Grand Rounds Recap 8.30.2017
/august morbidity and mortality conference with Dr. Gorder
Case 1: Therapeutic Paracentesis in the ED
- Indications:
- Tense ascites
- Refractory ascites (90% of cases can be managed medically)
- Palliative care
- Possible Complications
- Post-paracentesis Hypotension
- Likely caused by splanchnic vasodilation / decreased abdominal pressure leading to increased cardiac output
- BP usually nadirs at 2-3 hours following procedure
- Average MAP falls by 7mmHg
- Paracentesis-Induced Circulatory Dysfunction
- Usually occurs after large volume taps (>5 Liters)
- Fluid shifts lead to decreased circulatory volume
- Renin and sympathetic nervous system stimulation can lead to hepatorenal syndrome
- Risk is decreased with albumin administration
- Post-paracentesis Hypotension
- Summary / Recommendations
- Generally safe to perform in the ED, though time consuming
- Patients who have >5 liters removed should be given albumin (6-8 grams per liter of fluid removed)
- General practice is to not remove more than 10 liters, though not based on literature
- Patient should be observed for 2-3 hours to monitor for post tap hypotension / circulatory dysfunction
Case 2: ED Hyperkalemia Management
Hyperkalemia: K+ > 5.5 mEq/L puts patient at risk for conduction abnormalities and arrhythmia
Expected conduction changes / EKG abnormalities
- K+ >5.5: Begin to see repolarization abnormalities
- Peaked T waves on EKG
- K+ >6.5: Progressive paralysis of atria
- P Wave flattening
- PR Segment lengthening
- K+ >7.0: More severe conduction dysfunction and bradycardia
- Prolonged QRS
- High grade blocks
- K+ >9.0: High likelihood of cardiac arrest
- K+ >5.5: Begin to see repolarization abnormalities
***History of Hyperkalemia (ex. patients with CKD or ESRD) is not cardioprotective***
- Management in the ED
- Medications
- Calcium (Gluconate or Chloride): Decreases Myocardial Excitability
- Indication:
- Any EKG Changes in the setting of hyperkalemia
- OR serum potassium > 6.0 mEq/L
- Dose:
- Calcium Gluconate: 1.5 - 3g over 2-5 minutes
- Calcium Chloride: 500 - 1000mg over 2-5 minutes
- Onset/Duration
- Cardiac stabilization peaks at 10-15 minutes
- Re-Dose q 5-10 Minutes
- Titrate to EKG changes
- Risks:
- Tissue necrosis (Especially CaCl)
- Hemodynamic instability
- Potentiates cardiotoxic effects of digitalis
- Indication:
- Insulin / D50: Stimulates NA/K/ATPase Pump - Transcellular shift of K+ into cells
- Dose: 10 Units Regular Insulin IV push / 1 amp of D50
- Onset/Duration:
- Onset is almost immediate
- Intracellular effects last 4-6 hours
- Decreases serum potassium by 0.5mEq/L in first 15 minutes
- Decreases serum potassium by 1 mEq/L in first 2 hours
- Risks: Hypoglycemia
- Beta Agonists
- Dose: 10-20mg of inhaled albuterol (due to lack of IV in the US)
- Onset/Duration:
- 10 minutes to peak plasma concentration
- Half-Life 3.5-5 hours
- Decreases serum potassium of up to 0.6mEq in 30 minutes
- Decreases serum potassium of up to 1 mEq in 1 hour
- Re-dose q 1-2 hours
- Risks: Tachycardia, anxiety
- Sodium Bicarbonate
- Dose: 50mEq IV Bolus
- Onset/Duration:
- Rapid effect on pH
- May not affect K+ for 4-6 hours, if at all
- ***EFFICACY***
- Physiologically will only function if patient is acidotic (and patient is compensating)
- Overall efficacy for lowering K+ is debatable.
- Kayexalate
- Recommend against use in the ED
- Evidence of efficacy is poor, and onset >8 hours
- Case reports of harm (bowel necrosis, etc)
- Calcium (Gluconate or Chloride): Decreases Myocardial Excitability
- Frequent Reassessment
- Re-check potassium q1 hour
- Re-check EKG more frequently if abnormalities present
- Medications
Case 3: Procedural Sedation in the ED
What defines sedation?
"Procedural sedation is a technique of administering sedatives or dissociative agents with or without analgesics to induce a state that allows the patient to tolerate unpleasant procedures" - ACEP Policy Statement
- Levels of Sedation: Exists on a continuum that must be prepared for and is unique to the patient in front of you. The deeper the sedation, the greater the risk of adverse events.
- Minimal
- Moderate
- Deep
- General Anesthesia
- Most Common Adverse Events in the ED:
- Apnea
- Hypoxia
- Hypotension
- Vomiting
- High Risk Subgroups shown to have a higher risk of complication
- Age > 80 years old
- Poor airway protection (ex. Poor cough)
- Underlying respiratory disease (COPD, etc)
- Hypoxia at baseline
- Monitoring
- All patients require respiratory and cardiac monitoring during procedural sedation
- End Tidal CO2 Should be utilized
- Gives more immediate feedback on respiratory rate, depth, etc
- Pulse ox changes often delayed several minutes after development of respiratory depression.
Case 4: Refractory Shock
- Determining Etiology of Shock (Cardiogenic, Obstructive, Distributive, Hypovolemic)
- Early and dynamic use of the RUSH(ed) exam (Rapid Ultrasound for Shock and Hypotension)
- Heart (Parasternal long and apical 4 chamber view)
- Assess squeeze and valves, which is hypodynamic may suggest cardiogenic shock
- Hyperdynamic heart may suggest distributive or hypovolemic shock
- Right sided strain (D sign) or enlargement may suggest PE
- Lungs (anterior pulmonary view)
- Lung sliding
- Assess for B-lines which may suggest edema vs infection
- Morrison's and Splenorenal spaces w/ view of diaphragm
- Check for blood/fluid in abdomen or chest (hemothorax/effusion)
- IVC
- Assess for hypovolemia suggesting hypovolemic shock
- Aorta
- Assess for AAA
- Heart (Parasternal long and apical 4 chamber view)
- Early and dynamic use of the RUSH(ed) exam (Rapid Ultrasound for Shock and Hypotension)
- Management of refractory distributive shock
- Fluids: Do we give more?
- Excessive fluid resuscitation shown to worsen mortality
- FEAST trial showed significant increase in mortality with aggressive fluid expansion
- Evidence of fluid overload in EGDT septic shock patients showed increase in in-hospital mortality
- Recommend continuous evaluation of fluid responsiveness. Examples include:
- Assess pulse pressure variation
- Passive leg raise (with or without VTI)
- IVC diameter/variation
- Non-Invasive cardiac monitoring
- Excessive fluid resuscitation shown to worsen mortality
- Pressors: Which do we use?
- Norepinephrine: 1st choice
- Epinephrine: 2nd choice
- Vasopressin: VASST trial showed no benefit as solo pressor. Surviving sepsis campaign did demonstrate benefit when used in conjunction with norepinephrine in reduction of dose of norepi
- Dopamine: Usually not recommended except in profound bradycardia
- Push-Dose Calcium: Shown to worsen outcomes in all comers. May be of benefit in patients with hypocalcemia.
- Steroids:
- CORTICUS trial in 2008 demonstrated improved response to levophed (speeds reversal of shock without mortality benefit) with 50mg bolus of hydrocortisone
- Surviving Sepsis Guidelines suggest hydrocortisone in the setting of refractory hypotension despite adequate fluid resuscitation and vasopressor therapy, although admitting the evidence is weak.
- Sodium Bicarbonate
- Surviving Sepsis Campaign recommends against routine use
- In setting of severe acidosis pH < 7.1 and hemodynamic instability it may be considered (if patient compensating)
- However, recent meta-analyses with sepsis and severe acidosis were inconclusive
- Methylene Blue
- Inhibits NO production
- Has been shown in some studies to decrease pressor requirements
- Two large systematic reviews (Kwok et al 2006, Hosseinian et al 2016) were inconclusive/lacked high quality evidence
- May be used as last resort
- Fluids: Do we give more?
- Possible Future Therapies to Watch for:
- Esmolol: Reduce heart rate to allow for greater diastolic filling and increased CO.
- High Dose Insulin and Glucose: For inotropic benefit.
- Hypothermia: Slow/dampen dysregulated inflammatory system response
- Terlipressin
- CRRT: Remove and reduce inflammatory cytokines responsible for shock
- Vitamin C and Thiamine
- VA ECMO
Sports medicine: the physical exam with Dr. Betz
Definition: "Musculoskeletal Medicine." Focuses on injuries during sports and exercise, namely their prevention, diagnosis, treatment and rehabilitation.
Fellowship Opportunities:
- ACGME Approved Fellowship
- 140 programs available
- 7 are EM run
Clinical Exam Pearls for Shoulder Pain
- Important Anatomy
- Joints
- Sternoclavicular Joint (SC Joint)
- Acromioclavicular Joint (AC Joint)
- Glenohumeral Joint (GH Joint)
- Cervical Spine ***Consider neck injuries***
- Important Musculature
- Deltoid
- Teres Major
- Teres Minor
- Supraspinatus
- Infraspinatus
- Pec Major
- Pec Minor
- Serratus Anterior
- Trapezius
- Biceps (long and short head)
- Joints
Full Shoulder Exam
- Cervical Spine
- Spurling Test
- Rotate neck laterally TOWARDS injured shoulder
- Extend Neck
- Press on head providing axial load
- If shoulder pain is reproduced, likely cervical radiculopathy
- Spurling Test
- Palpate the Bony Joints: Assess for possible Injury/Tenderness/Deformity/Displacement
- SC Joint
- GH Joint
- AC Joint
- Assess Range of Motion (ROM)
- Forward Flexion: 180 Degrees
- Abduction: 180 Degree
- "Painful Arc"
- Pain between 0-60 Degrees: Likely rotator cuff injury
- Pain between 60-180 Degrees: Likely AC pathology
- External Rotation: 0-90 Degrees
- Internal Rotation: 0-90 Degrees
- Obrien's Test: Assess for injury of the labrum
- Patient flexes the shoulder to 90 degrees with elbow in full extension, adducted 10-15 degrees towards the midline
- They then internally rotate the arm until the thumb is pointing down
- The examiner then presses down on the arm.
- The patient then externally rotates the arm so that the palm is up
- The examiner then presses down on the arm again.
- Test is positive if pain is felt when pressing on the internally rotated arm and alleviated when the arm is externally rotated
- Assess the Rotator Cuff
- Assess muscular strength
- Supraspinatus: "Empty can position" (Both arms in 90 degree shoulder flexion with elbows fully extended, arm internally rotated.
- Infraspinatus: Elbow bent at 90 degrees. Externally rotate shoulder
- Subscapularis: Place hand behind back palm out. Elevate hand.
- Drop Arm Test (Assesses for suprispinatus tear)
- Patient holds arm abducted to 180 degrees (Straight up above head)
- Patient then gradually lowers/adducts arm
- Test is positive if patient is unable to smoothly control the arm/arm drops to the patient's side between 90 and 60 degrees.
- Hawkins Test (Suggests Subacromial impingement/Rotator Cuff tendonitis)
- Flex shoulder to 90 degrees with elbow flexed at 90 degrees
- Examiner then forcefully internally rotates the shoulder joint
- Test is positive if internal rotation reproduces pain
- Neer Test (Suggestive of Impingement)
- Patient is standing
- Fully internally rotates arm (Fully pronated)
- Examiner passively flexes shoulder with elbow in extension through through full 180 degrees of flexion
- Test is positive if pain is reproduced
- Crossover Test
- Patient places arm in 90 degrees of flexion with elbow in extension
- Examiner/patient adducts arm across the midline
- Pain in AC joint suggestive of impingement
- Assess muscular strength
- Assess the Biceps Tendon:
- Speed Test
- Patient flexes shoulder to 90 degrees with elbow in full extension
- Patient tries to flex shoulder against resistance
- Pain in the bicipital groove is indicative of biceps tendonitis
- Yergason Test
- Shoulder at side, elbow flexed to 90 degrees
- Patient starts with forearm in complete pronation
- Supinates against resistance
- Pain with supination suggestive of biceps tendonitis
- Speed Test
- Neurovascular Exam
Rapid ED Shoulder Exam
- Important Elements
- Neurovascular Exam
- Palpate Bony Joints (See Details Above)
- Limited ROM testing
- Adduction of Shoulder
- Internal Rotation
- Dugas Test (Quick test for shoulder dislocation)
- Patient reaches across midline with affected arm to opposite AC joint
- Inability to touch opposite AC joint indicative of shoulder dislocation
- Patient reaches across midline with affected arm to opposite AC joint
- Drop Arm Test (See Above)
Clinical Exam Pearls for Knee Pain
- Important Anatomy
- Bones
- Patella
- Femur
- Tibia
- Ligaments
- ACL
- PCL
- LCL
- MCL
- Cartilage
- Medial Meniscus
- Lateral meniscus
- Vessels
- Popliteal Artery
- Popliteal Vein
- Nerves
- Common Peroneal
- Sciatic
- Saphenous
- Bones
Full Knee Exam
- Assess for Effusion/Warmth
- Following trauma: Indicative of internal derangement (ACL, PCL, Meniscal injury, Fracture)
- Range of Motion
- Flexion and Extesion
- Assess for patellar tendon/quadriceps tear
- Patellar Exam
- Assess for tenderness
- Apprehension test: Lateral movement of the patella causing pain or contraction of the quadriceps
- Assess tracking during flexion and extension
- Patellar Grind Test: Downward pressure on patella while flexing quadriceps
- Palpate the Joint Line
- Assess the ACL and PCL
- Lachman's
- Knee is placed in 15 degrees of flexion
- Assess for anterior tibial translation
- Positive test is if there is a "soft endpoint" without feeling ligament abruptly halt movement
- Anterior and Posterior Drawer
- Patients hips flexed to 45 degrees, knees at 90 degrees
- Examiner braces/sits on patient's feet.
- Tibia is moved anteriorly and posteriorly
- Positive test is >6mm of anterior or posterior movement
- Lachman's
- Assess the MCL and LCL
- Varus and Valgus Stress
- Assess for meniscal injury
- McMurray Test
- Patient lies supine with knee and hip both flexed at 90 degrees
- Examiner applies valgus stress to the knee and external rotation of the foot
- Examiner then applies varus stress to the knee and internal rotation of the foot
- Reproducible clicking, locking, or pain indicative of meniscal injury
- McMurray Test
- Neurovascular Exam
- ALWAYS HAVE HIGH SUSPICION FOR KNEE DISLOCATION
- 50% Reduce prior to ED presentation
- Can Occur with Low Energy Mechanisms
- Obesity
- Hyperextension
- Can Lead to Significant Morbidity
- 3 out of 4 Major ligaments usually disrupted
- 40-50% have vascular injury
- Assess with CTA if concerned. ABIs may be less reliable
Environmental Injuries: accidental hypothermia with Dr. Makinen
Cold Related Injuries
Predisposing Factors
Alcohol #1
- Extremes of Age
- Mental Status
- Immobility Issues
- Body surface area to mass ratios
- Common Conditions
- Pernio
- Presentation
- Acute, painful, erythemetous plaques
- Usually associated with autoimmune disease
- Management
- Pain Control
- Slow Rewarming
- Nifedipine has been shown to be helpful
- Presentation
- Trench Foot
- Presentation
- Itching, burning
- Cold, blotchy feet
- Common in homeless population
- Complications
- Secondary infection
- Necrosis
- Gangrene
- Management
- Keep feet dry
- Replace socks and encourage changing regularly
- Pain control
- Supportive care
- Presentation
- Frost Bite
- Pathophysiology
- Freezing of tissue with crystal deposition
- Microvascular thrombi
- Ischemia/vasospasm
- Presentation similar to burn
- Good prognosis
- Blebs
- Edema
- Erythema
- Poor Prognosis
- Full thickness involvement
- Hemorrhagic blebs
- Violaceous
- No edema
- Good prognosis
- Management
- Rapid rewarming
- Shoot for 37-39 degrees
- Do not warm above 41 degrees
- Tetanus
- Avoid dry heat
- TPA?
- May possibly improve likelihood of limb salvage
- Must be administered within first 24 hours
- Rapid rewarming
- Pathophysiology
- Hypothermia
- Symptoms
- 34-36 C: Mild
- Excitatory response (Tachycardia, increased respiratory rate)
- Shivering
- Ataxia, dysarthria
- 30-34 C: Moderate
- Decreased / loss of shivering
- Bradycardia
- Hypotensive
- Depressed mental status
- Arrhythmia
- NST => Bradycardia => Atrial Arrhythmia => V-Fib => Asystole
- Osbourne Waves
- <30 C or Cardiac Arrest: Severe
- CNS: Loss of reflexes
- CV: Myocardial Irritability
- Pulm: Bronchorrhea
- Endocrine: Hyperglycemia (Insulin ceases to function)
- Heme: DIC
- 34-36 C: Mild
- Management
- Passive rewarming: Blankets, Remove wet clothing (Mild Hypothermia)
- Active rewarming: Heat packs, bear hugger, Arctic Sun, warm IV fluids (Mild to Moderate Hypothermia)
- Invasive / Core rewarming (Severe Hypothermia)
- Warmed air
- Thoracic lavage: 2 degree/hr
- Gastric lavage: 1 degree/hr
- Bladder lavage: 1 degree/hr expected warming
- Dialysis
- VA ECMO
- Indications
- <30 degrees
- Cardiac Arrest
- Indications
- Hypothermic Arrest
- Cardioversion
- Place on monitor
- May attempt shock, though likely refractory if hypothermic
- One attempt, retry when warm
- Code medications
- Evidence is unclear
- Pressors may be of benefit in animal models
- Active and Invasive rewarming
- Cardioversion
- Symptoms
- Pernio
R4 Soapbox: Chronic pain and depression with Dr. Ludmer
Background:
- Chronic pain: Pain lasting >3 months. May be intermittent.
- 100 Million affected nationwide
- Responsible for 200 million work days lost
- Summative cost to health care system estimated to be 635 billion dollars
- Represent a large portion of ED visits
- Chronic pain and depression often go hand in hand
- 30-60% of patients with chronic pain report depression
- 50% of patients with depression will suffer diffuse or chronic pain
Pathophysiology: The biological, cognitive, and behavioral links between chronic pain and depression
- Biological Connection
- Similar brain regions are activated in both physical and emotional pain
- Sections of the brain associated with fear, worry, threat, distress
- Anterior cingulate cortex
- Anterior insula
- Stimulation of these areas leads to remodeling, arborization
- Chronic stimulation from either emotional or physical pain may predispose to worsening of the other
- Sections of the brain associated with fear, worry, threat, distress
- Similar neurotransmitters involved in depression and pain modulation
- Seratonin, norepinephrine low in depression
- Norepinephrine important in descending pathway modulation of pain.
- Similar brain regions are activated in both physical and emotional pain
- Behavioral and Cognitive Connection
- Avoidance behavior: Chronic pain can cause patients to stop doing/avoid activities they enjoy. Can then lead to seclusion, isolation, perceived helplessness, and eventually depression
- Catastrophizing: Correlated with pain and depression independently.
Management: In order to better treat chronic pain, we must also recognize and treat depression
- Address Physical / Chronic Pain
- Analgesia
- Multimodal pain control is key
- Judicious use of opiates
- Referral to pain specialist
- Physical Therapy
- Often used for musculskeletal pain
- Efficacy
- Significant improvement in chronic pain when compared to no intervention at all
- Variable improvement in chronic pain when compared to placebo
- Surgery
- Some conditions, such as chronic arthritis, may benefit from surgery referral
- Of note: Patients who catastrophize are at higher risk for post operative chronic pain
- Analgesia
- Address Depression / Emotional Pain
- Antidepressant Therapy:
- Proven to be effective in depression
- Also shown to help with chronic pain
- SSRIs alone decreased pain in 31% of fibromyalgia patients
- Large study at VA demonstrated significant reduction in pain and depression with controlled anti-depressant regimen
- Antidepressants as analgesics
- TCAs and SNRIs that affect norepinephrine levels have been shown to have analgesic effect apart from antidepressant effect (Releived pain in non-depressed patients)
- Thought to increase norepinephrine activity in descending pathway
- Cognitive Behavioral Therapy
- Showed decrease in catastrophizing
- Studies have shown small to moderate improvement in pain
- Antidepressant Therapy:
What We Can do in the ED
- Screen for Depression in Chronic Pain Patients
- Depression is common among the ED patient population (Up to 23% in some studies)
- More common in chronic pain
- Manage Exacerbations of Acute Pain
- Rational Referral
- PCP: Many PCPs manage depression and chronic pain. Can help coordinate other services that might help
- Psychiatry
- Physical therapy
- Pain specialist
- Social Work: Can help with some of the socioeconomic factors that contribute to depression
- Surgery: If pain is caused by issue that might be amenable to surgery (i.e. joint replacement)
- PCP: Many PCPs manage depression and chronic pain. Can help coordinate other services that might help
GLOBAL Health update with Dr. Wright
Intro to Global Health / UC Global Health Program
- UC Program grew with involvement in Haiti
- Continues to grow/expand
Opportunities for Involvement
- Villiage Life (Shirati, Tanzania)
- Founded in 2003
- Received UC Health funding in 2014
- Partnered with SHED (Non-profit in Shirati, Tanzania)
- Daily experience
- Sota Clinic
- Roche Clinic
- Shirati Hospital
- Guatemala (Western Highlands of Guatemala)
- Partnership with Mayan Health Alliance
- Experience
- Home visits
- New Partnership with Lithuania University of Health Science
- Events with UCEM
- GR Lectures will be incorporated more often into grand rounds
- Global Health events
- Upcoming event 9/12
Taming the SRU: DKA with Dr. Colmer
Case: Young female presents to the ED obtunded. She had been dropped off and left outside of ED by private vehicle.
Initial Evaluation:
- Primary Survey
- Airway was patent
- Breathing seemed deep and rapid (Kussmaul Breathing)
- No obvious signs of breathing
- Vitals
- HR 122
- BP 83/68
- RR Rapid
- O2 98%
- Temp (Rectal) 89.9 Degrees
- ***FINGERSTICK GLUCOSE = HIGH***
- GCS
- E1
- V1
- M4
Diagnostics
- Notable Laboratory Studies
- pH: 6.69
- Renal Panel
- Glucose 1020
- Cr. 2.4
- Potassium 8.3
- Blood Count
- WBC 41.2
- Urinalysis: Ketones
- Imaging Negative
Assessment:
- AKI
- Hyperkalemia
- DKA
- Likely Sepsis
Learning Points:
- Fluid Resuscitation in DKA
- Fluid slection
- For most resuscitation, type of fluids likely doesn't have large impact
- In large volume resuscitation, less acidic fluid likely beneficial
- Large RCT assessed bicarbonate and Cl after resuscitation in DKA
- Higher pH fluid had lower chloride and higher bicarb than normal saline
- Retrospective analysis compared plasmalyte and NS
- Evaluated 4-6 hours following resuscitation
- NS had lower levels of bicarbonate and increased base deficit following resuscitation
- Large RCT assessed bicarbonate and Cl after resuscitation in DKA
- May be beneficial to choose normal pH fluid in DKA
- Fluid slection
- Management of Hyperkalemia
- See Morbidity and Mortality Case above
- Use of Calcium
- Calcium Chloride and Gluconate have similar efficacy
- Onset and duration
- 3-5 Minutes of onset
- Duration 30 minutes to 1 hour
- Dose q5 -10 minutes until effect
- Re-Dose