Grand Rounds Summary 9.20.17

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EMS GRAND ROUNDS:  KETAMINE, STROKE, AND THE DARK TOWER with dr. McMullan

Quick Refresher on Pre-Notification

Reasons for Notifications

  • Need for an order
    • Medications (Seizure medicine, pain medicine, etc.)
    • Restraint / notification of restrained patient
    • Need for Time of Death
  • Notification to facilitate preparation
    • Major trauma
    • Stroke
    • STEMI
    • Tox/contamination
    • etc

Types of Notifications

  • Notification from squad
    • Lots of runs, will only call on select patients
    • Trainees may make calls on more stable patients for practice
    • Important to be respectful and polite, good customer service
    • Try to limit questions to those that will change how you prepare.  Can get rest of the story on arrival
  • Notification from the tower
    • Tower (Dispatch) will make notification call if squad is too busy
    • Likely indicates sicker patient as squad is unable to call
    • They will not know much about the patient
    • May know the following
      • If multiple squads dispatched to same scene (How many can I expect)
      • They can estimate ETA

Current Research in EMS

Pre-Hospital Pain Dose Ketamine

  • Background
    • Examining utility of intra-nasal ketamine as analgesic
  • Who (Enrollment, Inclusion Criteria)
    • Will be conducted with CFD only
    • Inclusion criteria:
      • Traumatic pain
      • Male Patients(Cannot perform pregnancy test pre-hospital, Ketamine is class N)
      • UCMC only
  • What (Study Design/Methods)
    • Triple blinded RCT with 1:1 randomization
    • Compare 50mg intranasal Ketamine to placebo
    • Both groups will also receive fentanyl PRN
    • Will be examining the following outcomes
      • Primary:  Pain level in 30 minutes
      • Secondary:
        • Chronic pain in 30 days
        • PTSD at 90 days
  • When
    • Study to begin enrolling on 10/3
    • 18 month enrollment period
  • Role of UCED Providers
    • As always, continued support of research efforts
    • Do not throw away Pelican Box with study drug

Updates on Pre-Hospital Stroke Care

Background

  • Evolution of stroke care similar to STEMI
    • Debate over thrombolytics vs catheterization
      • Recently benefit has been shown for embolectomy in large vessel occlusions
    • Time sensitive complaint
      • Need to minimize transport times
      • Avoid unnecessary transfers
    • Development of dedicated centers
      • Outcomes better in high volume centers
      • More reps = better outcomes
  • With care evolving, new stroke centers developing, there is a need for new screening and triage tools within EMS. 

Dedicated Treatment Centers

  • Comprehensive Stroke Center (Recent nomenclature with push for catheterization/embolectomy for LVO)
    • Have catherization capability in addition to thrombolytics
    • 24/7 NSGY
    • Dedicated Neuro-ICU
    • Systems of care
    • Stroke specific protocols in ED
    • Rehabilitation services
  • Primary Stroke Center
    • Thrombolytic therapy available
    • Systems of care
    • Stroke specific protocols in ED
    • Rehabilitation services

EMS Triage tools for stroke

  • Stroke scales originally developed to aid in RECOGNITION of stroke
    • Face-Arm-Speech-Time (FAST)
    • Cincinnati Pre-Hospital Stroke Scale
    • Los Angeles Pre-Hospital Stroke Scale
  • Current Guidelines recommend all strokes go to nearest compreshensive center, however:
    • Risk of overloading UC as only comprehensive center
    • Need tools to be able to triage large strokes/LVO to comprehensive center, and smaller strokes to primary stroke centers
  • New scales evaluate for stroke severity to help triage
    • RACE Scale (Rapid Arterial Occlusion Evaluation)
    • Los Angeles Motor Scale
    • Cincinnati Stroke Triage Assessment Score (CSTAT)
      • All roughly equal
      • We will be employing CSTAT, because evaluated here with our patient population
  • CSTAT
    • Components:
      • 2 Points:  Conjugate gaze deviation
      • 1 Point:  Arm or leg falls to bed in under 10 seconds
      • 1 Point:  Can't answer 2 questions/follow 2 commands
    • Scoring/Decision making
      • > or = to 2:  Concern for large vessel occlusion
      • 0-1 = Not concerned for large vessel occlusion

Coming Soon:

  • CSTAT severity tool app will be implemented soon
  • Protocol to be implemented within 2018 protocols
    • Goal scene time < 10 minutes
    • CSTAT for triage
      • Transport to comprehensive stroke center if...
        • CSTAT Score > or = to 2
        • Onset < 6 hours
        • Comprehensive center is less than 15 minutes transport time
      • Transport to primary stroke center if...
        • CSTAT Score 0-1
        • Onset < 6 hours prior

CLINICAL DIAGNOSTICS:  LACTIC ACID WITH DR. SHAW

As a primer - check out Dr. Shaw's post here

Common Myths Regarding Lactate

  • Arterial samples are more accurate than venous samples (FALSE)
  • Lactic acid levels drawn from limb with tourniquet are falsely elevated (FALSE)
    • Study showing samples drawn from limb with tourniquet no different than peripheral sample at less than 5 minutes of tourniquet time.
  • Using Ringer's Lactate will lead to a false elevation of lactic acid (FALSE)
    • Concentration of lactate in LR is miniscule comparatively speaking
    • Will have no effect on lab value

Mechanism of Lactic Acid Prod†tuction:  It's not all anaerobic metabolism!

  • Increased Production
    • Beta 2 Stimulation
      • Levy et al (Shock), 2008
        • Induced shock states in mice
        • Measured lactic acid production in mice
        • Lactic acid production blunted in mice receiving beta blockers (propranolol)
        • Suggestive of Beta 2 stimulation's role in lactic acid production
      • Common causes of increased Beta 2 stimulation
        • Increased endogenous B2 production/release
          • Shock states
            • Trauma
          • Seizure
          • Cocaine
        • Exogenous epinephrine administration
        • Heavy bronchodilator use (asthma
    • Pyruvate Dehydrogenase (PDH) Dysfunction
      • Normally shunts pyruvate into mitochondria for TCA cycle
      • Defect leads to increased pyruvate in cytoplasm => increased lactate production
      • Can be seen in thiamine deficiency
    • Electron Transport Chain Dysfunction (Loss of Aerobic Metabolism)
      • Hypoxemia
      • Carbon monoxide poisoning
      • Cyanide poisoning
  • Decreased Clearance
    • Cirrhosis and Liver dysfunction
      • Impaired gluconeogenesis => Less conversion to pyruvate
    • Renal dysfunction
      • Less clearance
    • Medications
      • Older NRTIs
      • Linezolid

Cases:

  • Case 1:  31 year old male with no contributory PMHx found groggy and confused by wife.  He is somnolent and confused on exam.  PERRLA.  Withdraws to pain.  VS:  T 36.7, HR 118, RR 22, BP 135/71, O2 92% on 2L NC. 
    • Differential:  Neuro, infectious (sepsis), tox/ingestion
    • Suspicion for CO poisoning
    • Labs
      • Lactic Acid = 4.4(Hypoxia => Electron transport chain dysfunction)
      • Carboxyhemoglobin level = 20%
  • Case 2:  2 elderly females present with identical abdominal pain.  PMHx with significant risk factors for bowel ischemia (CAD, HTN, A-Fib on warfarin) 
    • Labs:
      • Patient 1:  Lactic acid of .9
        • Patient 2: Lactic acid of 3.1
    • Decision making:
      • Elevated lactic acid is correlated with higher mortality rates
      • Correlation with mortality is especially high in elderly patients
      • In general, can be used to help risk stratify in terms of dispo
      • However, can lactic acid in this case be used to rule out ischemia in patient 1?
        • NO
        • Lactic acid is late finding
        • Elderly patients may not mount significantly high lactates
          • Decreased adrenal function at baseline
          • Less adrenergic (Beta 2) stimulation and lactate production
  • Case 3:  Middle aged ill appearing male presents with abdominal pain.  He has a history of ETOH abuse, cirrhosis, possible kidney disease, and presents with nausea, vomiting, fevers, diarrhea, and melena. 
    • Lactic acid is 2.4
    • Can we attribute this to poor clearance?  (Hx of liver and kidney dysfunction)
      • NO
      • Patients with liver and kidney disease do not always have elevated lactate at baseline.
      • Must always consider other causes

CPC WITH DRS. HARTY AND TOTH

Case: Middle Aged female who presents with bilateral eye swelling, redness, and watering for 10 days.  She first noticed it upon returning from vacation.  Was treated for conjunctivitis by PCP, but has completed treatment and symptoms are still progressing.

PMH:  CKD, HTN, HLD, Wilms tumor s/p nephrectomy, RAS s/p stent

Meds:  Several anti-hypertensives, no ACE

Exam:  Notable for mild bilateral peri-orbital edema, erythema, and bilateral chemosis (L>R).  TMs were clear.  She was also noted to have both left and partial right 6th nerve palsies.  Visual acuity only mildly decreased in L eye compared to R.  

The Toth Approach:

  • Summary
    • 10 days of symptoms (Bilateral periorbital edema, chemosis, pain, conjunctival hemorrhage)
    • Photophobia present
    • Did not respond to treatment for conjunctivitis
    • Key Points
      • Bilateral
      • Progressive
      • Cranial nerve palsy is key
  • Differential
    • Eye
      • Irritant (sunscreen, swimming, boating, etc)
      • Infection (Viral conjunctivitis, periorbital or orbital cellulitis?)
      • Mechanical  (Glaucoma)
      • All unlikely to cause edema
      • Also bilateral
    • CNS
      • Neurologic process (MS, etc)
      • No other concomitant symptoms
      • Unlikely to cause edema
      • No contributory history
    • Vascular
      • Temporal areteritis could cause pain, vision change
      • Cavernous sinus thrombosis
        • Could cause edema
        • Can cause chemosis
        • Can cause nerve palsies
      • Angioedema
    • Infectious
      • Bad blephoritis
      • Conjunctivitis
    • Tox
    • Immunologic
      • Tolosa Hunt Syndrome
  • Final Answer
    • MRI Venogram with likely diagnosis of cavernous sinus thrombosis

The Big Reveal:  Carotid Cavernous Fistula, Diagnostic Test = MRI, MRA of head

Carotid Cavernous Fistula

  • Anatomy
    • Boundaries
      • Inferior/Medial:  Sphenoid Sinus
      • Lateral:  Dura, temporal bone
      • Anterior:  Orbit
      • Suprior:  Dura
    • Contents
      • Nerves
        • CN II
        • CN III
        • CN V(1)
        • CN V(2)
        • CN VI
    • Vessels
      • Internal Carotid Artery
  • Patholophysiology
    • Direct/High flow fistula (Artery to vein)
      • Usually 2/2 trauma
      • May be 2/2 aneurysm
      • Develops rapidly (Hours to days)
    • Indirect/Low flow fistula
      • Often ideopathic
      • May be from structural abnormality
        • Aneurysm
        • Ehler's Danlos
        • Microscopic pre-existing communication
      • Often develops slowly over days-weeks with mild symptoms
  • Classic Symptoms/Findings
    • Orbital bruit
    • Exophthalmos
    • Dilated conjuctival vessels
    • Chemosis
    • Venous congestion of eyelids
    • Elevated IOPs
    • CN Palsies (Usually VI, can be III
  • Evaluation
    • CT, CTA found to be largely equivalent to MRI
    • Gold standard is angiogram
  • Management
    • Indirect/Low flow
      • May be managed conservatively
      • Will need embolization if:
        • Severe proptosis
        • Worsening vision
        • CN Palsies
    • Direct/High flow
      • Almost always needs definitive treatment and embolization
      • 20% will need to go emergently

CLINICAL SOAP BOX:  NG TUBES AND THE IMPACT OF DOGMA IN MEDICINE WITH DR. GORDER

NG Tube Use in the Setting of Small Bowel Obstruction

  • Background
    • Commonly practiced / widely accepted as part of SBO care
    • Uncomfortable for patient
    • Is it actually worthwhile/helpful?
  • Commonly accepted reasoning for NG tube placement in SBO
    • Prevents aspiration
    • Helps predict/monitor for resolution of SBO (Decreased output)
    • Minimizes distention
    • May help to avoid surgery 
  • What's the evidence?
    • Supportive evidence
      • Extensive literature search reveals no RCTs or trials comparing NG tube to placebo
        • Best evidence found was a reference to Wangensteen's Treatise, written in 1921
      • Yet widely accepted by surgical community, and proposed as standard of care in many surgical textbooks
    • Evidence against
      • Single study from Yale in 2013  
        • Retrospective chart review
        • 290 SBOs
          • 235 received NGs
          • 68 patients without vomiting, many still received NGs
        • Results
          • Patients who received NG tubes showed higher complication rates
            • Pneumonia  (OR 11)
            • Respiratory failure  (OR 1.1)
            • Significant complications  (OR 19)
          • Did not decrease need for surgery
          • Increased average hospital stay
          • Time to resolution increased
  • Why do we still do it?
    • Not evidence based
    • Largely based on dogma and accepted norms

Dogma in Medicine

  • Why does medicine rely on dogma
    • Illusion of knowledge
      • Need to feel/appear more certain
    • Internal dogma
      • Need to believe in what is being done
      • Need to internally validate that what is being done is correct
    • Power of the anecdote
      • Personal experience
  • Impact of dogma
    • Takes a long time to change practice patterns
    • Roughly 40-50 year "Half Life" for unlearning disproven or obsolete practices
  • What can we do?
    • Read and know the literature
    • Critically appraise the literature
    • Apply it appropriately

PEDIATRIC SIM AND ORAL BOARDS

Oral Boards:

  • Case 1:  4 week old male with CC of fussiness.  First time parents.  Complain that child is more irritable than usual.  It seems to be episodic, primarily in the evening around dinner time and bed time.  The parents are worried he is in pain because he occasionally arches his back or curls into a ball.  He has been eating well, and has been urinating and stooling normally.  
    • History
      • Birth history
        • Term
        • Vaginal deliver
        • No complications
        • 2 day hospital stay
      • PMHx
        • No known medical problems
        • Follows with PMD
        • Normal growth to date
      • Family Hx, Surgical Hx
        • None
    • Exam:  GROSSLY NORMAL.   HEENT Normal, Neck Normal, CV/Pulm Normal, Abd soft, non-tender, non distended.  GU normal with descended testicles, circumcised.  SKin normal.  Extremities normal without hair tourniquets.  Circulation normal.
    •  Differential for fussy baby:  SPITFACE
      • S:  SVT, SBI
      • P:  Physical Abuse
      • I:  Intussusception, incarcerated hernia
      • T:  Torsion, tourniquet
      • F:  Foreign Body, Formula Intolerance
      • A:  Acute Abd, Anomalous LCA
      • C:  CHD, Corneal abrasion, colic
      • E:  Electrolytes, Errors of Metabolism
    • Conclusion:  Likely colic given timefram/symptoms.
  • Case 2:  5 year old male with "bug bites."  Mom and dad state that 3 days ago the patient began developing spots/marks on his legs.  They started out small, and gradually progressed to become larger and darker.  They are painful when touched.  They started on his feet and ankles and spread up his shins.  Apart from the rash he has also bee complaining of belly pain, and has been cranky.  No fevers, nausea, vomiting, diarrhea, or constipation.  No significant PMHx, PSHx, Medicines, etc
    • Exam:  Notable for purpuric rash on bilateral lower extremities and diffuse.  Negative for meningismus, heart and lungs clear, belly with mild diffuse non-focal tenderness
    • DDX
      • Dermatitis (Contact vs. other)
      • HSP
      • ITP/TTP
      • Tick Bourne Illness (RMSF, Lyme)
      • Nisseria
      • Vasculitides
      • Cellulitis
      • Dermatomyocytis
      • Malignancy
      • Tox/Drug reaction
    • Workup
      • CBC:  Evaluate platelets/Blood counts
      • BMP:  Evaluate kidney function
      • Urinalysis
    • Diagnosis:  HSP with mild AKI  (ADJUST CREATININE FOR AGE!!!)
    • Management:
      • Nephrology consult if available
      • Supportive Care
        • Pain control
          • Tylenol
            • NSAIDs if normal kidney function
          • May need to escalate
      • Steroids?
        • No benefit with regards to renal function
        • May help with abdominal pain if severe
      • Serial UAs and follow up
    • Disease Course
      • 1/3 will recur
      • Improves over 2-3 weeks
      • Usually affects children 3-10yo

Pediatric Simulation:  Peds Trauma

  • Case:  10 year old pedestrian struck by vehicle at approximately 30 mph.  Transported by EMS on backboard with C Collar in place.  Complaining of chest, belly, back and left arm pain.
    • Vital signs:
      • HR:  132
      • RR:  22
      • BP:  93/50
      • O2:  98%
    • Evaluation
      • Primary Survey
        • Airway patent
        • Breath sounds equal bilaterally
        • Saturating well
        • Tachycardic, BP on low end of normal
          • Abrasion over right chest and belly
          • Tenderness over this area
          • Pelvis stable
        • FAST adequate and negative
      • Secondary Survey
        • GSC 14  (3, 5, 6)
        • Diffuse spine tenderness
        • Chest, abdomen, and pelvis as above
        • Tenderness over L upper extremity
      • Labs
        • CBC, BMP, LFT, LIpase, TEG, type and screen, PT
      • Imaging
        • CT head, C Spine, Chest, abdomen, and pelvis with reconstitution of spines
        • X-Ray LUE
  • Learning Points
    • Utility of FAST Exam in pediatric trauma
      • Poor sensitivity (66%)
      • High specificity  (95%)
      • Conclusion
        • Cannot rule out bleed with negative fast
        • If pre-test probability is high, consider CT
    • Head CT:
      • Consider PECARN criteria
      • Well validated
    • Abdominal CT
      • PECARN rules do Exist, though less definitive
        • No obvious abdominal trauma (ex. seatbelt sign)
        • No thoracic wall trauma
        • GCS >13
        • No complaint of abdominal pain
        • No tenderness to palpation
        • No decreased breath sounds
        • No vomiting
      • Laboratory evaluations that may increase suspicion
        • LFTs and Lipase
          • Increased LFTs may be sign of injury/higher risk of injury
            • AST> 200
            • ALT> 125
        • CBC
          • HCT< 30
        • UA
          • >5 RBCs