Grand Rounds Recap 9.22.21
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Research with Dr. Freiermuth
Tips and tricks for starting research as a resident:
Make a Pubmed Account to save searches and get alerts of new publications. Create collections while writing to keep track of what you have reviewed. You can also start a bio-sketch with information about yourself (qualifications, interests) and to track your publications. This can be seen by others and keeping it up to date will help with any grant proposals you may complete.
Use MeSH terms to increase the specificity and yield of your searches. You can also set up searches to notify you of new literature on a topic you are following.
Starting a research project: Your research questions should be something that has not already been answered and something that your colleagues would be interested. Reach out to mentors and department leadership to build a team to help you. Dr. Freiermuth is happy to help with this here.
Statistics/Analysis: Think about analysis prior to starting your project so that you have adequate power and plan for analysis. Electronic health records can be a great resource for retrospective studies or when determining the frequency of a certain diagnosis to plan the duration of a prospective study. This should occur after you have developed a research plan. Consultant services at UC can help guide you to the correct stats test.
Research resources
IRB approval: There are some blanket protocols in place at UC, including EIP and EMQUIRI that can help facilitate this. Note that retrospective studies may be exempt, but this is determined by the IRB.
Building a database: Software must be HIPPA compliant and secure. REDcap is a free resource that can be used to develop a database.
Chart Abstraction: Set out clear goals before you start so that you gather all of the data that you need. Power calculations are important to determine the number of charts you need to review. Reliability is also important (is the data recorded the same way each time, or does it require interpretation by the abstractor?)
Publish your findings: You can only answer questions that were asked a priori. A trend toward significance has no meaning. Negative studies contribute to the body of knowledge.
Residency research grant: Up to $2500 is available to residents to help fund a project.
Eye Emergencies with Dr. Martinez
Dr. Martinez joins us from the Department of Ophthalmology to discuss pearls and pitfalls of common ocular emergencies.
Ocular Vital Signs: visual acuity, pupils (reactivity and APD), confrontation testing of visual fields, EOM, IOP
Topical anesthetic is almost always safe and facilitates a better exam.
The only exam you should defer to ophthalmology is an open globe.
See Dr. Hill’s post on paperclips to facilitate the eye exam: https://www.tamingthesru.com/blog/2018/10/31/the-mighty-paper-clip
Corneal abrasions:
Need to be followed closely by eye care provider as they can cause corneal scarring and vision loss
Autoimmune diseases and diabetes slow healing
Treat with ointment
Require appropriate antibiotics +/- antifungal coverage (Natamycin if there is concern for organic matter)
Corneal foreign bodies:
Make sure you evaluate the depth that the object goes to
Use slit beam at an oblique angle to view the full thickness of the cornea
Removal of corneal foreign body
Make sure it is not open globe or full thickness (80% penetration of foreign body raises concern for open globe on removal)
Anesthetize with tetracaine
Consider vigamox drops prior to removal
Bend 30 g needle and use the bevel to scrape off the foreign body
Seidel test after removal to ensure that there was not open globe
Discharge with antibiotic drops and follow-up
Open globe:
Signs of surrounding trauma: 360 degree conjunctival hemorrhage, conjunctival laceration, scleral laceration
Seidel sign suggests deep corneal laceration
Other clues: flat anterior chamber, pupil abnormalities, severely decreased vision
CT findings of globe irregularity (CT cannot rule out open globe)
Low/unreliable IOP (check this last and only if no other signs)
Cover immediately with an eye shield
IV levofloxacin while awaiting ophthalmology treatment
Conjunctival laceration
Laceration of the conjunctiva over the sclera
Generally heal well with supportive care and ointment
Should see healthy white sclera under the laceration
Scleral laceration
Deeper than conjunctival and can visualize red tissue under laceration
May require surgical repair
Increased risk of infection compared to conjunctival laceration
Chemical burns:
Check pH before starting with pH paper
Ideally remove contact before irrigation, but don’t delay irrigation
Irrigate with normal saline (pH5.5), distilled water (pH 7.0), LR (pH 6.5), or normosol (pH 7.4)
Ensure you are irrigating the superior and inferior fornices
Morgan lens is useful, but make sure to move it around
Irrigation continues until pH neutralized
Eye exam after irrigation
Conjunctival injection is a promising finding as it suggest ongoing blood flow
Treatment for home: artificial tears, cyclopentolate for pain, antibiotics (moxifloxacin) if corneal defect present, consider topical steroid QID (particularly if alkali injury)
Very close outpatient follow-up
Orbital compartment syndrome
Technically a clinical diagnosis: Proptosis, APD, reduced EOMs, poor/no vision
Severely elevated IOP supports diagnosis
CT scan with retro-orbital hemorrhage
Treatment: lateral canthotomy
Crush with hemostats to devascularize
Use scissors to cut the lower canthus and canthal tendon
Lower lid should be freely mobile
Erythromycin ointment
A deeper review of lateral canthotomy can be found here.
Iritis (anterior uveitis)
Can be traumatic, autoimmune, bacterial
Generally have severe photophobia
Cell in the anterior chamber
If not history of trauma, consider other etiologies (autoimmune and infectious)
Treat with topical steroid and dilating drops
Follow with ophthalmology
Monocular vision loss, anterior to posterior causes:
Acute Glaucoma (angle closure, neovascular, lens induced)
Sudden awareness of cataract
Vitreous opacity (hemorrhage, uveitis, fungal/bacterial endophthalmitis)
Retinal ischemia (amarousis fugax, CRAO, CRVO, giant cell arteritis)
Retinal Detachment
Maculopathies (wet AMD, CSCR)
Optic nerve compression, inflammation, ischemia
Useful resources for the amateur ophthalmologist:
Wills Eye Manual
Eye Handbook App (iOS and Android)
Cobalt blue light for a quick and dirty fluorescein exam
Pinhole occluder: corrects 3 diopters
R4 Capstone with Dr. Thode
10 useful things I’ve learned in residency:
1.) Don’t avoid the ultrasound guided IV
Placement decreases rate of central line placement
Practice Increases rate of first pass success
UGIVs Increase patient satisfaction
2.) Respect the potassium, especially in a sick patient.
BRASH Syndrome: Dr. Mand covered this in a prior M&M https://www.tamingthesru.com/blog/grand-rounds/recap-032421?rq=BRASH%20syndrome
3.) Take time for what is important to you
4.) Get the dog/cat/pet
5.) If someone else’s spidey sense is tingling, listen to what they say
6.) Get the family involved in the code
7. )Fight for what you think is right for your patients
8.) It’s okay to not have all the answers
9.) Befriend your consultants
10.) Moonlight!
Learn how to love residency
Self Promotion: How to Write a Letter of Recommendation with Dr. Leenellet
Self-promotion is powerful and important: Only you know what you have accomplished and letting others know allows others to open doors for you and keep you in mind when opportunity arises. Promoting yourself if not bragging if what you say is true and delivered appropriately. We all enjoy hearing about the cool things others are doing; they want to hear those things from you too. You can start (and improve your own sense of accomplishment) by having a brief “brag bite” of your most recent accomplishment when someone asks you what you have been doing.
Promoting yourself carries into writing your own letters of recommendation for a new position, award, etc. Not only do you know your accomplishments best, but writing the letter forces you to assess your own accomplishments and weaknesses.
Why draft your own letter of recommendation:
You know your qualifications for an award, position, etc. better than anyone else and provide far more details than someone else can
Submitting others for awards is often not on people’s radar. Once you win an award a positive feedback loop begins that makes you more likely to win another award. Additionally, you are far more likely to win an award than you may think.
It is much less time commitment for your letter writer to edit a letter you wrote. This frees them up to focus on specific stories, rather than the mechanics of letter writing.
Writing the letter forces you to assess your own accomplishments and weaknesses.
Before you start writing, review:
Your CV for what applies to tell a story
The award description and selection criteria
All required elements. Often, letters are graded with a score sheet for each criteria.
Anatomy of the letter:
Nominator credentials
Relationship: How do you know the nominee? For how long?
Why does this person deserve the award or position?
Address specific criteria and include the verbiage of the award. You can even break them out into separate paragraphs to make it easier to read.
Use active language and tell the story with passion.
It is okay to bold words to highlight important text that fulfill the criteria
A variety of biases can affect the language you use in an award. The best way to combat this is to evaluate your own biases before you start. The resources below can elucidate how these biases affect you:
R4 Sim with Drs. Frederick, Thode, Urbanowicz, and Wolochatiuk
Iron Toxicity
Based on the dose of elemental iron in the preparation (not the iron salts)
Children’s multivitamins - up to 20mg of elemental iron
Adult multivitamins - up to 50mg
Prenatal vitamins - up to 100mg
Fun fact: Iron Carbonyl (hand warmers) - very low toxicity - no published reports of serious or fatal poisoning.
How much do they have to ingest?
20mg/kg usually ok
20-60mg/kg low potential for serious toxicity
>60 mg/kg associated with severe toxicity and death.
The stages of Iron Toxicity
Stage 1: GI symptoms of (vomiting, abdominal pain, diarrhea, bowel wall necrosis) within 6 hours
Stage 2: Latent period of continued GI injury, but improved symptoms at 6-24 hours
Stage 3: 12-48 hours after ingestion
Continued acidosis due to production of hydrogen ions- Fe3+ + 3H2O -> Fe(OH)3 + 3H+
Hepatic dysfunction
Hypotension and shock - negative inotropic properties, vasodilatory effects, and hypovolemia (GI losses) with a mixed shock picture
GI symptoms - bleeding, bowel perf, nausea, vomiting
CNS - seizures
Coagulopathy - free iron inhibits the coagulation cascade
Acute lung injury - ARDS
Once a “critical amount” of iron reaches the mitochondria, therapies are not effective and outcome is poor.
Stage 4: Hepatic failure if serum iron levels >1000 mcg/dL at 2-3 days after ingestion
Stage 5: 2-8 weeks after ingestion
Subacute inflammatory process
GI strictures, obstruction, and fistulas
Workup and Management:
Call poison control - try to figure out how much iron they ingested
Serum iron level 4-6 hours after ingestion - levels >300 micrograms/dL are concerning (above the TIBC range)
350- 500, mild to moderate GI symptoms
>500 serious systemic toxicity
Acetaminophen level, electrolytes, liver function tests, coag studies, abdominal x-ray
Therapies
Fluid resuscitation
Whole bowel irrigation - activated charcoal does not bind iron
1000 ml/hr of polyethylene glycol for age 6 months - 12 years
2000 ml/hr of polyethylene glycol for age >13 years
Deferoxamine chelates iron and aluminum in the serum (once the iron gets into cells it's too late).
Indicated for: severe symptoms, AGMA, peak iron level > 500, or ingestion >60 mg/kg
IV administration at 15mg/kg/hr
Side effects - hypotension, renal failure, respiratory distress (support with fluids instead of slowing down rate)
Complex is renally excreted so if there is significant renal failure, dialysis will be needed
Infantile Botulism:
Typically occurs in the first six months of life. Most common form of botulism in the United States and the incidence appears to be increasing over the last quarter century.
Botulism is due to exposure to preformed toxin or spores. Exposure may be from ingestion of infected food, an infected wound, or may be from colonization of the gastrointestinal tract (due to aerosolization through earthquakes, construction, etc).
Incidence is related to the density of the organism found in the soil and varies regionally. The highest incidences are in Pennsylvania, Utah, and California.
C. botulinum species are a heterogenous group of anaerobic bacilli with their own serologically distinct neurotoxin (type A through G).
The neurotoxin blocks the release of acetylcholine at neuromuscular junctions causing symmetric descending paralysis.
Symptoms start with constipation that progresses to lethargy, weakness, and decreased feeding. Duration of symptoms prior to presentation ranges from 1 to 20 days. Fever is not typical, but presentation may otherwise resemble sepsis or meningitis.
The lack of a gag reflex, hypotonia, and hyporeflexia helps distinguish it from other causes of lethargy and decreased feeding. Dehydration due to bulbar dysfunction is common. Botulism may progress to respiratory failure and intubation.
Toxin can be recovered from wounds or the GI tract of affected infants.
Treatment: botulism immune globulin intravenous (BIG-IV), which is only available through the California Department of Health Services. Administration significantly improves outcomes:
Decreased length of hospitalization (2.6 weeks as compared to 5.7 weeks in placebo),
Decreased ICU stay (1.8 weeks compared to 5.0 wks)
Decreased ventilator days (1.8 weeks compared to 4.4 weeks)
Decreased tube feeding days (3.6 weeks compared to 10.0 weeks)
Salicylate Toxicity
Sources of Exposure: Salicylates are found in hundreds of over-the-counter (OTC) medications and in numerous prescription drugs, including: Pepto-Bismol, aspirin, methyl salicylate (oil of wintergreen).
Pathophysiology: Salicylates stimulate the respiratory center, leading to hyperventilation and respiratory alkalosis. Interference with the Krebs cycle limits production of ATP, increases lactate production, and leads to ketosis and a wide anion-gap metabolic acidosis.
Severity of Ingestion:
LD50 ~10-30g for average adult, ~3g for child
A 16% morbidity rate and a 1% mortality rate are associated with patients presenting with an acute overdose.
Prognosis is worse for chronic overdose/exposure.
Severity and morbidity of a sing acute, nonenteric-coated, salicylate ingestion:
From 150-300 mg/kg - Mild-to-moderate toxicity
From 301-500 mg/kg - Serious toxicity
Greater than 500 mg/kg - Potentially lethal toxicity
Workup and Management:
Glucose: if altered mental status present, give D50 even if POC is normal due to relative CNS hypoglycemia. Reassess frequently as delayed hypoglycemia can occur.
Blood gas: pH may be close to normal due to competing acid-base derangements (Respiratory alkalosis + anion-gap metabolic acidosis + metabolic contraction alkalosis).
Electrolytes: Severe hypokalemia
Serum salicylate level initially then every 2 hours until level falls.
Avoid the use of the Done nomogram
Serum levels determined less than 6 hours post-ingestion do not rule out impending toxicity due to ongoing absorption.
In chronic ingestion, measured toxic levels may be only 30-40 mg/d.
Obtain hepatic, hematologic, and coagulation profiles for patients with clinical evidence of moderate-to-severe toxicity.
Chest x-ray if evidence of severe intoxication, pulmonary edema, or hypoxemia are present
Abdominal x-ray if an aspirin concretion is suspected.
GI decontamination:
Gastric lavage may be beneficial
Oral activated charcoal (within one hour of ingestion): dose 50g
Whole bowel irrigation should be considered when enteric coated tablets are ingested or salicylate levels do not decrease after activated charcoal treatment.
Urine decontamination
Use if levels >35 or in severe acute ingestions
Single IV bolus of NaHCO3 at 1-2 mEq/kg.
Follow with infusion of D5W with NaHCO 3 100-150 mEq/L and KCl 20-40 mEq/L at 1.5-2.5 mL/kg/h to produce a urine flow of 0.5-1 mL/kg/h.
Obtain urinalysis every 2 hours to maintain the urinary pH between 7.5-8.
When the urine pH increases to 8 from 5, renal clearance of salicylate increases 10-20 times, and urinary excretion is dependent on serum potassium
Dialysis indications: seizures, pulmonary edema, coagulopathy, pH < 7.20, initial ASA level (>90 if AKI present)
