Grand Rounds Summary 9.27.17

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MORBIDITY AND MORTALITY CONFERENCE WITH DR. TITONE

Case 1:  Tuberculosis

Courtesy of Ljstalpers via https://commons.wikimedia.org/wiki/File:Tuberculosis_in_the_USA_1861-2014.pngCC Share-a-like 4.0

Background

  • Overall decrease in prevalence
  • However, prevalence among at risk populations like prison system is similar

Risk factors for TB

  • Poor defense
    • Substance abuse
      • Smoking
      • Alcoholism
      • Drug Use
    • Systemic disease/medical comorbidities
      • Renal disease
      • Hematologic malignancies
      • Diabetes
      • Cirrhosis
      • etc.
    • Immunosuppression
      • HIV
      • Chronic steroids
      • TNF Alpha inhibitors
      • Transplant patients
      • Poor nutrition
        • BMI < 18.5 is a risk
    • Frequent/Prolonged Exposure
      • Household contacts with TB
      • High risk settings (Jail, shelters, etc)
      • Low socioeconomic status
      • Immigrated/traveling from endemic areas
        • Does not need to have moved recently
        • 40% of patients moved from country of origin >20 years ago
  • Clinical Presentation
    • Primary infection
      • Very non-descript symptoms
        • Pulmonary symptoms in only 33%
        • Fever in 30%
      • 10% Will develop active pneumonia
      • 90% of immuno-competent people will develop latent TB
    • Reactivation
      • Classic symptoms
        • Fever, worse at night
        • Cough, worse in morning
        • Anorexia
        • Cachexia
      • Usually indolent course - Can remain undiagnosed for years
  • Diagnosis
    • Clinical picture
      • 83% had some risk factor (listed above)
      • 75% had CXR findings typical of TB
        • Primary TB
          • Perihilar adenopathy
          • Effusion
          • Infiltrate  (27%)
        • Reactivation TB
          • Apical and posterior segments in (70-87%)
          • Cavitary lesions are rare (27%)
        • Symptoms are less reliable / can be vague
  • Testing
    • Quantiferon Gold
      • Useful screening in LATENT TB (Spec 95%, Sens 80%)
      • Not useable in HIV (requires immune response)
      • Not useful in active TB due to temporary anergy of acute illness
    • Sputum Cultures
      • Diagnosis of active TB
      • Usually 3 cultures 8 hours apart
      • Can used nebulized hypertonic saline to induce sputum/cough
  • Recommendations
    • Risk factors + CXR findings = Active TB until proven otherwise
    • If concern for latent TB, consider quantiferon gold
    • If concern for active TB, consider Sputum Cultures and admission

Case 2:  Ketonuria

  • Ketonuria
    • Ketones produced from catabolism of fat stores
      • Beta-hydroxybuterate
      • Acetoacetate
    • Ketones excreted in urine => Ketonuria
    • Occurs when:
      1. Caloric intake does not match caloric need
        • Poor diet/intake
          • Dieting
          • Nausea and vomiting preventing PO
          • Poor access to food
          • Missed meals, etc
        • Increased physical activity
      2. Unable to utilize glucose as energy
      • Diabetes
      • Body relies on other sources such as fat catabolism
    • URINE TEST
      • Measures acetoacetate
      • Acetoacetate and beta-hydroxybuterate produced at ration of 1:3
      • If ketones in urine, likely 3 times that in blood
  • Glucosuria
    • Occurs when seum glucose > 160-180
    • Occurs in pregnancy
    • Occurs when receiving IV Fluids with sugar (ex. D5)
  • Ketonuria AND Glucosuria
    • Diabetes
      • Body has high circulating glucose => Spilling glucose in urine
      • Body is unable to utilize high circulating glucose => fat catabolism => ketone production
    • Screening for DKA
      • Ketonuria in presence of hyperglycemia very sensitive for DKA
      • Specificity is lower (30-70%)
  • Summary
    • Presence of ketones and glucose in the urine warrants further investigation / rule out DKA
    • Keep differential broad

Case 3:  Knee Dislocation

Background:

  • Classically high energy mechanism
    • Sports injuries (ex Tackle in football)
    • Motor vehicle accident
  • 20-50% reduce spontaneously
  • High risk for complication
    • Popliteal artery injury in 10-40%
    • Peroneal nerve injury in 23%
    • Amputation after 8 hours up to 86%

Low Energy Knee Dislocations

  • Becoming more common 2/2 obesity
  • Force on knee proportional to body weight
  • Also high risk for complications
    • Case study with 17 patients
      • 41% with popliteal artery injury
      • 41% with peroneal nerve injury
      • 12% required AKA
  • Recent vascular surgery study comparing high to low energy dislocations
    • High energy injuries
      • Average BMI = 29
      • More likely to have concomitant injury
    • Low energy injuries
      • Average BMI = 41
      • Stratified by BMI
      • Higher BMI correlated with increased likelihood of vascular and nerve injuries
      • More likely to have isolated knee dislocation without concomitant injury

Assessing for Arterial Injury

  • Pulses
    • Not reliable for ruling out arterial injury
      • Intimal flap can cause delayed occlusion/pulselessness
      • Collateral flow in distal artery may mask more proximal occlusion
    • Doppler can help with this assessing for tri-phasic pulse
  • Ankle-Brachial Index
    • More reliable
    • ABI >0.9 and palpable pulses reassuring
      • Recent study has shown no complications in 6 months if both present
      • However, still recommend 48 hours of observation
  • CTA
    • Recommendations in literature are variable
    • General thoughts
      • CTA patients with high BMI and suspicion for knee dislocation
        • Physical exam is difficult (Pulses and ABIs)
        • Higher rate of complications
      • CTA all patients with signs concerning for arterial injury
        • Diminished pulses
        • Decreased ABI
      • Can consider CTA vs. observation in patients with low BMI
        • Should have discussion with consulting service on CTA vs. Observation

Case 4:  Typhlitis

Definition:  Neutropenic necrotizing enterocolitis of the cecum

  • Presents as RLQ pain in patients with ANC < 500
    • Most often in hematologic malignancies
    • Immunosuppression
  • Average mortality in adults:  40-50%
  • Mortality in children is lower

Pathophysiology:  

  • Stasis in colon and disruption of mucosa
  • Bacteria invade/proliferate in cecal wall
  • Necrosis and perforation

Presentation:

  • RLQ Pain
  • Fevers, chills
  • Nausea, vomiting
  • Usually occurs 2-3 weeks after chemo induction due to nadir of neutropenia
  • Diagnosis:
    • CT Abdomen and pelvis
      • Common findings
        • 100% have bowel thickening
        • 52% with stranding
        • Less common to see pneumatosis

"Classic Presentation"

  • Hx of CLL or hematologic malignancy
  • Neutropenia
  • RLQ pain / ileocecal colitis
  • Shock

Management:

  • Early surgical consult - Though may actually delay surgery in lieu of medical management as patients are often not great surgical candidates
    • Indications for surgery
      • Continuing to bleed despite correction with product
      • Bowel perforation
      • Uncontrolled sepsis and deterioration
  • Broad spectrum antibiotics - Anaerobic and Pseudomonal coverage
  • Restoration of neutrophil count (Filgrastim)
  • Correction of coagulopathies with blood products
  • Recommendations:
    • Early recognition:  Neutropenia + RLQ pain = Typhlitis until proven otherwise
    • Early surgical consult
    • Manage aggressively
      • Resuscitation
      • Broad spectrum antibiotics with pseudomonal coverage 

Case 5:  Alcohol Withdrawal

Definitions

  • Mild alcohol withdrawal (6-12 hours since last drink)
    • Tremulousness
      • Constant intention tremor without fatigue
        • Can include the tongue
        • 7-10 Hz
    • Mild agitation
    • Poor sleep
    • GI upset
  • Severe alcohol withdrawal 
    • Extreme agitation
    • Withdrawal seizures (Within 24 hours of last drink)
      • NOT predictive of development of DTs
    • Hallucinations and delirium (Usually 2-3 days after last drink)
  • Delirium Tremens  (Usually 3-5 days after last drink)
    • 5% of severe alcohol withdrawal develops DTs
      • Severe alcohol withdrawal (See above) PLUS Autonomic instability
        • Tachycardia
        • Hypertension
        • Fever
        • Diaphoresis
      • At risk for arrhythmia
      • Can be fatal
        • Usually from arrhythmia
        • Can be from underlying cause that made them stop drinking
          • Underlying illness
          • Injury
          • etc.

Management (see our EmergencyKT protocol) 

  • Mild withdrawal
    • RCT in VA system comparing inpatient to outpatient management
      • Showed shorter length of treatment in outpatient management
      • No difference in complication/failure rates
      • HOWEVER: VA system ensured good daily follow up with outpatient group
      • May not be applicable to general ED population
    • Patients likely able to succeed with outpatient management
      • 2 assessments of CIWA < 8 taken 1-2 hours apart
      • No evidence of severe alcohol withdrawal
      • No history of severe withdrawal
      • No uncontrolled comorbidities
    • Benzodiazepines?
      • Practice patterns vary
        • Fixed vs. Scheduled symptomatic dosing
        • Many do not prescribe, very social situation dependent 
      • Preferred medications
        • Chlordiazepoxide (Librium)
          • Active metabolites => long duration of action
          • Thought to have less risk of abuse
  • Severe withdrawal
    • Admission to ICU
    • Rapid escalation of benzodiazepines
      • Oral diazepam
        • Rapid onset of action ideal for titrating dose to effect
        • Long half life ideal for withdrawal
      • IV lorazepam
      • Consider drip, though general push is to avoid it
        • Increased complications
        • Longer hospital stays
      • Phenobarb if withdrawal refractory to benzos

R4 CASE FOLLOW UP:  INGESTION OF HOUSEHOLD CLEANER WITH DR. GOEL

Case:  50 year old male presenting for suicide attempt with ingestion of 3/4 of a 48oz bottle of Pinesol.  Presents lethargic, requiring oxygen despite no Hx of respiratory disease.  He arrests several hours after admission.

Contents of Cleaner

  • Hydrocarbons
    • 10% Pine Oil
      • Derived from turpentine
      • Used in disinfectants and essential oils
    • Cause of toxicity
      • Primarily affects lungs and CNS
        • Lungs
          • Direct inhalation is #1 injury pattern
          • Breaks down surfactant, and can lead to ARDS
          • Respiratory symptoms within 2 hours of arrival predicts bad course
          • Stages after inhalation
            • Euphoria
            • Headache and dizziness
            • Blurred vision/weakness
            • Slurred speech and lethargy
  • Management of hydrocarbon toxicity
    • Monitor for 6-8 hours
    • Supportive care if symptomatic
    • In large ingestion, consider intubation and NG Tube
      • Evaporates fast
      • Ingestion also leads to significant inhalation
  • Isopropyl alcohol
    • Contained in rubbing alcohol/cleaning agents
    • Toxicity
      • CNS depression similar to ethanol
      • Can cause tracheobronchitis
      • Can cause peripheral vasodilation and hypotension
    • Diagnosis
      • Isopropyl alcohol
      • Will not cause anion gap (metabolized to acetone)
      • Osmolar gap  (Measured serum osms - Calculated serum osms)
    • Management
      • Most asymptomatic
      • PPI for gastritis or discomfort
      • May be dialyzed in severe ingestion
  • Glycolic acid (Metabolite of ethylene glycol)
    • Ethylene glycol
      • Metabolism
        • Ethylene glycol (alcohol dehydrogenase) => Glycoaldehyde (Alcohol dehydrogenase) => Glycolic acid => Calcium oxylate crystals
      • Toxicity
        • Peak concentration 1-3 hours
        • Metabolites peak at 6-8 hours
          • Glycolic acid
            • CNS Toxicity
            • Acidosis leads to cardiac symptoms
          • Calcium oxylate crystals
            • Renal toxicity
        • PHASES
          • (0-12 hours) CNS PHASE: Nystagmus, hyporeflexia
          • (12-36 hours) CARDIOPULMONARY PHASE:  Hyper or hypotension, CHF: pulmonary edema
          • (24-72 hours) RENAL PHASE:  AKI, renal failure
      • Management
        • Largely supportive
        • Competitive inhibition (if ethylene glycol, will not work if already glycolic acid)
          • Fomepizole
          • Alcohol
        • Dialysis if needed

TAMING THE SRU:  TORSADES DE POINTE WITH DR. BAEZ

Case:  Middle aged male brought in via EMS after out of hospital arrest.  Bystander CPR was started prior to EMS arrival.  EMS continued CPR, obtained access, and intubated the patient.  Patient was initially in shockable rhythm receiving shock X2 and amiodarone.  ROSC was achieved and patient presented to the ED.  Initial EKG shows prolonged QTC of 694.  EMS is able to print original rhythm strip demonstrating torsades de pointe

Background:

  • First described in 1966
  • Described as "Twisting around EKG axis" which is where it derives its name
  • Incidence is 3.2 per 1 million people
  • Usually self terminating, thought to be largely unrecognized

Pathophysiology:

  • Standard phases of cardiac depolarization
    • Phase 0: Sodium channels open causing depolarization
    • Phase 1: Sodium channels close. Potassium channels open causing outward current of K+ out of the cells.
    • Phase 2: Calcium channels open causing positive influx, balancing continued potassium efflux
    • Phase 3: Calcium channels close, but potassium channels are still open causing net efflux of positive charge until repolarization
    • Phase 4: Exciting triggers cause minor depolariztions, eventually leading to Na + opening and restarting at phase 0
  • Torsades
    • Cell depolarizes before complete repolarization = "Early afterdepolarization"
    • Triggers V Tach

Predisposing Factors:

  • Prolonged QT
    • Congenital channelopathy
    • Drug induced
      • 3% of all prescriptions prolong QT
      • Most common reason for drugs to be pulled by FDA
  • Bradycardia
  • Exaggerated U Waves
    • Ratio of amplitude compared to T waves predictive of torsades
  • PVCs or PACs
  • Electrolyte abnormalities
  • Females 2X more likely than males

Presentation:

  • Sycnope/Arrest
  • Often brief and self terminating
    • Dizzines
    • Lightheadedness
    • Palpitations

Management:

  • Magnsium (2 grams over 15 minutes)
  • Repeat magnesium if refractory (Monitor for toxicity)
  • Optimize electrolytes
    • Consider magnesium
    • Potassium
    • Calcium
  • Increase heart rate:  
    • Pharmocologic
      • Isoproterenol
        • Shortens refractory period
        • Able to titrate to effect (HR 100 or so)
      • Electrically
        • External pacing
  • Defibrillate
  • Other anti-arrhythmics
    • Lidocaine
    • Clonidine
    • Amiodarone?:  Likely not
      • Can prolong QT
      • Can cause torsades

TESTICULAR COMPLAINTS WITH DR. SKROBUT

Henry Vandyke Carter [Public domain], via Wikimedia Commons

Areas of focus

  • Pathology within the scrotum (Penile complaints excluded)
  • Will not cover torsion (Covered fairly commonly)

Background:

  • Anatomy
    • Scrotum
      • Skin
      • Several underlying fascial layers
    • Testicular anatomy
      • Single testicular artery
      • Pampiniform plexus
      • Epididymus
      • Vas Deferens
  • Causes of Testicular Pain
    • Torsion of appendix testis
      • Presentation
        • Gradual onset in testicular pain
        • Usually no nausea or vomiting
      • Exam
        • Maybe mild tenderness
        • Blue dot sign in 10%
      • Management
        • Scrotal support
        • NSAIDS
        • No need for urology follow up
    • Epididymitis
      • Presentation
        • 4 months - 80 years old
        • Testicular pain
        • May have fever
        • 20% with urethral symptoms: discharge, itching or pain
      • Exam
        • Tenderness over epididymis / posterior aspect of testicle
      • Management
        • Adults
          • Typically bacterial in this age group
          • Get urine culture
          • Consider TB in endemic areas / immunocompromised
          • If sexually active
            • No =>  Cover for enteric organisms with Levaquin
            • Yes 
            • Anal sex => Cover for enterics and STI (ceftriaxone and levofloxacin)
            • No anal sex => ceftriaxone and doxycycline
        • Peds
          • Often viral or ideopathic => supportive care
            • Rest, ice, NSAIDS
          • Urine culture
          • Antibiose if culture positive
    • Orchitis
      • Causes
        • Viral most common
          • Mumps is most common of these
        • Bacterial causes
          • Usually epididymal spread
          • Often more systemically ill appearing
      • Presentation
        • Painful swollen testicle
        • Testicular erythema
        • Usually febrile
      • Exam
        • Significantly swollen, tender
        • May have systemic signs of illness
      • Management
        • If viral => supportive care
          • If mumps, isolation for 5 days
        • If bacterial
          • Antibiotics
          • US for abscess
          • Urology consult
    • Testicular Mass / Cancer
      • Presentation
        • Usually painless
        • Firm mass adhered to testicle
        • MAY BE PAINFUL
          • Internal hemorrhage or hematoma
          • Creates pressure on tunica
      • Assess for signs of metastasis
        • Headaches
        • Respiratory problems
        • Weight loss and B signs
      • Management
        • If well appearing, close outpatient urology follow up
        • If unwell, or signs of metastasis, consider admission and urology/heme onc consults
    • Scrotal and testicular trauma
      • Scrotal laceration
        • No fascial violation
          • Suture at bedside (3-4 chromic gut)
        • Fascial violation
          • Urology consult
          • Likely OR for washout
      • Evaluate for concomitant pelvic or urethral trauma
      • Testicular ultrasound
        • Assess for torsion
        • Assess for testicular rupture
        • Consult urology if present
    • Hydrocele
      • Presentation
        • Hemiscrotum may appear enalarged
        • Uniform structure
      • Diagnosis
        • Trans-illumination test
      • Management
        • Kids
          • Nothing to do
          • Often resolves spontaneously
          • Urology follow up if lasting > 12 months
        • Adults
          • Present in 1%
          • May be 2/2 other pathology
            • Torsion
            • Trauma
          • Further evaluation may be necessary
    • Varicocele
      • Presentation
        • 15% of adolescents and adults
        • Often asymptomatic
      • Red Flags!
        • > 40 years old or R sided varicocele =>  Consider causes of venous compression
          • Renal adenocarcinoma
          • Other mass
          • Clot
        • Kids
          • If not decompressed when lying flat, indicative of mass (Wilms?)
    • Spermatocele
      • Presentation
        • 20-60 years old
        • Aching
        • Heaviness in testicle
      • Exam
        • Pedunculated cystic mass on epididymis
      • Management
        • Can follow up with PCP
        • Urology outpatient follow up if significantly painful
    • Inguinal hernia
      • Presentation
        • Swollen hemiscrotum
        • Bowel sounds present
        • May be painful or uncomfortable
      • Management
        • Reducible:  Outpatient follow up
        • Non-Reducible (Incarcerated):  
          • Ice
          • Trendelenburg
          • Call surgery (They will likely attempt)
        • Strangulated:  Emergent surgical consultation
  • TAKE HOME POINTS
    • Torsion, abscess, cancer with poor follow up => Ultrasound
    • Toxic patients with orchitis, epididymitis => Admission and Abx
    • Anything else that's stable without torsion likely appropriate for outpatient follow up