Grand Rounds Summary 10.18.17

/

R1 CLINICAL DIAGNOSTICS: LABS IN PREGNANCY with DR. GOTTULA

Check out Dr. Gottula's full post here.

Hemolytic disease of the newborn initially treated with intrauterine transfusions, however now we can prevent Anti-D antibody formation with Anti-Rh(D) Immunoglobulin (RhoGAM) prophylaxis

Potential Sensitizing Events: threatened or active miscarriage, ectopic pregnancy, antepartum hemorrhage, abdominal trauma, IUFD, delivery and more 

Rho-GAM

  • Prophylactic dose of 300 micrograms at 28 weeks covers up to 30mL of Rh D-positive fetal blood
  • Second dose usually given after birth
  • Can give up to 7 vials at once
  • Medial half life of 23 days
  • ACEP recommends administration of 50 micrograms in all cases of first trimester loss and minor trauma
  • ACOG says any loss requiring instrumentation, ectopic, antenatal hemorrhage in 2nd and 3rd trimester

Indirect Coombs Test (The Screen of Type and Screen) for the Rh negative patient

  • Lasts only 72 hours (takes a minimum of 72 hours for the body to respond)
  • Can space this out in patients with frequent vaginal bleeding (up to 3 weeks)
  • If patient has received RhoGAM they will have a positive anti-D antibody
  • Titers must exceed 1:4 to be considered sensitized

KB Test

  • Relies on detection of HbF in maternal blood
  • Lack of standarizadation for interpretation of results make it difficult especially for the EM physician
  • Not required in pregnancies <20 weeks because fetal circulating volume is <30mL which is covered by one dose of RhoGAM
  • Not required in a sensitized pregnancy
  • Not necessary to wait for results prior to giving initial RhoGAM (may infer need to additional dosing)
  • Not accurate in people with high percentages of HbF (sickle cell, beta that, etc)

Case 1: 24 y/o G1P0 at 12 weeks presenting with post-coital vaginal bleeding x 2 hours
Two weeks ago type and screen showed O negative without antibodies
Pelvic exam shows BRB in the vaginal vaults with a dilated cervix with protrusion of tissue
Treatment: 1 vial of RhoGAM given eminent miscarriage 

Case 2: 26 y/o G5P4004 at 38 weeks presents with gush of fluids 2 hours ago with contractions every 2-3 minutes. Received RhoGAM for O negative blood without antibodies at 28 weeks. No vaginal bleeding or recent trauma
Labs show O negative without antiboides present
Treatment: Administer RhoGAM after birth

Case 3: 27 y/o female who presents after MVC with shoulder and abdominal pain. Negative FAST. 
Labs: Serum qualitative HCG positive, beta quant 126,000, T&S =AB negative
Treatment: RhoGAM; if fetus > 16 weeks, consult OB GYN for possible KB testing to ascertain whether the initial RhoGAM dose was appropriate

CPC with Dr. OWENS and Dr. FARYAR

Case: Elderly patient with a history of sickle cell disease, dementia, hepatitis and R hip AVN who presents with R knee pain. Per the nursing home, the patient was confused yesterday off their baseline and fell this morning while trying to get to the bathroom. Since then, the patient has been complaining of R knee pain, so they brought the patient in to the ER. The patient is not able to add to her history due to dementia and altered mental status.
PMH: DM, gout, anxiety, HTN, hypothyroidism, sickle cell anemia
Vitals: HR 108, BP 120/61, temp 98.6, 90% on RA
Exam: Notable for R knee swelling without erythema or warmth, some TTP over the sternum, otherwise unremarkable and limited 2/2 dementia
EKG: sinus tach
Labs: notable for WBC of 57.2, lactate 3.8, Cr 1.7
Knee and hip X-RAY: R hip arthroplasty with AVN changes noted
CT knee: osseus infacts c/w AVN
CXR: Normal 

Faculty Discussion
Differential includes trauma, septic joint, AVN, and gout flare
Patient had a profound leukocytosis with a neutrophilic predominance. For this, the differential includes primary causes—such as myeloproliferative disorders—and secondary causes. Secondary causes include: infection, stress.  medication induced, asplenia, heatstroke  and non-hematologic malignancy.   
Leukostasiss is a condition in which patients with very high WBCs (50-100k), usually secondary to malignancy, cause vascular stasis and multiple complications including AMS, bone pain, pulmonary/GI infarcts, fevers, etc

Diagnostic Test
Arthrocentesis was performed with frank pus removed. The patient had >500k nucleated cells in her synovial fluid consistent with septic arthritis.
Septic arthritis: 

  • Typically presents with red, hot, swollen joint with decreased ROM
  • Bimodal distribution in children and the elderly
  • In the elderly, patients may have a delayed or atypical presentation due to underlying comorbidities and functional immunocompromized state
  • Mortality in patients >65 is 4.8%
  • In this patient, she was asplenic secondary to sickle cell disease, therefore at higher risk for infection. Sickle cell patients are also more likely to have an atypical presentation or present with "typical sickle cell pain,” which can lead to the diagnosis being missed
  • Patients with sickle cell disease are also more likely to have a more profound leukocytosis
  • This patient was started on cefepime, linezolid and flagyl; cultures were notable for gram positive cocci in chains and ultimately grew out strep bovis
  • Due to the strep bovis infection, a diagnosis of colon cancer was considered but after a family discussion, no further workup was preformed

Spine Trauma with Dr. Ferhan Asghar

The most important role for the Emergency Physician in dealing with spine trauma is to recognize an unstable fracture and potential neurologic compromise. There are three columns to the spine: anterior, medial and posterior columns.  The anterior column fracture is the most commonly involved in a compression fracture, especially in the elderly or in specific types of injuries. Flexion/extension type injuries frequently disrupt the posterior ligaments. The more columns that are injured, the more unstable the fracture and the greater need for surgical intervention and fixation.

Classic indications for surgery: 3 column injury or neurologic symptoms

"Concerning" Fractures
1. Compression fracture with one of the following

  • 50% vertebral body height loss
  • >20 degrees traumatic kyphosis
  • >50% canal encroachment
  • Facet involvement
  • >3 contiguous vertebral body involvement
  • Cervical fracture

2. Two column/Three column injury including the following

  • Burst fracture
  • Chance fracture
  • Fracture dislocation injury

3. PLC injury suggested on CT

  • Widened interspinous space
  • Avulsions and transverse fractures of SP or articular facets
  • Widened or dislocated facet joints
  • Vertebral body translation or rotations

Which brace or collar??

  • Upper cervical spine - difficult to control upper neck and especially hard to control extension; usually put Miami j but if you’re really concerned they'll need a halo
  • Mid cervical spine: Miami J
  • Cervicothoracic junction: Miami J or Aspen collar with thoracic extension
  • Thoracolumbar junction: Off the shelf TLSO vs custom TLSO
  • Low lumbar injuries: Small back brace or off the shelf LSO with thigh extension

Case: Middle aged patient in an MVC with L1 burst fracture which involves the anterior and middle columns with retropulsion. He has full strength in his legs. However, this patient needs a thorough neuro exam including examination of perineal sensation and rectal tone to evaluate for a conus injury. 

He has no involvement of the posterior column and his posterior ligaments are intact. Because of this, this injury will heal well over the course of 8-12 weeks. This patient will be placed in a brace, and upright films should be obtained to ensure stability. The patient should be discharged with close orthopedic follow up and movement restrictions.

Pearls

  • If you find a chronic stable fracture, these usually do not require treatment unless they have neurologic changes, severe kyphosis or severe pain
  • Fractures in patients with ankylosis spondylitis are frequently severe and require surgical intervention
  • Facet fractures can cause vertebral artery injuries; CTA should be performed in anyone where you are concerned about the possibility of a foraminal injury. Facet fracture require very close follow up.
  • TP fractures: These are usually due to internal stretching/tearing forces due to muscular contraction during trauma. These fractures are usually insignificant, often management involves corset for comfort. Heal within weeks. 

Thoracolumbar Injury Classification Scale (TLICS)

  • Looks at whether the posterior ligamentous complex (PLC) is intact and whether the patient is neurologically intact
  • In general, a TLICS scale of 5 or greater requires surgery; if the fracture is distracted, this gives you 4 points due to the possibility for spinal cord injury

Opiate Abuse and ED Innovations with guest lecturer Dr. D’Onofrio

Drug overdose is the leading cause of accidental death in the US (2016 data)
64,070 deaths in 2016, most from synthetic opioids and heroin
20.1 million Americans greater than 12 y/o with substance use disorder in the US
Over the past 10 years, the national rate per 100,000 population of opioid related ED visits has significantly increased. Ohio is currently at 287/100,000 for ED visits, which is the fourth highest in the nation. Ohio has the fastest rate of increase in this statistic the nation.

One in five patients seek treatment so what can we do about it?

  • The biggest thing we can do as Emergency Physicians is work to increase access to care. In the ED, we are in a unique position to interact with many individuals who have opiate use disorders who would otherwise not interact with the health care system. We can initiate therapy in the ED and link individuals with treatment. We can treat opioid overdoses as we would any other emergency. 

Nov 2016: Surgeon General's report which stated that addiction should be treated like any other disease and that buprenorphine should be available in the ER. As with any other chronic disease such as diabetes, treatment needs to include medication as well as behavioral changes.

Does medication work?

  • Study in the Lancet (2003) showed that individuals who received ongoing buprenorphine therapy instead of a short taper had a greater probability of remaining in treatment, while those who received a quick taper were almost all not in treatment after one year. 
  • 2013 study in AJPH showed decreasing heroin overdoses and deaths as buprenorphine and methadone expansions occurred. 

For every dollar spent on addiction treatment, there is a return of 4-7 in the form of less crime, improved employment, and health care expenditures however, less than 1/3 of treatment centers use medication assisted therapy (MAT)

Once buprenorphine was FDA approved in 2002, EDs started giving this out. It is a partial mu agonist which is often combined with naloxone.  You do need specific training in order to receive DEA approval to prescribe this. However, you can administer buprenorphine for the purpose of relieving acute withdrawal symptoms while arranging for the patient's referral for treatment. This can be done for 72 hours only. 

JAMA study: Goal was to compare the efficacy of 3 interventions for opioid dependent ED patients. The interventions were referral to treatment, a brief intervention with a facilitated referral, and a brief intervention with ED-initiated buprenorphine. 329 patients were enrolled over four years. The outcome measures were enrollment in a formal addiction treatment at day 30, self-reported non-prescription opioid use, and the use of addiction treatment services

  • Almost 80% in the buprenorphine group were enrolled in treatment at 30 days (p<0.001) as compared to the other groups which were <50%. They were also less likely to be using non-prescribed opiates.

Patients are at greatest risk for overdose if they:

  • Have a prior non-fatal opiate OD
  • Are leaving a controlled setting (e.g. jail, treatment facility)
  • Are taking > 90 MME (milligram morphine equivalents) per day
  • Are taking benzos with their opiates
  • Use via an IV route
  • Are exposed to high-potency opioids such as fentanyl
  • Are new users or have a low tolerance
  • Have sleep apnea.

We can reduce overdose risk by:

  • Accelerating patient's entry into treatment
  • Increasing access to naloxone
  • Not prescribing unnecessary opiates and using safe prescribing when we do
  • Maximizing the use of EHR
  • Using ED-centric resources like case management and social work
  • Parterning with local community groups

R1 CLINICAL KNOWLEDGE: INDUSTRIAL INJURIES WITH DR. HALL

Case 1: 23 y/o male suffered injury to dominant hand using industrial strength paint gun one hour prior. Intact neurovascular exam with small puncture wound noted.

High Pressure Injection Injuries
Toxic material (or water!) injected at very high pressure
Often presents with a completely normal exam minus a small injection site
Important to find out what was injected (calling poison control can be helpful for possible systemic symptoms)
Remember to ask about tetanus and perform an in-depth neurovasicular exam
Amputation rate 48%...this is a surgical emergency even with a normal exam so get consultant on board early!
Patient's often present hours after injury as they can be initially asymptomatic
X-rays can be helpful to see radio-opaque material (like paint with lead) or to see subcutaneous emphysema
Avoid digital blocks because of the increased volume/pressures in an already tight compartment
Injury is usually due to ischemia, necrosis, direct toxin effect and then secondary infection
Start broad spectrum antibiotics 

Case 2: 33 y/o with abdominal pain x 1 month, hemoglobin 10.5, creatinine 1.2, normal colonoscopy. ROS: arthralgias, fatigue, and difficulty concentration. New job striping rust off a bridge

Lead Poisoning
Most adult exposure are from industry: making batteries, radiator repair, construction, pipe fitters, jewelry, demolition
Absorbed by GI tract and respiratory tract, half life 20-30 years
High affinity for sulfhydrl groups thus affecting hemoglobin synthesis
Lead also competes with calcium which is why it is found deposited in bone
Symptoms: mood complaints, kidney damage, wrist/foot drop, GI symptoms, spontaneous abortion, decrease in sperm production, parasthesias
Take action with levels around 5-10
Most common treatment is removal from exposure
Chelation only for severe exposure

  • DMSA/succimer: PO, hepatotoxic and neutropenia
  • Penicillamine: PO, zinc deficiency
  • Dimercaprol/BAL: IM, first line in encephalopathy
  • Calcium disodium EDTA: IV or IM, often drug of choice, does not cross blood-brain-barrier

R4 CLINICAL SOAPBOX: epic with DR. POLSINELLI

  • MACRA (Medicare Access and CHIP Reauthorization Program) passed in 2015 includes the Quality Payment Program which focuses on quality, cost, and use of certified electronic health records. It aims to consolidate several reporting programs into a simpler program to reduce clinician burden in reporting. Reporting = $$ for hospitals
  • MIPS (Merit Based Incentive Payment System) is a specific path in the Quality Payment Program for reporting on quality metrics. It consists of Quality, Advancing Care Information, Improvement Activities and Costs. There are specific requirements for reporting on quality metrics in each of these categories and these requirements are facilitated using certified electronic health systems such as Epic. Reporting and showing improvement in quality and EMR use = $$ for hospitals.
  • EPIC offers access to classes to learn skills such as making smartforms, flowsheets, best practice advisories and much more through their Epic Training program. Visit userweb.epic.com to request an account to find out more information. Physicians working for an Epic customer can get free access to these courses.