Grand Rounds Recap 9.5.18

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Airway Grand Rounds WITH DR. Carleton

  • The bougie was invented in 1949 and is the most commonly used airway adjunct.
  • Classically it has been used for Cormack-Lehane Grade III and IV views; however, there is now more evidence to suggest it may be of benefit even in Cormack-Lehane Grade I and II views.
  • The bougie uses tactile feedback to differentiate between tracheal and esophageal placement
    • Tracheal ring "Clicks" occur when the bougie runs along the tracheal rings.  To feel these you must hold the bougie gently the pads of your fingers.  Reported to be only felt 65% of the time.
    • The "Hold-Up" sign is the sensation of brief resistance when the bougie strikes the carina.  
  • Trauma related to the use of the bougie is estimated to occur in less than 5% of patients with the greatest concern being perforation of the airway leading to significant mortality.  
    • To help mitigate risk associated with use of the bougie:
      • Never pass the bougie beyond 45cm.  
      • Once the bougie passes the cords be very gentle when advancing further
      • Feel for tracheal "clicks" once you have passed 21cm
      • If you have no tactile feedback by the time you reach 28cm be cautious as you are likely beyond the level of the carina.
  • Recent studies such as: Driver, B et al. The Bougie and First-Pass Success in the Emergency Department. Ann Emerg Med 2017, suggest that there may be benefit to using the bougie in all patients rather than just in difficult airways.  Providers are encouraged to review the literature for themselves to guide their own practice.

Complex laceration repairs  WITH DR. Kiser and Dr. Gensic

Ear Lacerations

  • Hemostasis of the ear can typically be obtained with direct pressure.
  • An auricular block can be considered for complex ear lacerations.
  • Significant cartilage defect is a consideration for involvement in a surgical specialist.  Removal of approximately 5mm or less of cartilage typically does not lead to a significant cosmetic defect.
  • 6-0 non-absorbable suture is the preferred suture material.
  • Sutures should be removed in 3-5 days.
  • Prophylactic antibiotics should be given for significant cartilage defects.  Simple ear lacerations do not require antibiotics.
  • With complex ear lacerations consider placing a mastoid or bolstered dressing to prevent accumulation of a hematoma.
  • Any involvement of cartilage defect, even if you repair it yourself, should prompt follow-up with a specialist.

Peri-orbital lacerations

  • Take care with lacerations medial to the puncta or that involve the eyelid.  Damage to the medial canthus, cannicula, nasolacrimal duct, levator palpebra etc need specialist management.
  • ll peri-orbital lacerations should prompt evaluation for involvement of eye trauma.  Remember to evaluate for open globe, foreign bodies, associated facial fractures.
  • 6-0 non-absorbable suture is the preferred suture material; however, if repairing an eyelid laceration many providers are now using absorbable suture, such as Vicryl Rapide, due to the pain associated with subsequent suture material.

Large extremity lacerations

  • Important to evaluate for injury to underlying structures.  Always evaluate for vascular, nerve, tendon, muscle, and joint injury.
  • If you have concern for violation of the joint capsule at the knee you can load the joint to evaluate for violation.
    • Loading the joint may require large volumes of fluid - up to 190 mL
    • Ranging the joint after loading can increase the sensitivity
    • Adding methylene blue to the saline solution can increase visibility 
    • CT is more sensitive and can be used in cases where you have a high suspicion or if the patient will not tolerate this procedure.
  • To increase the sensitivity of your evaluation for tendon injury make sure to explore the wound through range of motion.
  • Muscle does not hold suture well.  To improve the closure make sure to take "big bites" and ensure that your suture also goes through the fascia which is much stronger.

distal fingertip amputation

  • Injuries are divided anatomically by zone.

    • Zone I: Distal soft tissue only without exposed bone.  Typically allowed to heal by secondary intention.
    • Zone II: Distal to the lunula.  Can consider V-Y plasty or hand surgery consultation.
    • Zone III: Proximal to the lunula.  Hand surgery consultation is required.  Often requires repair in OR.
  • Can consider placement of a proximal finger tourniquet to achieve hemostasis for repair.  A digital block of the affected finger can be used for anesthesia.

EMS Grand Rounds WITH DR. Neth

epinephrine utility in out of hospital cardiac arrest

  • Lin et al. 2014 Resuscitation
    • Meta-analysis/Systematic Review of patients with out of hospital cardiac arrest receiving ACLS.  Interventions/Comparison included Epi vs. Vasopression, Epi vs. Epi/Vasopressin, standard dose epi vs. high dose epi, and epi vs. placebo.  Primary outcome was survival to hospital discharge and secondary outcomes were ROSC, survival to hospital admission, survival to hospital discharge with favorable neurologic outcome.
    • Epi vs. Vasopression (n=336):  No difference in all outcomes.
    • Epi vs. Epi/Vasopression (n=5202): No difference in all outcomes
    • SD Epi vs. HD Epi (n=6174): Increase in ROSC and survival to admission with HD Epi but no difference in neurologic outcome or survival to discharge.
    • SD Epi vs. Placebo (n=534): Increase in ROSC and survival to admission with SD Epi but no difference in neurologic outcome or survival to discharge. 
  • There are two interventions shown to definatively improve outcomes in out of hospital cardiac arrest.
    • Early defibrillation
    • Early high-quality CPR
      • Rate:100-120 per minute
      • Depth: 5-6 cm with full recoil between compressions
      • Limiting pauses to less than 10 seconds
      • Maximizing chest compression fracture to >80% during the code
      • Avoiding hyperventilation by ventilating at a rate of 8-10 breaths per minute

mechanical cpr

  • Advantages:
    • Allows for a standard depth and rate without a decline in quality over time.
    • Continues high quality compressions while moving the patient (down stairs, back of ambulance etc)
    • Frees up the hands of providers to perform other interventions (Central access, Intubation etc)
  • Limitations:
    • May not fit certain body types
    • Can shift leading to poor positioning and therefore inadequate compressions
    • Mechanical device failures 
    • Compression interruptions while setting up machine
  • Evidence (comparing mechanical CPR to standard CPR):
    • Hallstrom et al. 2006 JAMA: No difference to survival at 4 hours and worse neurologic outcomes.  Caveat - this study was done with the mechanical CPR set to a rate of 80 compared to standard CPR at 100.
    • Wik et al 2014 Resuscitation: No difference in survival to hospital discharge or modified rankin scale at hospital discharge.
    • Rubertsson et al. 2014 JAMA: No difference in survival to 4 hours and no difference in neurologic outcomes at hospital discharge.
    • Take Home:  Evidence suggests that mechanical CPR is not superior to standard CPR; however, it may be equivalent.  There are other advantages listed above that may make mechanical CPR the preferred modality for out of hospital cardiac arrest care.

R4 Case Follow-Up: Wernicke's Encephalopathy WITH DR. Soria

38 yo male presented to the ED with altered mental status and difficulty walking.  He had a recent admission to the hospital for severe hyponatremia with seizure but left against medical advice.  He represented to another hospital in the interim with concern for seizure, was diagnosed with alcohol withdrawal, provided treatment, and subsequently discharged.  Due to his now altered mental state a medical hold was signed and he was admitted to the hospital.  Ultimately, following treatment with IV thiamine and supportive care his mental status improved such that he regained capacity and left against medical advice.     

Wernicke's Encephalopathy

  • Caused by depleted intracellular thiamine (vitamin B1)
  • Epidemiology: Affects 3% of the population.  Affects men more often than women.  Clinically under recognized.
  • Associated with conditions that lead to poor nutrition: bariatric surgery, AIDS, malignancy, eating disorders, CHF, elderly, prisoners, homeless, alcoholism.
  • Diagnosis / Clinical Presentation:
    • Classic Triad: Encephalopathy, gait ataxia, and oculomotor dysfunction.  All three are only seen in 10% of patients.
    • Caine Criteria (Presence of 2 or more suggests diagnosis of Wernicke's Encephalopathy): Dietary deficiencies, oculomotor abnormalities, cerebellar dysfunction, and altered mental state/mild memory impairment.
  • Treatment: Thiamine 500mg IV TID for 2 days then Thiamine 250mg IV/IM  for 5 days then oral thiamine replacement daily thereafter.
    • Ensure to check for other associated electrolyte abnormalities
    • Can administer 100mg Thiamine IM to high risk patients presenting to the ED.  This provides protection against development of WE for approximately 1-2 weeks.         

CPC: Ocular syphilis WITH DR. Li and Dr. Goel

Case:
Chief Complaint: headache and vision abnormality

HPI: Middle aged male presents with left sided headache for approximately 2 months. Headache is in left temporal region and feels "tender" and associated with stress. Initially controlled with Tylenol and Ibuprofen. 3 weeks ago had some right sided jaw pain. 2 weeks ago began having wavy vision in left eye. Headache has occasionally woken him up from sleep and has been associated with mild nausea. No dental issues, no recent trauma. Saw ophthalmology recently and started on steroids with mild improvement of symptoms. Ophthalmology reportedly noted crowded up and optic disc swelling in left eye. 

ROS: fatigue, poor sleep, headache, vision changes, stiff neck, seasonal allergies

Past Medical History: no significant history
Family History: HTN father, Ovarian CA mother
Past Surgical History: right cataract surgery, achilles tendon repair
Social History: MSM, no drugs, occasional alcohol, no smoking

Physical Exam:
General: NAD, nontoxic
Head: atraumatic, normocephalic, no palpable cords in temporal regions
Eyes: EOMI, PERRLA, no discharge, 20/20 right 20/40 left
Neck: normal rom and supple
Cardiovascular: regular rate, regular rhythm, 2+ radials
Pulm/chest: normal respiratory effort, clear lungs bilaterally
Neuro: AOx4, no speech slurring, no facial droop, 5/5 upper and lower extremity strength, no gross sensory deficit on face or extremities, normal finger to nose bilaterally, no pronator drift
Skin: no rashes, warm, dry

Labs / Imaging:
CBC: WBC 11, neutrophils 89.6%, otherwise unremarkable
BMP: glucose 131, otherwise normal
MRI head from OSH: nonspecific white matter changes, likely age related, otherwise normal
Lumbar Puncture: opening pressure 13 cm H2O, clear fluid, labs pending

And then a test was ordered ...

Syphilis tests: RPR, Treponemal ab, CSF VDRL
Diagnosis: Ocular syphilis

Syphilis rates were high in the pre-antibiotic era. Penicillin decreased syphilis prevalence due to successful treatment. Unfortunately, syphilis cases have been increasing every year since 2005. Ocular syphilis is a rare presentation, occurring in 0.53% of all cases reported in 2015. It can affect any part of the eye with posterior uveitis being the most common. 

Patient's LP results were suggestive of neurosyphilis with ocular involvement. Had elevated leukocytes and protein in CSF analysis which is diagnostic of neurosyphilis in setting of positive syphilis screening tests. Be aware that in patients with HIV, their HIV can cause an elevation in leukocytes and protein in CSF which clouds the diagnosis. Positive CSF VDRL is diagnostic of neurosyphilis, however note that this lab is oftentimes negative in the setting of neurosyphilis.

RPR/VDRL are sensitive tests that are not specific. It is a measure of inflammatory products that come from damage from spirochetes. Other inflammatory processes can cause elevated RPR/VDRL as well. Treponemal specific tests are very specific, however past infection with syphilis will lead to life long positive treponemal test results. A combination are often used to screen and confirm a syphilis diagnosis. The quantitative RPR can also be used to monitor treatment success or failure.

Penicillin is the best treatment for neurosyphilis. In penicillin allergic patients, a densensitization protocol can be used while patient is hospitalized to allow for IV penicillin treatment. Two weeks of treatment will be required and follow up labs should be drawn to track whether or not treatment was successful. Also be aware of the Jarisch-Herxheimer reaction that occurs as spirochetes die from treatment. Symptoms include fever, headache, body aches, hypotension, flushing, tachycardia, vasodilation, and joint pain.

 R1 Clinical diagnostics: nectrotizing fasciitis and lrinec WITH DR. berger

Nectrotizing fasciitis

Background

  • Rare, rapidly progressive bacterial soft tissue infection that tracks along the fascia
  • Occurs deeper than common soft tissue infections such as erysipelas, cellulitis, and abscess
  • Mortality is 20-30%
  • Classifications
    • Type 1: Polymicrobial, occurs in co-morbid patients
    • Type 2: Monomicrobial, occurs in previously well patients
    • Type 3: Vibrio vulnificus, occurs with marine exposure
    • Type 4: Fungal, occurs in immunocompromised

Diagnosis

  • Challenging due to similarity to more common diagnoses in early stages
  • >70% of cases are initially misdiagnosed
  • Early findings
    • Pain out of proportion to exam
    • Pain outside of the erythematous margin
    • Rapid progression
  • Late findings
    • Violaceous lesions
    • Hemorrhagic bullae
    • Crepitus
    • Vital sign derangement
  • Imaging
    • Air in the soft tissue on XR, CT, MRI is diagnostic if seen
      • Absence does not exclude diagnosis
    • CT with contrast is the most sensitive imaging modality: 95% sensitive

Treatment

  • Definitive treatment is surgical debridement
    • Time to OR is key determinant of mortality
  • Adjunctive treatment
    • Broad spectrum antibiotics
      • Vancomycin + Zosyn + Clindamycin is typical treatment
    • Hemodynamic support
      • Sepsis appropriate fluids and pressors

LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis)

  • Wong et al., 2004 Critical Care Medicine
  • Identified 6 lab values as independent predictors of necrotizing fasciitis vs. cellulitis / abscess via chart review, logistic regression, and validation cohort:  CRP, WBC, Hgb, Na, Cr, Glucose
  • Assigned Point values for lab results to create a diagnostic aid
    • 0-5: Low Risk, 6-7: Intermediate Risk, 8-13: High Risk
    • 96% NPV, 92% PPV for diagnosis of necrotizing fasciitis

Critique of LRINEC

  • LRINEC has not held up well when applied to subsequent cohorts and is not recommended to exclude the diagnosis of necrotizing fasciitis in the ED.  There has been a subsequent chart review showing only 80% sensitivity in the ED population.  A case report showed a diagnosed case of necrotizing fasciitis with a LRINEC score of 0.

Conclusion

  • Necrotizing fasciitis is a clinical diagnosis with a high mortality
  • LRINEC is not sufficiently sensitive to rule out necrotizing fasciits
  • Definitive treatment of necrotizing fasciitis is surgical debridement with supportive care including broad spectrum antibiotics, fluids, and pressors while arranging surgical management.