Grand Rounds Recap 8.14.24

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Early Pregnancy Loss (EPL) WITH Dr. Pensak

  • Definition: Non-viable, intrauterine pregnancy with either an empty gestational sac or gestational sac containing an embryo without cardiac activity

  • > 500,000 visits a year for EPL

Diagnosis

  • Symptoms like bleeding and cramping can be common in early pregnancy

  • There are many variabilities between presentations of a threatened abortion

  • Dx of early pregnancy loss may be made by a combination of ultrasound findings and abnormally progressing beta-hCG levels

Management Options and Counseling

  • Expectant management

    • 80% effective with adequate time (up to 8 weeks)

    • May be more effective in symptomatic patients

    • Follow-up ultrasound recommended to assess for passage of gestational sac

  • Medical management

    • Regimen: 800 mcg misoprostol vaginally, repeat dose if needed for no bleeding (>3 hours, less than 7 days)

    • Effectiveness: 70% with one dose, 84% with second dose as needed

  • Medical and Expect Management Counseling

    • Counseling should include anticipatory guidance on expected bleeding, pain, and the potential need for surgical intervention

    • Adequate pain medication should be given as passage of pregnancy can be very painful

    • Follow-up with ultrasound or b-hcg should be performed to confirm completion

  • Surgical Management

    • 99% effective

    • Should be performed immediately with any signs of hemodynamic instability or infection

    • Can be offered in OR, outpatient office or some ER settings with electric vacuum aspirator (EVA) or manual vacuum aspirator (MVA)

    • Use of antibiotics recommended (200 mg doxy x 1 pre-op)

Implication of Policy on EPL

  • Laws surrounding pregnancy and abortion can have significant impact on people experiencing EPL and pregnancy of unknown location

  • Under “fetal harm legislation” people have been charged with crimes related to pregnancy loss in cases when they have experienced physical trauma, declined medical advise, or used drugs in pregnancy

Supporting Patients after EPL

  • Patients experiences pregnancy loss differently. There is no “right” or “wrong” way to feel, but it is important to recognize when our patients may need additional emotion support

    • Future pregnancy planning; address patients desires in regards to future pregnancy planning and counsel accordingly.

    • Screen for risk of depression. Offer SW contact or follow-up visit if needed

STemi mimics WITH Dr. Lang

History of STEMI definitions

  • ST-elevation criteria was developed in 1980s

  • 1994: Meta-analysis of thrombolytics

Fourth Universal Definition of MI

  • Type 1: Plaque rupture

  • Type 2: Supply/demand mismatch

  • Type 3: Sudden death

  • Type 4: PCI-related MI

  • Type 5: CABG-related MI

The Occlusion MI (OMI) manifesto

  • Helps find people with early occlusions who benefit from PCI

  • STEMI definition misses 25-30% OMI

  • STEMI (-) OMI patients do worse

What are the OMI criteria?

  • Hyperacute T waves

    • Can the QRS complex fit under the T waves?

    • De Winters T waves

      • Upsloping ST depression

  • Posterior MIs

    • 1/2m mm ST elevation needed in V7, V8, V9 for posterior STEMI

  • Acute pathologic Q waves

    • Q waves do not always mean completed infarct

    • Under normal circumstances, Q waves are not seen in the precordial leads

  • Terminal QRS distortion

    • Loss of the preceding S wave

Ischemia Mimics

  • Pericarditis

  • Benign early repolarization

    • Diffuse concave STE

    • STE:T wave <0.25

    • J waves

    • Increase with bradycardia

  • Hyperkalemia

  • LVH

  • Isolated AVR elevation

  • LBBB

  • Brugada

Peds triple threat WITH Drs. Chang and khan

Lumbar Puncture

  • Indications

    • Meningitis, encephalitis

    • ICH

    • Increased IOP with negative HCT imaging

  • Why use spinal needle with stylet

    • Intraspinal dermoid cysts/tumors theoretically a risk of using a spinal needle without a stylet (through the skin)

  • Setup

    • Do the positioning that is comfortable for you

    • Lateral decubitus

      • Make sure the spine is parallel to the bed and hips/shoulders are perpendicular to the bed

  • Complications

    • Traumatic tap

      • Often comes from advancing too quickly through the venous plexus

Oral boards/Patient case

  • Patient case: 20 month old with 6 days of fever. Tachycardic and febrile to 40.2 degrees C.

    • Cranky with decreased PO but drinking liquids with wet diapers. Mild cough today. Noted a rash 2 days ago, but went away. He also he had red eyes at the pediatrician office yesterday. Fully vaccinated

    • Physical exam notable for: 

      • Clear lungs, 3 second capillary refill

      • Red lips, red tongue that is not enlarged, erythematous posterior oropharynx

      • R sided lymph node

      • Normal neck movement

    Kawasaki disease

    • Criteria

      • Fever persisting for at least 5 days PLUS

        • At least 4 of the following

          • Extremity changes (erythema, peeling, edema)

          • Rash (polymorphous exanthema, NOT bullous)

          • Changes in lips and oral cavity (erythema, cracked lips, strawberry tongue)

          • Conjunctival injection (bilateral, bulbar sparing limbus, non-purulent

          • Cervical lymphadenopathy (>1.5 cm in diameter, usually unilateral)

      • Infants with fever >7 days without other explanation

      • Clinical features do not have to be at time of presentation but within illness period

    • Management

      • IVIG

        • Exact mechanism unknown

        • 10-20% of kids have refractory KD-fever comes back so need repeat IVIG plus prednisone

      • ASA: 80-100mg/kg/day divided q6h until fever free then transition to low dose

Simulation

Patient presentation: Neonate with bradycardia, hypoglycemia, hypothermia

  • DDx: sepsis, respiratory distress syndrome, congenital heart disease, intrathroacic lesion

  • NRP

    • Decision to use PPV should take <1 minute

      • Should be given 40-60 breaths per minute (breath, 2, 3, breath, 2, 3)

      • PEEP 5, PIP 20

    • If still not ventilating well, go through MRSOPA

      • M: mask adjustment

      • R: reposition airway

      • S: suction mouth

      • O: open mouth

      • P: pressure increase

      • A: airway alternative

  • Hypoglycemia

    • In neonate is <40

    • Treatment: bolus 2mL/kg of D10

    • Infusion: D10W 60ml/kg/24hr= 2.5 ml/kg/hr

  • Umbilical vein catheter

    • 3 supplies

      • Catheter, UVC tray, normal saline flush

    • 3 steps

      • Clean, tie, cut

    • 3 steps for catheter

      • Attach stopsock, attach flush, flush catheter and stopcock

    • Advance 2-4 cm in premature neonate and 3-5 cm in term neonate until get blood flow

  • Questions for Mom

    • When did water break?

    • Significant amount of blood?

    • History of diabetes