Grand Rounds Recap 8.2.23
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Sick vs. Not Sick WITH Dr. knight
“The eye cannot see what the mind does not know”
There is a middle ground between minimalist and risk-averse evaluation of patient
EM physicians can use system 1 thinking pretty accurately to describe disposition for patients based off of initial gestalt
“What do I see when I walk in the room?”
Ask it on morning report/oral board prep, this is your first great indication of how sick the patient is
Look at the patient’s eyes, check pulses, how are they interacting with you? Are they agitated, comfortable, or somnolent?
Gut vs. Data
If you aren’t thinking about it, you will not test for it
If that test crosses your mind and you are talking yourself out of it, you should probably do/order that test
You overconfidence is your weakness and be aware of your own wellness bias
Sometimes you do have to make quick decisions, but majority of situations you have the ability to take your time, take a deep breath, and assess the situation
Clinical Pearls:
Pay attention to alarms (including when nursing raises the alarm)
Vital signs are vital signs - stop trying to explain them away if you don’t have a good reason for specific vital sign abnormalities
You can’t fake diaphoresis
Review your own images
You are going to make mistakes, learn from them. Especially from your supervisors and teachers mistakes
Clinicopathologic Case (CPC) WITH Drs. Della porta and Kimmel
Ovarian cysts are ubiquitous but often physiologic and self limited
Lack of adnexal tenderness ≠ no ovarian cyst (think rupture!)
Consider serial abdominal exams and repeat CBC
Does the patient have greater than 48 hrs of pain or concern for torsion? The patient needs a transvaginal ultrasound w/ doppler with gynecology consult and possible laparotomy
TVUS is not just for torsion, it can also be used for ectopic pregnancies or pregnancy of unknown location
Acute Ischemic Stroke Updates WITH Drs. Demel and kreitzer
Expanding indications for Thrombolytics
Initial tPA window of 0-3 hours number needed to treat (NNT) to achieve a good outcome was 10. The expanded window of 3-4.5 hours increased the NNT for a good outcome to 20.
The MRI Wake Up protocol allows for an additional group of patients, who wake up with unknown onset of symptoms, so receive an MRI within 3 hours of symptom recognition. If there is a “mismatch” between DWI and Flair windows, then this enables patients to be treated with tPA within 4.5 hours of symptom recognition.
Novel Thrombolytics
Tenecteplase (TNK) is a mutant variant of alteplase which has a theoretical lower risk of complications and longer half-life, so only a bolus is needed.
Throughout multiple trials, TNK was found to be at least non-inferior to tPA and at best slightly better functional outcomes for patients with similar complication rates
Expanding Indications for Endovascular thrombectomy (EVT) - Now available up to 24 hours after symptom onset, but requires there to be an LVO and some additional imaging such as CT perfusion to assess for core infarct vs. penumbra past 6 hours of symptoms.
Recent Updates - There are many trials coming up or active to continue to broaden acute ischemic stroke care. This include increasing EVT scope for smaller vessel lesions, treatment of large core strokes, treatment of patients with low NIHSS, and those with previous disabilities.
EKg quick hits: AV blocks WITH Dr. Lang
1st degree - can occur from multiple factors, but often a normal variant
2nd degree type 1 - Progressively prolonged PR interval with a dropped beat
Patients are normally not symptomatic because of this
Do not need cardiology, spectrum of normal variant
2nd degree type 2 - Consistent PR interval with randomly dropped beats
Can be seen in anterior MI, different anti-arrhythmic medications
Usually a problem within the His-Purkinje system, usually diseased tissue or fibrosis
More likely to lead to 3rd degree heart block compared to 1st degree and 2nd degree type 1
3rd degree - complete dissociation between p waves and Q waves
If you are not sure - 2 minute rhythm strip and look at lead V1 and II, can increase paper speed and amplitude, and can use lewis leads (look at leads I and II)
R4 Capstone: overtesting in the ed WITH dr. yates
Over-testing and overdiagnosis do not change outcome positively and have a physical, social, and economic cost to our patients and the healthcare system
There are a multitude of reasons why emergency physicians over-test, including concern for malpractice fear, perfectionism and desire for diagnostic certainty, consultant recommendations, and difficulties getting tests outpatient or from other hospital systems.
Some solutions include patient engagement, tort reform, and improved physician education and feedback and their own imaging practices and clinical decision rules.
Research Grand rounds WITH Drs. Freiermuth and Sucharew
How do you determine what data your trust?
There is a hierarchy of evidence from case reports, opinion papers, and letters all the way to meta-analyses and systematic reviews
You should look at authors and funding sources of the study. Are there conflicts of interest and do the authors have relevant expertise?
Study validity looks at if you can easily determine what question is being answers, are the methods clear, how many participants were excluded and why, and was bias appropriately minimized?
In regards to results of a study, you will need to determine if all outcomes discussed in the introduction were reported, if side effects were reported, if confidence intervals were included, and if the conclusions actually match the results.
How do you apply the knowledge of studies you review?
Do you trust the data?
Is the study generalizable to the population or environment you will be applying this knowledge?
Will need to review and discuss the risks and benefits of the intervention.
