Grand Rounds Recap 1/13
/R1 Clinical Knowledge on Esophageal Emergencies with Dr. Continenza
Boerhaave's syndrome: Full thickness esophageal perforation
Thought to be due to suddenly increased intra-esophageal pressure
60% of perforations thought to be iatrogenic, most commonly related to upper endoscopy
Chest X ray most of the time will have some abnormality, although it may just appear as a pneumonia. Pneumopericardium and obvious signs of mediastinitis may be rare on initial chest X ray, especially early in the disease process or with smaller esophageal tears and less mediastinal inoculation
CT scan is diagnostic modality of choice. If unavailable, upper GI series with Gastrograffin (less sensitive than barium though also less inflammatory reaction) is a better option that barium (greater sensitivity, more associated inflammation/potential for mediastinitis).
Treatment is broad spectrum antibiotics as a broad spectrum of oral and pharyngeal bacteria can be involved
Mortality is high and increases drastically with delays in diagnosis
Swallowed Foreign Body
- It is critical to have on your differential in the pediatric patient presenting with sudden and/or unwitnessed onset of respiratory distress
- Many FB are not radio-opaque and will not show up on plain radiographs
- Button battery ingestions are relatively common in young children and can cause esophageal perforation due to battery acids
Esophagitis
- There are a variety of causative agents however the immunocompromised are at particular risk
- Pill esophagitis results from inability to completely swallow a pill (think motility issues) which can cause strictures of perforation. Can occur with essentially any type of pill.
Diffuse Esophageal Spasm (DES)
- Presentations can be impressive and mimic myocardial infarction as patients complain of crushing substernal chest pain with diaphoresis
- Nitroglycerins may cause them to feel better as they cause dilatation
R4 Case Follow Up with Dr. Strong
Whereas many approach the ECG as a system of rules to be memorized, it is important to remember that ECG is a 3 dimensional map showing the vector of depolarization of the heart. Approaching the ECG as a 3D map of cardiac electrical activity promotes a deeper understanding of its meaning and decreases the need for memorizing rules of common pathologies. That being said, below are examples of commonly encountered electrical conduction abnormalities and associated links to their better understanding via LiTFL:
Visiting Lecture Series with Dr. Deborah Diercks
...on Chest Pain Risk Stratification in the ED
As a lecture preface: Emergency medicine is difficult. You will make mistakes and you will have misses. You never want to leave a shift with the lingering thought that you discharged a patient with an incomplete work up--those are the ones that you will lose sleep over. Err on the side of doing more and do what you need to on shift to be able to sleep well that night.
Troponins are becoming better and better assays--at the cost of becoming lousier test. We do not yet use high-sensitivity troponins in the US, but they are coming. Better assays (and higher sensitivity) may make the results more difficult to interpret as a higher rate of false positives is generated.
If you look at the sensitivity and specificity (ROC curves) of moderate sensitivity troponin, the added value of a troponin at time=6hrs is essentially non existent compared to time=3hrs. In other words, using moderate sensitivity troponins (what we use in our shop and in the US), if the troponin is negative at 3 hours it will be negative at 6, which questions the utility of keeping someone overnight to "rule out" troponins.
High sensitivity troponins: at time 0, these are better diagnostic tests. After time 0, they are likely no better than moderate sensitivity.
Confused as to when to order a second troponin? Is it an hour? 90 minutes? 3 hours? Don't worry--you are not alone. There is no established consensus on when the delta troponin is most advantageous. Bottom line: if the troponin goes up, well, that's bad mmmkay.
Does everybody I send cardiac markers on need follow up functional studies? What drives our decision making is "safe discharge"--can I safely discharge this patient.
The TIMI Score, in its initial study, included patients who either had EKG changes or positive troponins. This is not our undifferentiated ED population. However, higher TIMI scores do worse clinically.
GRACE score is useful for helping who to transfer to higher level of care. Another study that is used in EDs across the country though has questionable applicability to the ED. User beware.
Check out the ADAPT Trial (A 2-hour diagnostic protocol for possible cardiac chest pain in the emergency department: a randomized clinical trial, JAMA, 2014). These New Zealanders set out to prove that, via RCT, a clinical pathway can be used to identify patients with possible cardiac chest pain as low risk and safe for discharge with a low rate of MACE (major adverse cardiac events). In the experimental group they used troponin I, ECG, and the modified TIMI score to risk stratify patients. Those with normal troponins, no ischemic changes on ECG, and modified TIMI=0 received repeat testing at 2-hour and, if still negative went home. Results? More people going home with acceptable levels of MACE. Unfortunately, subsequent validation in the US has not been as successful.
Emergency department providers across the country (and world) are using GRACE, HEART, modified TIMI, and PreTest Consult to help make decisions on disposition of presumed cardiac chest pain. Dr. Diercks says that none of these are perfect, though it is reasonable to incorporate them into practice.
The bottom line: As emergency department clinicians we want to be able to identify a group of people presenting with seemingly cardiac chest pain who are safe for discharge and who do not need follow up functional testing. As of yet there is no perfect test though we are getting closer, particularly when we frame the discussion for our patients that we can provide a high degree of likelihood of safe discharge without MACE for the next 1-3 months. Risk benefit discussions and shared decision making models can be of particular help in some of these interactions.
...on Academics and Balance
Keep who you are distinct from what you do. Do not let your job define you as you are much, much more.
Balance: a state in which different things occur in equal or proper amounts or have an equal or proper amount of importance. It is up to you to define what those things are. Finding greater balance may help with overall happiness.
Over time, learn to say "no," although "no" will always be interpreted as a negative and have consequences and saying "yes," particularly early in your career, may prove beneficial.
EM-Peds Combined Conference with Dr. Wilson on 2015 Updates to Pediatric Advanced Life Support and NRP
The 2015 AHA Guidelines for CPR and ECG (see section on pediatrics for peds-specific recommendations and changes)
Interestingly, MRTs (medical response team) and PEW scores (pediatric early warning scores) have no supporting evidence that they improve patient outcomes. Some interpret this to mean that their use is reasonable.
The routine administration of atropine pre-intubation in the pediatric population has no supporting evidence that it improves mortality. Its routine use is no longer favored though in particularly high-risk intubations its use should be considered.
For pediatric patients in refractory VF, observational studies favor lidocaine over amiodarone in achieving higher rates of ROSC.
Always good to review, here is a link to the neonatal resuscitation algorithm.
Human Trafficking with Mrs. Hountz
Human trafficking is an issue gaining more and more awareness around the country and it is critical that we, as emergency department providers, be able to recognize it.
Nationally, the average age of those trafficked is 12-14 years old.
More than 1,000 children annually are trafficked in the state of Ohio and more than 3,000 are at risk.
Evaluation: red flags should be raised in patients who present as part of a domestic assault/violence evaluation, in those who have recurrent presentations for abuse, multiple presentations for STIs, signs of trauma incurred related to violent sex acts.
Always use a certified translator when communicating with patients who speak a different primary language. Relying on "family members" can lead to misinformation and the interview can be controlled by someone misrepresenting the patient.
Tattoos are frequently used as "brands" within the human trafficking trade and special attention should be payed to them.
The Local Hotline number is 513-800-1863. Call any time that you have a concern that someone is being trafficked or someone is trafficking.
R4 Capstone with Dr. Mann
There are a number of factors that make the University of Cincinnati Emergency Medicine Residency exceptional. One of the greatest of those factors is our faculty. Thank you to you all for your wisdom and willingness to impart it!
