Grand Rounds Recap 09.30.20
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MORBIDITY & MORTALITY WITH DR. HUGHES
Case 1 - Undifferentiated Dyspnea
Auscultation lacks sensitivity in differentiating etiologies of dyspnea
While heart failure remains a clinical diagnosis, BNP is particularly useful if there is intermediate pre-test probability
Routine BNP testing in patients with underlying asthma/COPD can lead to a new diagnosis of heart failure
Cardiopulmonary ultrasound for undifferentiated dyspnea:
Decreases time to diagnosis
Can change the leading diagnosis and/or treatment plan up to 50% of the time
Potentially increases diagnostic certainty
Case 2 - Back Pain with Blast Crisis and Leriche Syndrome
Up to 5% of all acute back pain presentations will have serious causes
There is a lack of consensus on “red flags” with evidence supporting:
Older age
Prolonged corticosteroid drugs
Severe trauma
Presence of contusion or abrasion
History of malignancy
Multiple red flags
Consider non-mechanical etiologies of back pain, particularly in acute presentations, as they are often excluded from diagnostic algorithms
Case 3 - Sickle Cell Pain Crisis
Patients with sickle cell disease have a higher incidence of pulmonary embolism, even in the setting of lower CT utilization
Pulmonary emboli in segmental regions only can cause cardiac death, up to 13% of all PE-related cardiac arrests in one study
Diagnostic momentum has the potential to carry through to the inpatient team, it is important to reflect any diagnostic uncertainty if is exists
Case 4 - Shortness of Breath
Up to 4% of all ED intubations will result in cardiac arrest with predictors including:
Hypoxemia
Hypotension
Shock index (HR/SBP) >= 0.8
Availability bias leads to overdiagnosis of common etiologies and underdiagnosis of rare pathologies
While obstructive shock only accounted for 0.9% of all cases in one study, the most common medical etiology of cardiac tamponade is cancer, especially lung and breast, accounting for one-third of all cases
Case 5 - Hyperkalemia
Despite lack of robust evidence, the most important component of hyperkalemia treatment is calcium
Ensure elemental dosing equivalency between chloride (needs 1g) and gluconate (needs 3g)
Re-dose at appropriate intervals, as calcium only lasts 30-60 minutes
Talk to your team to understand limitations of order initiation
Triage cueing aka pod bias is a cognitive bias that can be addressed by forming your own impression prior to:
Reading the triage summary
Reading nurses’ notes
Hearing a learner’s case presentation
Case 6 - Headache
Physical exam findings are not sensitive for meningitis
While SAH and bacterial meningitis are unlikely in the subacute period, there are multiple other etiologies of headache to consider for which LP is diagnostic including: cryptococcal meningitis, tuberculosis meningitis, lyme meningoencephalitis, and idiopathic intracranial hypertension
Delay in diagnosing cryptococcal meningitis increases the risk for long term neurologic deficits
Case 7 - Tumor Lysis Syndrome
Care turnovers can lead to medical errors but also opportunity for rescue when reevaluation offers a fresh perspective
Have a high suspicion for tumor lysis syndrome if there is hyperkalemia in the setting of cancer (new or known) or insignificant acute kidney injury
The rate of misdiagnosis in emergency medicine is exceedly low, only 0.6% per one study
AIRWAY GRAND ROUNDS WITH DR. CARLETON
Case 1: Male in his 80s had a witnessed cardiac arrest in the pre-hospital setting, presented with an iGel in place after being unable to be intubated in the field.
Intubating through an iGel
The benefit of intubating through an iGel is preserved ventilation. Consider it for patients when the iGel was placed for rescue because a competent team could not intubate or when the patient is extremely tenuous from an oxygenation standpoint. Steps include:
Subtotally intubate the iGel with an ETT
Inflate the ETT balloon with 2-3ml to lock it into the iGel and continue to ventilate through it
Attach a bronchoscopy adapter to the ETT and ventilate through it
Pass endoscope through the diaphragm on the bronchoscopy adapter and intubate to the level of the carina with the endoscope with continuous ventilation
Deflate the ETT balloon and pass it over the endoscope through the iGel to hub it
Inflate the ETT balloon here and ventilate
Confirm intubation as the endoscope is withdrawn and ventilate
Remove the iGel over the ETT with a smaller ETT and ventilate
Case 2: Male in his 30s who presents after an MVC saturating 83% on 15Lpm while being bagged. Noted to have facial trauma with blood in mouth, obvious left rib fractures, and coarse breath sounds that are decreased on the left. Bagged up to a sat of 92%. First attempt was made with ketamine sedation and no paralytic, ETT passed through cords however ETCO2 failed and ETT was pulled. iGel inserted and rescue bagged with sat recovery. Second attempt with RSI and succinylcholine administered with successful passage of ETT.
Overcoming mediocre pre-oxygenation
Patient positioning
Escalate to positive pressure if needed, high-flow delivery and more aggressive apneic oxygenation
Consider DSI - optimize patient’s oxygenation with the sedation
Sedation-only intubation: con is that they still have their airway reflexes and can vomit; pro is that they will maintain their own respiratory drive
Intubation confirmation:
Waveform capnography
Colorimetric ETCO2
Pulse oximetry, knowing there is a latency (Lung to finger circulation time: Can have 15 seconds of delay in pulse ox sat reading in a normal individual post-intubation, and this can be up to 30-45 seconds of delay in a critically ill patient with peripheral vasoconstriction)
Direct vision
Chest rise & fall/breath sounds/ETT fog
Case 3: Female in her 50s presenting in status epilepticus. On presentation, she is noted to have gurgling respirations, drooling, and diminished breath sounds in the setting of prehospital versed 10mg IM. Starting O2 sat was 95%. First attempt at RSI with inability to pass ETT successfully. Second attempt with bougie also unable to pass due to the airway being anterior. Third attempt was made with a D-blade and rigid stylet that was successful. Extubated inpatient once seizures aborted.
What should you do when the view is adequate, but you can’t make the ETT go anterior enough?
BURP +/- jaw thrust
Rigid stylet
Magill forceps
Extend neck (if nasal ETT)
Side-saddle rotation of the ETT
Endotrol ETT
VL with channel blade (King vision, airtraq)
Combined VL/endoscopy
Case 4: Male in his 20s with history of cerebral palsy who presents after a seizure at home. Given versed 10mg IM en route. On presentation, noted to be seizing, biting his tongue with blood and saliva drooling from his mouth. Given concern for lack of airway protection, the decision was made to proceed with RSI with etomidate and succinylcholine that was unsuccessful. Second attempt made with propofol added, which was successful.
Intubating in Status Epilepticus
For neurolytic intubation, consider 1.5mg/kg propofol + 2mg/kg ketamine + paralytic to optimize RSI in status epilepticus as a strategy to control the airway, possibly abort the seizure, and permit aggressive antiepileptic therapy. Consider contraindications of paralytics in the seizing patients; succinylcholine may lead to increased risk for hyperkalemia in a patient presenting with status epilepticus that may already be developing rhabdomyolysis.
R4 CAPSTONE WITH DR. KOEHLER
Breathing and Stress: Heart rate variability is a marker of autonomic nervous system activity and can contribute to stress. Therefore, reducing your heart rate can reduce stress. Two techniques include:
Prolonged exhalation - take a deep breath in and let it out slowly
Tactical breathing, or “box breathing” - inhale, hold, exhale, hold
Passion: Contributing 20% of your work effort towards something that you are passionate about reduces burn out by one third and increases engagement.
Time Away from Work: Find people you like! Exercise with benefits including improved learning, improved task acquisition, and decreased memory decline. Use reflective structures, as leaders build time and space for themselves and for reflection.
ATTENDING CASE FOLLOW UP WITH DRS. CONTINEZA, R. THOMPSON, AND SABEDRA
DR. CONTINENZA’S CASE
A woman in her 40s with no PMHx presented with 1 week of abdominal pain, suddenly worsened on the day of presentation, described as constant, severe, sharp and mostly located in the epigastric/RUQ region. Also endorsed distension, nausea, non-bloody vomiting, and diarrea. Physical exam: Noted to be tachycardic and hypertensive on presentation. Uncomfortable, pacing around the bed and vomiting into the emesis basin. Minimal tenderness most pronounced in the RUQ/epigastric region. Diagnostic work up: CBC, BMP, LFTs, lipase, and UA were largely unremarkable. POCUS RUQ demonstrated a gallstone with no gallbladder wall thickening or pericholecystic fluid. CT abdomen/pelvis notable for complete thrombosis of the SMV with edematous, hypoenhancing loops of jejunum in the left abdomen suggestive of ischemia.
Cognitive Bias
Fast versus slow thinking. Fast thinking is unconscious, automatic or “pattern recognition”, and error prone. Slow thinking is conscious, effortful, and reliable.
Mesenteric Ischemia
Rare (1/1000 admissions) etiology of abdominal pain with high morbidity and mortality (70%) where early intervention is key
Occlusions are arterial 77% and venous 32% of the time, coming from thrombosis (20-30%), embolus (40-50%), non-occlusive/low flow state such as from vasoconstriction (5-15%), and venous occlusive states such as hypercoagulability (5-15%)
Peritonitis is a late finding, as initially only the bowel mucosa is affected leading to the class “pain out of proportion to exam”
While labs can be falsely reassuring, CT angio has a +LR of 17.5 and -LR 0.09
Management is 1) surgical consultation and/or revascularization with catheter directed lysis, 2) anticoagulation, and 3) broad spectrum antibiotics
DR. R THOMPSON’S CASE
A man in his 30s presented with mid-thoracic back pain for 8 days that was not improved with acetaminophen or ibuprofen. He works at a warehouse and does a lot of heavy lifting, but also uses IV drugs. No fever or bowel/urinary symptoms. He is noted to be tachycardic on presentation with no midline tenderness and no neurologic deficits but does have bilateral thoracic paraspinal muscle tenderness. While his WBC was normal, his ESR and CPR were elevated. Prior to MRI, he left AMA but returned 2 days later at which time it was performed and showed discitis/osteomyelitis at T6-7 with ventral epidural abscess. He underwent IR aspiration of the abscess and was sent to a SNF on IV abx
Spinal epidural abscess
Triad of fever, back pain, and neuro deficits is very rare in spinal epidural abscess presentations
Have a high level of suspicion for infectious spinal pathology in “back pain plus”, particularly in patients with history of IVDU
ESR and CRP are more useful than WBC
Strongly consider MRI
Give buprenorphine early on to curb withdrawal symptoms
DR. SABEDRA’S CASE
A man in his 30s with a history of GERD and NASH presented with one week of epigastric pain, described as constant and pressure-like worse with movements and deep breaths. He was seen at an OSH ED a few hours prior to presentation where CBC, BMP, and LFTs were remarkable only for mildly elevated AST/ALT. He received a GI cocktail and Zofran without relief of his symptoms. He was well appearing with normal VS, and only mild tenderness on exam. On further chart review, he was noted to have a history of DVT/PE on Xarelto but has been off of medications due to insurance issues. CT obtained and demonstrated acute left portal vein thrombosis.
Portal vein thrombosis
Prevalence is 1% with predisposing conditions including cirrhosis, hepatobiliary malignancy, major infectious or inflammatory abdominal disease, and myeloproliferative disorders
LFTs can often be normal because hepatic arterial blood flow compensates for decreased portal inflow
Evidence for CT use is limited, while MRI has high sensitivity and specificity based on low level evidence
Treatment includes anticoagulation, antibiotics if a septic PVT, and surgical exploration if there is intentional infarction
Cognitive biases
Anchoring: Prematurely settling on a diagnosis based on a few features of the initial presentation and failing to adjust as new information became available
Search satisfying & premature closure: Seeking only as much information as necessary to form an initiation clinical impression and then failing to consider alternative diagnoses after the initial impression is formed
Confirmation bias: Once you have an initial impression, you tend to only notice the evidence that supports you and to dismiss contrary evidence
