Grand Rounds Recap 10/14
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NEUROIMAGING WITH DR. KNIGHT
Case 1: Patient came in with sudden onset hemiparesis. CTA performed showing no apparent intracranial or extracranial flow unilaterally, concerning for common carotid injury. Taken to angio where a normal Circle of Willis was found. Initial CT findings resulted from air embolism from brachial artery PICC. This case brings up the point that knowing the mechanics of the test is important for interpretation. CTA is a venous study timed for the arterial phase.
Case 2: Patient with sudden onset unresponsiveness who had rhythmic shaking with any stimulation, treated for status epilepticus. CTA initially read by the ED physician as negative, so patient was called to the Stroke Team as a likely seizure presentation. CTA read as basilar artery occlusion, treated with thrombectomy with reconstitution after procedure. Not all shaking is seizure activity.
Case 3: Young male fell after being tased by police. Was oriented to person and localized briskly to pain but did not follow commands and had confused speech. Found to have L temporal subdural hematoma and traumatic subarachnoid hemorrhage. Developed hippus in the Neuroscience ICU, which is spasmodic rhythmic irregular dilating and contracting pupillary movements suggestive of a frontal lobe dysfunction and is a poor prognostic sign. Blood in the temporal region has a high likelihood of uncal herniation given proximity.
Case 4: Young male with traumatic injury including coup/counter coup injury requiring L hemicraniectomy who decompensated post-operatively. Repeat CT head non-con showed blossomed contusions, left to right midline shift, and new epidural hematoma. Developed a pseudomeningocele 5th ventricle on routine CT, which is treated with cranioplasty once cerebral edema is resolved.
Case 5: Young male with GSW, E2V1M5 localizing RUE briskly. Found to have comminuted skull fracture, percussion contusion (wave like), penetrating wound, and foreign bodies. CT head showed empty delta sign - where contrast should be located but is absent due to sagittal sinus thrombosis. Due to the location of bullet injury, CTA performed to assess for transverse sinus injury. CTA is likely sufficient for sinus venous thrombosis if there is also concern for arterial pathology.
JOURNAL CLUB: TRAUMA THEME LED BY DRS. CONNELLY, HUNT, & IRANKUNDA WITH QUICK HITS BY DR. MOELLMAN
Article 1: Michailidou M, O'Keeffe T, Mosier JM, et al. A comparison of video laryngoscopy to direct laryngoscopy for the emergency intubation of trauma patients. World J Surg. 2015;39(3):782-788.
Question: Does VL perform better than DL in trauma airways ?
Population: All trauma patients that were emergently intubated at a Level 1 Trauma Center from 2008-2011 (n = 709)
Results: VL had a significantly higher success rate (88%) than DL (83%) in trauma patients intubated emergently, with cervical spine immobilization as a predictor of higher initial success with VL
Article 2: Chreiman KM, Dumas RP, Seamon MJ, et al. The intraosseous have it: A prospective observational study of vascular access success rates in patients in extremis using video review. J Trauma Acute Care Surg. 2018;84(4):558-563.
Question: Is obtaining IO access faster than peripheral IV or CVC access in critically ill trauma patients?
Population: All patients undergoing emergency department thoracotomy from 2016 to 2017 (n = 39)
Results: PIV and IO are faster than CVC attempts but no difference in timing between the two, though IO had higher success rates
Article 3: Sims CA, Holena D, Kim P, et al. Effect of Low-Dose Supplementation of Arginine Vasopressin on Need for Blood Product Transfusions in Patients With Trauma and Hemorrhagic Shock: A Randomized Clinical Trial. JAMA Surg. 2019;154(11):994-1003.
Question: Does use of low dose arginine vasopressin (AVP) in hemorrhagic shock reduce need for transfused blood product during resuscitation?
Population: Adult trauma patients who received at least 6 units of any blood product within 12 hours of injury at a level 1 trauma center (n = 100)
Results: Patients who received AVP required significantly less blood product but there was no difference in crystalloid or vasopressor use with similar mortality, though the AVP group did have less DVTs (11% versus 34%).
Adaptive Clinical Trials - Quick Hits!
Definition: A clinical trial design that allows for prospectively planned modifications to one or more aspects of the design based on accumulating data from subjects in the trial (FDA Nov 2019)
Adaptations can include sample size, inclusion/exclusion criteria, study dose, treatment duration, study endpoints, criteria for evaluation and assessment of clinical endpoints, and statistical changes (randomization, hypothesis, methods), but must be identified in advance.
Pros: Flexible, efficient, increased exposure to effective doses and decreased exposure to ineffective doses in terms of patient outcomes, quicker decision making ability for safety and efficacy
Cons: Bayesian statistical approach (based on probabilities instead of pre-specified significance level), type 1 error not as controllable, significant preplanning and upfront work, complicated logistics, difficult to interpret with unexpected bias
Being used now in relation to COVID-19, such as the ACCORD study
R4 CAPSTONE WITH DR. LI
Kindness
Kindness should not be devalued when in comes to evaluations
If things are slow, spend that extra time with the patient
Be kind to yourself
Attitude
Attitude is contagious, more important than facts or education
Small changes in how we act can lead to big results
Our attitudes surrounding COVID have changed, from being team-based healthcare heroes to frustration, which we should be mindful of as we head into flu season
Breaks
We should be taking breaks while on shift, as we don’t do well taking care of our physiological needs (O’Shea WJEM 2020)
The concept of being “hangry” has been proven in the literature; hunger can in fact increase likeliness of anger
Taking a break on shift is NOT a weakness
Breaks for pumping are especially important
QUARTERLY SIM
Simulation Case: 8 year old healthy girl who is fully immunized presenting with flu-like syndrome. Initial VS showed HR 154, SBP 80, RR 32. Patient was placed on the monitor, which showed sinus tachycardia. IV access was established by EMS, who also gave 1L NS. Upon further history from the mother, patient has been having nausea, vomiting, and abdominal pain for the past several days. No other symptoms. No sick contacts. Exam notably for lethargy but otherwise non-focal. Labs show pH 7.1/23/10 with a gap of 42 and BS >1400 in the setting of a likely UTI. After fluid administration, the patient became more hypoxic and unresponsive concerning for cerebral edema requiring intubation.
Diagnosis: New onset DKA complicated by cerebral edema
Learning points:
The differential for isolated vomiting in pediatrics is broad including abdominal pathologies, viral illness, head trauma, and DKA
Don’t forget to correct the sodium in severe hyperglycemia
Cerebral edema needs to be considered in pediatric DKA, especially with rapid correction of sodium. However, in a large prospective RCT, neither the rate nor sodium concentration of IVF impacted neurologic outcomes. (Kuppermann N Engl J Med 2018)
If you have to intubate a patient with severe metabolic acidosis, consider bagging the patient during the apneic period if there is a critically low pH and set respiratory rate on the ventilator to match the pre-intubation efforts
Oral Boards Case 1: Elderly Blunt Trauma
Get a general impression (“What do I see when I walk in the room?”) and a primary survey on all trauma patients. This will help you decide if this is an ABC patient (needs stabilizing interventions) or a HPI patient (one you can get a full systematic H&P on).
Draw a stick figure on your paper and use a checklist as a reminder for exam components you frequently miss (antibiotic prophylaxis, tetanus, treating pain). Do a FULL trauma exam (even GU) every patient, every time, and draw your findings on your stick figure to keep track of your patient’s injury complex.
Elderly blunt trauma (defined age > 65) consumed a 1/3 of healthcare trauma resources
Mortality predictors: Male sex, Black, higher ISS, GCS motor score, lower SBP (SBP < 110 doubles mortality compared to SBP 130-150), hypothermia, and need for mechanical ventilation
Oral Boards Case 2: PTA
PTA: fever, severe sore throat, dysphagia/odynophagia, trismus
Steroids: Difference in pain at 24 hours after decadron, however the difference disappears within 48 hours. Trismus was also improved in the steroid group.
2016 Cochrane review (11 studies with n = 674, peds and adult)
Very low quality evidence to suggest that I&D may be associated with a lower chance of recurrence than needle aspiration
Very low quality evidence to suggest that needle aspiration is less painful
Clinical diagnosis: poor performance in differentiating cellulitis from abscess - 78% SN and 50% SP
CT with IV contrast: Rim-enhancing fluid collection adjacent to an enlarged/inflamed tonsil - 75% SN and 100% SP, can get false positive from phlegmon
POCUS: Complex hypoechoic collection 0.5-2.5 cm anteromedial to the ICA, can use color Doppler to visualize the artery, associated with decreased ED LOS when compared to CT
Intraoral: Study in pediatrics found that the learning curve is short at only 3-4 patients, 89-95% SN and 78-100% SP depending on training/field, aspiration with landmarks only vs IOU technique showed 100% accuracy with US but only 64% accuracy with landmark technique with a 7-fold decrease in subspecialty consultation
Transcervical: Better for peds or if the patient has trismus, submandibular probe placement of linear transducer, angle cranially and posteriorly, not many studies for SN/SP (best guess 80-91% SN and 80-93% SP)
