Grand Rounds Recap 8.11.21
/R1 CLinical Knowledge: Mesenteric Ischemia with dr. haffner - R4 Capstone with Dr. Roblee: Coping with Patient Death - Quality Improvement patient safety with Dr. Thompson- Trauma consultant corner: Product resuscitation with dr. goodman- pediatric emergency medicine combined conference: neonatal sepsis
R1 Clinical knowledge: Mesenteric ischemic WITH Dr. Haffner
The Case
An elderly male presents with a chief complaint of abdominal pain, nausea, and vomiting. The pain started suddenly two hours prior to arrival, it is constant, and 10/10. He has a history of a myocardial infarction 2 weeks ago, but until today has been recovering well. On examination the patient is tachycardic to 118 with an irregularly irregular rhythm, he is hypotensive with a blood pressure of 92/58, he is tachypneic to 28 but saturating well on room air, and his temperature is normal. He has a mildly distended abdomen that is minimally tender despite significant abdominal pain, and there is no rebound or involuntary guarding.
Epidemiology
45% of cases of mesenteric ischemia are due to arterial embolism, 25% are due to thrombosis, 20% are due to non-occlusive arterial disease, and 10% are due to venous thrombosis.
Presentation
Mesenteric ischemia typically presents with severe abdominal pain that is out of proportion to exam, nausea, vomiting, forceful evacuation of the bowel (vomiting and diarrhea).
Evaluation
Bloodwork frequently demonstrates hyperphosphatemia, metabolic (specifically lactic) acidosis, and leukocytosis (may initially be reactive but these patients can become septic quickly).
Lactic acid has a sensitivity of ~86% and a specificity of ~44% for mesenteric ischemia. However, there is no cutoff, at any pretest probability, where a negative lactate will rule out mesenteric ischemic and so clinical suspicion always warrants imaging.
A CTA of the abdomen and pelvis with and without IV contrast has a sensitivity of 93.3% and a specificity of 95.9%, although its use is limited in non-occlusive mesenteric ischemia. Use of oral contrast is not recommended as it delays obtaining imaging (as you wait for the contrast to travel through the gut) and it can interfere with the detection of subtle findings of ischemia.
Ultrasound evaluation of flow velocities through the celiac artery and SMA is the gold standard for diagnosis of chronic mesenteric ischemia, however ultrasound is less useful in acute mesenteric ischemia.
Treatment
Pain control, aggressive fluid resuscitation, and repletion of electrolytes are the initial steps in treating a patient with suspected mesenteric ischemia. A heparin drip should be started promptly to prevent further clot propagation and stenosis/thrombosis. Avoid pressors if at all possible, and if you do have to use a pressor, prefer to use dobutamine, low dose dopamine, or milrinone. Start antibiotics which cover intestinal flora, typically cephalosporin and metronidazole. Contact general surgery and vascular surgery, which team intervenes will depend on how proximal/distal the occlusion is, how ischemic the gut has become and local preferences. Frequently, operative management requires involvement from both services, so get them involved early to avoid delays to the operating room.
r4 Capstone: Coping with Patient Death WITH Dr. Roblee
The Case
Toned out on Aircare for ‘teen vs car’. On arrival on scene, the patient was on the stretcher in the back of the ambulance. The patient was pale, unresponsive with a GCS of 5, profoundly tachycardic with a palpable only blood pressure, and hypoxic to the 70s.The patient was intubated, started on blood products, and was given TXA and hypertonic saline before being transported to the helicopter. In the helicopter the patient had a cardiac arrest. Bilateral needle thoracostomies were performed along with a cardiac echo which demonstrated a large pericardial effusion, and so a pericardiocentesis was also performed. ROS was obtained but the patient lost pulses again shortly after arrival to the emergency department and subsequently passed away.
The initial thoughts of the provider focus on ‘what else could I have done for this patient?’.
What makes a patient's death more emotionally powerful for physicians?
Patient age
The death of a younger patient is typically more challenging for physicians than the death of an older patient.
Cause of Death
The specific cause of death may be more challenging for a physician to cope with. Specifically sudden and unexpected deaths, as these can increase the feelings of loss, or when the cause of death is unknown which can insight guilt and prevent closure.
Family Members
The presence of family members and how they react to the death of their loved one.
Patient similarity
The death of a patient who is very similar to yourself or a loved one may be particularly difficult to handle as a physician.
A sense of responsibility
The feeling that something you did or did not do may have been ultimately responsible for their death.
How do emergency physicians react to the death of a patient?
Studies suggest the most common reactions are sadness, disappointment, acceptance, frustration, stress, and guilt.
55% of EM physicians reported experiencing physical symptoms as well, including chest pain, nausea, insomnia, difficulty concentrating, and fatigue.
Long term effects may include:
Grief spillover into your personal life
Burnout
Changing future treatment decisions based on a that specific case
Distraction
Motivation to provide better care
How do we cope?
Talking to colleagues
Talking to friends and family
Continue working
Talk to the patient’s family
Exercise, meditation, and prayer
Case follow up: an autopsy of the teenage patient who was flown from a motor vehicle accident revealed widespread blunt trauma which resulted in profound internal bleeding.
As challenging as this case was, the providers did what they could do for this patient with the resources they had. Unfortunately, sometimes the extent of our patients’ illness is beyond the limits of modern medicine or what resources we have access to in time sensitive illnesses.
The sixth stage of guilt: finding meaning in our work
Every patient encounter, no matter the outcome, makes us better physicians and allows us to take better care of the next patient.
Sometimes despite futility, knowing that you did everything you could to give your patient their best chance at survival, can provide peace and closure.
qaulity improvement patient safety WITH dr. thompson
The three prongs of quality improvement in healthcare:
Improving patient experience
Measures: ED length of stay and boarding times, patients receiving updates throughout their care, their interface with the healthcare system both during and after their encounter
Improving health and reducing harm
Measures targeted at improving patient outcomes and minimizing chances of harm at various points in patient care
Reducing cost
Measures: Mindful prescribing and testing
Run charts
A run chart is a line graph of data plotted over time. It typically includes a centerline (green) which represents the median of the data. These are simple and do not require statistics to produce or interpret.
An example of a run chart
Types of variation seen in runcharts:
Common cause variation (blue data points below)- variation that is due to random chance over time. Note how on small samples of the graph this can look like a trend rather than random variation over time.
Special cause variation (red data points below) - when one or more factors systematically affect the data in a non-random way. Special cause variation results in a change in the data set that alters the center line (either up or down). Quality improvement work strives for special cause variation.
Run chart with common cause and special cause variaiton demonstrated\
Control Charts
Like run charts, the x-axis is time, and the y-axis is occurrences. However, the center line in control charts is the mean. You then denote the upper control limit (3 standard deviations above) and the lower control limit (3 standard deviations below).
We can use control charts to target change within the department. From them we can develop key driver diagrams (left) which instill means of change, the impact of which can be measured with control charts (right). For example:
trauma consultant corner WITH dr. goodman
Hemostatic resuscitation - how to prevent coagulopathy and medical bleeding before surgical bleeding is controlled.
Goals of Trauma Resuscitation
Achieve normovolemia and hemodynamic stability
Correct major acid-base disturbances
Improve organ function and microvascular blood flow
Prevent reperfusion injury
Normalize oxygen delivery to tissues
Compensate for fluid shifts
Hemorrhagic shock
Hemorrhagic shock comes in 4 classes. Note that class I hemorrhagic shock has no change in any vital sign
Where can blood be lost: the chest, the abdomen, the pelvis and retroperitoneum, the thigh, the GI tract, and the street or the OR.
Classes of Shock
Replacing blood loss:
Crystalloids: replace every 1 mL of blood lost with 3 mL of crystalloid
Colloid: replace every 1 mL of blood lost with 1 mL of colloid
Blood product: replace every 1mL of blood lost with 1 mL of blood product
Packed RBCs
Have a shelf life of 42 days
Each unit contains 250 mL -350 mL of red cells and preservatives, some of which are anticoagulants - something to be mindful of in a large volume transfusion
Fresh Frozen Plasma
A unit of plasma takes about 45 minutes to thaw, once thawed it only lasts about 5 days.
The INR of plasma is 1.3 -1.7. 1 unit increases the level of each clotting factor by about 2-3%
Plasma needs to be ABO-compatible but does not require Rh typing because there is no cellular component that could cause a reaction.
Platelets
May be pooled from multiple donors or spun down from a single donor.
Platelets are stored at room temperature, and last for 5 days.
Each 10-12 units of pRBCs decrease the platelet count by 50%, remember to be mindful of this in massive transfusion
Give 1u of platelets for every 6 units of PRBCs
Cryoprecipitate
Collected by thawing plasma at 4 degrees Celsius
Contains Von Willebrand factor, Factor VIII, XIII, and fibrinogen
The Hemorrhaging Trauma Patient
40% of trauma related deaths are due to hemorrhage. Hemorrhage represents the most common cause of preventable death after trauma.
2-5% of trauma patients end up requiring massive transfusion
Tissue injury + shock leads to an acute traumatic coagulopathy. This situation gives rise to the lethal triad of acidosis, hypothermia, and coagulopathy.
Damage control resuscitation in trauma
Limit crystalloid administration in order to prevent dilution, acidosis, and edema
Use whole blood or use high platelet and plasma ratios
Embrace permissive hypotension until the bleeding can be surgically controlled, this minimizes ongoing hemorrhage and aims to keep transfused blood in the vessels.
Studies have evaluated a 1:1:1 massive transfusion protocol vs a 1:1:2 massive transfusion protocols. There was no difference found between the two protocols in 24 hour or 30-day mortality. Additionally, there was no difference in complications (ARDS, sepsis, transfusion reactions). However, fewer patients bled to death within 3 hours in the 1:1:1 group.
Whole blood delivers the same components as 1:1:1 in less total volume than its summative counterparts, but it also contains less total anticoagulant.
Massive Transfusion Triggers
The ABC score
Having 2 of the below findings indicates a 50% chance of needing MTP, 3 =75%, and 4= you need MTP.
HR > 120
sBP < 90
Positive FAST exam
Penetrating MOI
Massive Transfusion Complications
TRALI/TACO
Citrate Toxicity - hypocalcemia, hypotension, narrowed pulse pressure, cardiac arrhythmias
TEG for product resuscitation guidance
A TEG evaluates various aspects of the blood's ability to form and maintain a clot. It can guide product resuscitation and predict the need for massive transfusion.
For details on interpreting a TEG, check out this post on TamingTheSRU. Tough guidelines for product resuscitation based on TEG results are as follows:
If the R time is over 55 seconds, give plasma
If the angle is less than 55 degrees, give cryoprecipitate
If the MA is less than 55mm, give platelets
If the LY30 is over 3%, give TXA
TXA
CRASH-2 trial: Prehospital TXA reduced all-cause mortality 14.5 to 16%
CRASH-3 trial: looked at TXA in TBI and found improved mortality in patients with mild to moderate head-injuries, but not in patients with severe head injury
Dr. Goodman’s thoughts on when to give TXA
Give prehospital TXA only if the systolic blood pressure is less than 70 mmHg
Give TXA if you are already giving blood and the Ly30 is > 3% on the first TEG
Give TXA If you have activated MTP and are through the first cooler (6+6) and you do not have a TEG back yet
Give TXA In patients with a TBI who have a GCS < 12 with proven intracranial blood, or any proven TBI + hemorrhage and hypotension.
pediatric emergency medicine combined conference: neonatal sepsis WITH Dr. Ketabchi
Ill-appearing neonates with or without fever/hypothermia should have a full sepsis evaluation
Neonates are a patient population where ‘trusting your gut’ can lead you astray, so rely more on clinical decision rules and testing in this population.
What is a fever and what is hypothermia: a temp > 38 degrees Celsius or < 36 degrees Celsius. Rectal temperature is the gold standard but do not disregard alarming temperatures obtained by other modalities.
Bundling affects skin temperature but not the rectal temperature.
Critical points in the history of a febrile or hypothermic neonate
Was the child premature and was there a NICU stay?
Did mom have any infections during pregnancy or birth?
How is baby feeding?
Goal is 1-3 oz q2-3hr in the first few weeks of life or 10-15 minutes q2-3hrs if breast-feeding
How many wet diapers in the last 24 hours?
Goal is at least 3
Have they regained their birth weight by then end of the second week of life?
Critical points in the physical exam
Feel the fontanelle, it should be soft and flat. The anterior fontanelle closes completely around 2 years of age.
Capillary refill - neonates normally have acrocyanosis and delayed peripheral capillary refill (even healthy ones!), so check their capillary refill on their chest.
Be wary of rashes, specifically vesicular ones.
Check tone and reflexes.
The Hypothermic Neonate
Up to 8% of neonates who present with hypothermia have a serious bacterial infection or HSV
Neonatal HSV
It is rare, approximately 3-30 per 100,00 live births
85% of infections occur through perinatal transmission. The majority of transmission occurs in mothers without known HSV.
The peak incidence of neonatal HSV is in the first 2 weeks of life. The incidence declines dramatically after the first month of life.
Clinical features of neonatal HSV include vesicular lesions, conjunctivitis, oral ulceration, seizures, lethargy, and poor feeding. Skin findings are present in only about 60-70% of cases. Patients with severe disease can develop sepsis, hypotension, and DIC.
Neonatal brains are not fully myelinated yet, and so generalized tonic-clonic seizures may not present the way we typically picture them. Instead, the seizures may be very subtle, so be hesitant to dismiss parental concerns for subtle seizure-like activity that otherwise may not sound like a typical seizure.
Infants with fever or hypothermia: what do we do?
Infants < 29 days old
Get a full sepsis workup, antibiotics, and admission
Infants 29-60 days
Apply the PECARN stratification tool
Infants with soft tissue infections; do they need a full workup?
In a study of 172 kids that had cellulitis or an abscess, only one had a serious bacterial infection.
Another study looked at 104 afebrile neonates with a soft tissue infection. 84% of these patients had cellulitis and 55% of them had an abscess. All were admitted to the hospital for observation. None of these patients had a serious bacterial infection.
