for residual NMB activity and complications.
Pharmacy Updates with Nicole Harger
Critical shortages of “caines” (be flexible and patient), bacitracin ophthalmic ointment, protamine injections (reviewed on case by case basis for use), 50/100/250/ NaCl bags
Discontinued products - Abciximab (Reopro)
COVID Vaccines
Current J&J lot expiration date extended and we can continue to vaccinate ED patients, but not to any patients with signs/symptoms consistent with COVID
Outpatient administration is now offered through outpatient pharmacy. Appointments helpful, but not necessary. Information sheets available. Just reach out.
Rx Savings Assist
When a patient is prescribed a medication, RX Savings Assist will help identify any savings offers and print information on the patient’s AVS. It also considers patients’ payor type. Active at time of disposition.
Medication Access Services advocates for insured, underinsured, uninsured patients to access their necessary prescription and infusion medications; located in UC Health Business Center
Have helped over 40,000 patients obtain access to medications and net cost avoidance of $32.1 million dollars for FY21 and $6.5 million revenue.
Place an order and refer for Medication Access on EPIC
STI
Updated guidelines for treatment of empiric Gonorrhea/Chlamydia: Doxycycline 100 mg BID PO x 7 days, Ceftriaxone 500 mg IM
Some concern about applicability of recommendations for certain populations, including adolescents. This is in part based on concerns for poorer adherence to Doxycycline regimen.
