Grand Rounds Recap 10.23.24
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Morbidity and mortality WITH dr. Gobble
Case #1: Abdominal Pain
Hypertriglyceride induced pancreatitis is the 3rd most common cause for acute pancreatitis
Hypertriglyceridemia is defined as fasting triglyceride levels >150, but pancreatitis does not typically occur until levels >1000
Triglycerides are not inherently toxic to the pancreatic acinar cells, but their breakdown into free fatty acids is what causes acinar necrosis
Management focuses on standard supportive care as well as addition of insulin, heparin, and oral therapies
Plasmapheresis is considered is extreme cases, but there are no studies showing statistically significant benefit.
Case #2: Facial Swelling
CT imaging has seen a significant increase in the last 20 years.
Although there has been an increase in imaging, diagnostic yield has remained relatively stable
Factors the impact imaging decision includes reliability of the physical exam as well as extrinsic factors such as consultants and admitting services.
There are no evidence-based recommendations for repeat imaging after initial negative work-up, but several studies have seen positive findings on repeat imaging up to 30%.
Although cancer diagnosis is not the primary goal of the care we provide in the emergency department, we can make a substantial impact on long term mortality
HNSCC is rapidly invasive and the time to diagnosis often significantly impacts long-term morbidity and mortality in these patients.
Case #3: Altered Mental Status
Alcohol breakdown occurs in the liver, where it is ultimately oxidized into acetate and released into the blood stream.
Toxic byproducts from reactive oxygen species are what cause damage to the liver tissue
Neurologic complications comes from binding of EtOH at the GABA receptors
Tolerance occurs due to increased # of GABA receptors
Acute intoxication can present as critical illness, with several EKG changes associated with acute intoxication
Respiratory failure and resultant intubation are the most frequent complication of acute alcohol intoxication
Although no meta-analyses exist, several case series have shown that dialysis significantly improves the rate of elimination
Providers should consider engaging renal for dialysis in patients with serum ethanol levels >assay level and those with 1 or more signs of acute organ toxicity.
Case #4: Chest Pain
Aortic dissections have an estimated mortality rate of 40% on initial presentation that increases by 1% every hour that passes without intervention.
Severe, sudden onset chest pain and hypertension were the most frequently seen symptoms, but even these are unreliable.
38% of aortic dissections are still missed on initial exam and 28% found on post-mortem.
female patients; those with atypical symptoms that were not abrupt or did not include chest, back, or any pain; patients with an absence of pulse deficit or hypotension; or those who initially presented to a nontertiary care hospital.
Mildness of disease and patients who are walk0in arrivals to the emergency department are associated with increased likelihood of misdiagnosis.
Complications from the dissection can also complicate the picture on the final diagnosis, particularly in patients who present with neurologic symptoms.
Case #5: Assault
Most hospital systems have some variation of med/surg, telemetry, step-down and ICU level of care.
Antecedent bradycardia was seen in >50% of patient with IHCA and decreased monitoring has been associated with increased risk of mortality from IHCA
Telemetry is intentionally very specific and there are specific guidelines released by the AHA to guide choosing which patient will benefit from telemetry
The PeRRT score is designed to help determine what patients have an increased risk of triggering a rapid response on the floor.
Case #6: Cardiac Arrest
Out of Hospital Cardiac Arrests (OHCA) remain a huge cause of morbidity and mortality in the US and worldwide.
Despite adherence to strict ACLS protocols, neurologic outcomes remain poor.
eCPR is the specific acronym for extracorporeal membrane oxygenation (ECMO) for the arresting patient. The VA-ECMO set-up is specifically used for eCPR
Meta-analyses for eCPR have shown aggregate survival rates with good neurologic outcomes up to 21.3%
R2 CPC: WITH drs. Qin and Bryant
Wilms tumor classically presents as a firm, non-tender mass that does not cross the midline in a young child, typically 2-4 year old
If not diagnosed early, it can present with abdominal pain, hypertension, gross hematuria, and hematologic derangements
Initial workup should include a broad differential for abdominal pain, hematuria, and renal pathology based on presenting symptoms
Oncology should be consulted early to guide additional workup, as well as facilitate discussing the diagnosis and intended treatment plan with patients and their families
Diagnosis of Wilms tumor can often be made based on imaging alone, the use of biopsy before surgical resection is controversial but employed in circumstances where there is atypical presentation or imaging, or it can help reduce the intensity of the treatment plan
Sonographic features include: Solid mass with smooth margins, tumor necrosis, some cystic areas but not predominant, scattered calcifications, associated tumor thrombus
R3 Taming The SRU WITH Dr. Wilson
Have a resource that can be your external brain that you can reference quickly to make you more comfortable in an uncomfortable situation.
When breaking bad news follow a structure for your conversation and practice your plain language ahead of time.
Debrief codes and odd encounters for yourself, your team, and your hospital system.
Your words matter, know how to avoid misgendering your patients and know how you will correct your team when it happens.
R4 Capstone with dr. wright
Rural America is facing a worsening crisis in healthcare, including emergency care, with 140 rural hospitals closing since 2010 - and 700 more at risk of following suit.
Increased distance to emergency care has real consequences for patients living in rural America, increasing rates of morbidity and mortality for emergent, life-threatening conditions for adult and pediatric patients alike.
Some government programs have been developed to help support rural hospitals in staying open, but such programs, such as the Rural Emergency Hospitals designation, requires small hospitals to convert to entirely emergency care and close inpatient beds.
Factors contributing to healthcare deserts in rural settings include poor insurance payments from predominantly private insurers, "rural bypass", fixed operational costs with low volume, and difficulty recruiting medical staff.
