Grand Rounds Recap 8.07.2024

/

abem updates WITH dr. melissa platt, abem board of directors

  • Beginning 2026, ABEM will be requiring a new certifying exam to replace the previous oral boards. This was felt to be a necessary change in response to decreasing ITE scores and first-time board pass rates

  • The written exam will still be required and is not changing

  • The new certifying exam will be offered in-person in Raleigh, North Carolina with 9 sessions per year

  • There will be two case types: clinical care cases and objective structured clinical examination (OSCE) cases

  • Continuing certification requirements (aka CME) will be required every 5 years after passing the boards

  • ABEM will publish sample cases online in advance of the new certifying exam

r4 capstone WITH dr. lawton

  • A “frequent flier” in the ED is defined as someone with >4 ED visits per year

    • Occur more frequently in patients who are insured by Medicare and Medicaid

  • ED “super-utilizers” have >18 ED visits annually

    • Represent ~3% of all ED visits

    • For certain chief complaints such as abdominal pain, back pain, or headache, may account for up to 40% of all ED visits

  • High ED utilization is associated with adverse effects

    • Episodic, fragment care

    • At risk for both over- and under-treatment

    • Contributes to longer ED wait times and strain on the healthcare system

    • Contributes to ED physician burnout

    • The Emergency Department is often not best suited to meet these patients’ complex care needs

  • ED physicians are impacted by our biases, and it is important to recognize our explicit and implicit biases, especially when caring for ED frequent fliers and super-utilizers

sepsis operations update WITH dr. shewakramani

  • Sepsis is a condition that carries high morbidity and mortality

  • Bundled sepsis care has been shown to improve mortality

  • CMS definitions are important to recognize; especially because hospital reimbursement is affected by compliance with the sepsis bundle in an “all-or-nothing” fashion

    • Severe Sepsis

      • Source of infection PLUS

      • 2 or more SIRS criteria:

        • Temp <36 or >38

        • HR >90

        • RR >20

        • WBC <4k or >12k or >10% bands

      • End Organ Dysfunction

        • Elevated creatinine, troponin, lactate, INR, or bilirubin

        • Decreased platelets

    • Septic Shock

      • Lactate >4

      • Hypotension

  • Sepsis Reassessment

    • Within 3 hours

      • Lactate measurement (repeat if >2)

      • Blood cultures

      • Antibiotics

      • IV Fluids (30 cc/kg bolus if in septic shock)

    • Within 6 hours (if septic shock)

      • Pressor initiation

      • Reassessment of tissue perfusion

  • CMS sepsis compliance data is available online to the general public

r3 taming the sru: “7 Airways in 7 Hours” WITH dr. artiga

  • Inhalational injuries can be characterized by their anatomic location

    • Supraglottic Inhalational Injury

      • Caused by direct thermal injury

      • Usually present within the first 24 hours

    • Infraglottic Inhalational Injury

      • Caused by mucosal sloughing from inhalation of noxious chemicals

      • Presentation can be delayed by up to 36 hours

  • There is some data that we over-triage to intubation for burn victims, as many of these patients get extubated quickly

  • Little data on which burn victims need to be intubated, but there is some consensus that any signs of upper airway compromise such as stridor, respiratory distress, accessory muscle use, or any edema or blistering of the oropharynx

    • Our typical indications for intubation still apply: failure to oxygenate, failure to ventilate, failure to protect airway, and anticipated clinical course

  • Pregnant patients are at high risk of physiologic compromise during the intubation period

    • Hormonal changes cause increased edema of the vocal cord structures

    • Diaphragm elevation reduces functional residual capacity

      • Pre-oxygenation is especially important

      • Consider an awake look intubation in ill patients who are less likely to tolerate the apnea period

    • Increased intra-abdominal pressures and reduced lower esophageal sphincter tone predisposes to vomiting

  • Positioning is very important in pregnant patients

    • Position the woman with the HOB at 30 degrees and left lateral tilt to improve venous return by reducing pressure on the IVC

diarrheal illnesses WITH dr. roche

  • Diarrheal illnesses carry significant morbidity and mortality worldwide

  • Food-borne illness tends to present within the first 6 hours after exposure, can be caused by the bacteria themselves or pre-formed bacterial endo-toxins

  • Traveler’s diarrhea can occur in >20% of travelers to high-risk regions (includes many areas of South America, Africa, and Southeast Asia)

    • ‘Traveler’s diarrhea’ is a misnomer, can occur in patients that live in these regions

    • Most common cause is ETEC (enterotoxigenic E. coli)

    • Can have serious consequences in the young, elderly, and immunocompromised patients

    • Prevention:

      • Avoid drinking non-bottled or non-treated water or consuming ice or mayonnaise-based foods

      • Pepto-Bismol at high-doses (500 mg QID) can be effective in preventing traveler’s diarrhea

      • Rifaximin may be used for prophylaxis in high-risk individuals

        • Azithromycin is commonly prescribed for prophylaxis but is generally not recommended due to risk of resistance

      • Chronic GI illnesses and PPI use are associated with increased risk of traveler’s disease

    • Treatment

      • Single-dose ciprofloxacin

        • Previously first-line, though certain areas have high rates of resistance

      • Single-dose azithromycin (1000 mg once)

  • Life-Threatening Causes of Diarrhea

    • Cholera

      • Mortality rate approaches 50%, associated with significant hypovolemia and electrolyte derangements

      • Oral rehydration is the mainstay of treatment

        • Ideal “home regimen”: 6 tsps sugar + 1/2 tsp salt in 1L water

      • Doxycycline and azithromycin can be used for treatment to reduce length of illnesses, but many improve with rehydration alone

    • Typhoid

      • High risk of progressing to bowel perforation and death

      • Can be spread by fingers, flies, fomites, and feces (“Four F’s of Typhoid”)

    • EHEC (Enterohemorrhagic E. Coli)

      • Associated with hemolytic uremic syndrome (HUS), especially in children

      • Avoid treating children with bloody diarrhea with antibiotics, can increase the risk of developing HUS

  • Water Purification

    • Water in the United States is treated to reduce colony counts below pathogenic levels but not completely sterilized

      • Common commercial methods of treating water include flocculation, settling, filtration, purification, and disinfection (usually a halogen, such as chlorine, which stays in the water and can treat any downstream contamination; UV light can also be used)

    • If you have no way to treat your water, allowing it to sit and “settle” in a container for 2-3 days will cause most pathogens to sink to the bottom, allowing clean water to rise to the top

    • Allowing water to sit in bottles in the heat in regions near the equator can also be effective in disinfecting water