Grand Rounds Recap 9.25.2024
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morbidity and mortality conference WITH dr. shaw
Motor Vehicle Accident and Tertiary Examinations
A significant number of injuries in trauma patients are missed during the initial trauma assessment
All trauma patients should have a structured tertiary exam performed that occurs after the initial resuscitative and investigative phase of their care
Pelvis x-ray in blunt trauma has little utility outside of determining the need for immediate life-saving interventions such as placement of a pelvic binder
Hypertensive Emergency
Hypertension is extremely common in our patient population and a common presenting chief complaint in the Emergency Department
In patients with asymptomatic hypertension, routine screening and medical intervention in the Emergency Department is not required
It is important to distinguish severe asymptomatic hypertension from hypertensive emergency, as workup and management are different
Aggressive treatment of hypertension with IV anti-hypertensives should be reserved for patients with hypertensive emergency
B12 Deficiency and Subacute Combined Degeneration (SCD)
Recreational use of nitrous oxide can cause severely low serum vitamin B12 levels and rarely can cause subacute combined degeneration
Macrocytosis on CBC may raise suspicion in the ED for an underlying B12 deficiency. Confirmatory testing involves methylmalonic acid and homocysteine levels, which do not result in real time
SCD is treated with high-dose IV vitamin B12
Spinal Epidural Abscess (SEA)
Spinal epidural abscesses are not as rare as we think, making up 10% of all spinal infections
The classic triad of fever + back pain + neurologic symptoms is rarely seen in patients presenting to the Emergency Department
Neurologic findings in SEA are late findings and have significant associated morbidity
In patients with risk factors, an ESR can be used to further risk stratify the patient. If the ESR is elevated, providers should have a low threshold to obtain confirmatory imaging
Small Bowel Obstruction in a Nonverbal Patient
Patients discharged with abnormal vital signs have increased risk of adverse events after discharge
The presence of any vital sign abnormality at discharge is associated with a 3x increased likelihood of death within 15 days of ED discharge (OR 3.09)
Agitation and Non-Convulsive Status Epilepticus
Bupropion ingested in large amounts can predispose to both cardiotoxicity and neurotoxicity
QRS widening from bupropion toxicity may not respond to sodium bicarbonate
When patients present with agitation, emergency providers should work to distinguish medical causes from those that are functional or psychiatric in nature
Ketamine has the fastest time-to-onset of routine medications for agitation management. However, patients receiving ketamine at higher doses are at increased risk of airway compromise requiring intubation
r3 taming the sru WITH dr. rodriguez
Up to 17% of third-degree AV block is secondary to ischemia or an MI. Other causes need to be considered, such as medications, hypothyroidism, and underlying pre-existing heart disease
Initial treatment for symptomatic bradycardia includes atropine, however this is often ineffective in third-degree AV block as atropine decreases parasympathetic tone and increases SA node impulses, but the location of the block in third-degree AV block is often located below the level of the AV node
Transcutaneous pacing should be initiated in patients with continued hemodynamic instability after atropine failure
If transcutaneous pacing fails, the next line of treatment is transvenous pacing
If transvenous pacing fails, troubleshooting strategies include:
Twisting the wire to capitalize on its existing curvature
Use bedside ultrasound to confirm placement within the RV
Increase voltage and decrease sensitivity on the pacer controller box
Use epinephrine as a vaospressor and chronotrope
“i am no jedi”: Creating a unique pathway within academic emergency medicine WITH dr. sabedra
Success is personal, and there are many different ways to find your niche in Emergency Medicine
Success can be defined by academic/career goals, personal goals, family goals, etc.
It is okay to progress at your own pace. Try not to compare yourself to your peers (easier said than done!)
Cynicism, guilt, and imposter syndrome frequently plague emergency physicians. It is important to identify what is important to you outside of work and find ways to incorporate these into your day-to-day life and not “lose yourself” to emergency medicine
Don’t “say yes” to every opportunity for the sake of being involved, but “be ready and be open” for opportunities that come your way
visual diagnosis: orthopedic injuries WITH dr. gobble
A lunate dislocation has the "spilled teacup” appearance due to the lunate not articulating with capitate or radius
Posterior shoulder dislocations may look normal on AP view. Look for the light bulb sign and always evaluate with scapular 'Y' view
Lateral ankle fractures are classified by the Weber Classification, which is based on fracture location relative to the tibiotalar joint line
A Jones fracture is a fracture at the 4th/5th metatarsal articulation. Pseudo-Jones fractures are proximal to that and also referred to as avulsion fractures
The sail sign is an elevation of the pericapsular fat pad due to displacement from a joint effusion in setting of elbow injury
Posterior fat pads are always pathologic. Anterior fat pads can be normal
Galeazzi injuries are a radial shaft fracture with an ulna dislocation whereas Monteggia injuries are ulna fractures with radial dislocations
Scaphoids injuries are prone to avascular necrosis due to variable blood supply
r2 cpc: Acute Salicylate toxicity WITH drs. newton and milligan
Salicylate poisoning has no typical presentation and should be considered in any case of AMS
Treatment cornerstones include alkalinization of serum/urine, empiric glucose therapy, and volume resuscitation
Contact DPIC (poison control) early and often if you have a case of suspected or confirmed salicylate poisoning
Dialysis should be initiated early in severe cases based on laboratory and clinical criteria
Avoid intubation and be very wary of respiratory fatigue as both can trigger worsening acidosis and lead to cardiovascular collapse and death
r1 core content: Penile disorders WITH dr. amin
Low-flow or ischemic priapism is an emergency, whereas high-flow priapism is not
Corporal aspiration is the hallmark of low-flow priapism management
A dorsal penile nerve block is an option for pain control
Paraphimosis can cause ischemia of the glans penis and is a urologic emergency
Management of paraphimosis includes manual reduction +/- swelling management
Phimosis is only a urologic emergency if it causes urinary retention
r4 capstone WITH dr. sobocinski
Humanity is currently on a path towards a world around 2.5-4.5 C above historical average.
There are predicted to be a significant loss of species and potential ecosystem collapse at higher levels of warming
There will be a significant increase in heat-related illness, particularly in the equatorial regions of the world.
Crop yields will decrease on average 7 % per each 1 ° C increase above historical average, potentially leading to widescale famine
CKD may be caused by recurrent heat stress and is likely to increase with increasing global temperature.
Mortality from asthma and COPD is predicted to increase due to increasing humidity and concentration of particulate matter.
The endemic regions of vector-borne diseases will change significantly, with large increases. Malaria and dengue may inflict an additional 4.7 B.
Increasing temperature and severe weather events can lead to increases in mental illness such as: violence, depression, anxiety, suicide, and PTSD
