Grand Rounds Recap 10.26

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Morbidity and Mortality Conference with Dr. Betham

Case 1

Elderly male, morbidly obese, awoke in middle of night and collapsed snoring, stopped breathing, EMS called, found in asystole, arrived with mid position fixed pupils, eventually code was called.  Previous charts from outside hospital noted to have patient leaving hospital AMA with history concerning for ACS.

Coroner’s report:

Cause of death from pericardial tamponade from ruptured pericardium from previous myocardial infarction.  

Post-MI Shock:

  • Severe LV dysfunction (75%)
  • Acute mitral regurgitation (8.3%)
    • Either from papillary muscle rupture or LV dilation
  • Free wall rupture (rare)

Free wall rupture/tamponade

  • 50% within 5 days after MI
  • 90% within 2 weeks
  • Most are rapidly fatal
    • A small subset may survive to surgery

Did our patient suffer rupture from CPR or before? (chicken or the egg)

  • Systematic review and pooled analysis of post CPR complications
    • Myocardial rupture or perforation in less than 1%
    • Pneumothorax rate of 3%

Bedside focused echo as predictor for survival in cardiac arrest

 Meta-analysis with 568 patients (mixed trauma and non-trauma)

  • Ultrasound was performed during cardiac arrest
  • Outcome measure of ROSC
  • Sensitivity of 91.6% (cardiac contractility on ultrasound was found in 91.6% of ROSC patients)
    •  However, very non-specific
  • 2.4% of cardiac standstill patients went on to ROSC

CAUSE paper (cardiac arrest ultrasound exam)

  •  Focused ultrasound for causes of PEA
  •  Performed in living patients (not during cardiac arrest)
  •  Cardiac tamponade
    •  sensitivity 96%, specificity 98%
  •  PE (RV dilation)
    •  56% sensitive, 90% specific
  • Tension pneumothorax
    • 92% sensitive, 99.6% specific

Keep in mind that clotted blood has a much more hyperechoic appearance on ultrasound than liquid blood.  May mimic myocardium and make it harder to pick up on bedside ultrasound.

Structured approach to PEA:

  • Evaluate PEA based on the rhythm you see (QRS narrow vs wide)
  • Keep in mind people with pre-existing bundle branch block can have wide QRS without the pathologic arrest causes

PEA questions to ask:

  • what was the first rhythm?
  • narrow or wide?
  • fast or slow?

Case 2

Elderly patient with history of HTN, atrial fibrillation, mitral valve prolapse, presents with neck pain.  Intermittent fevers/chills, some relief with ibuprofen.  Completed course of doxycycline and azithromycin.  Family notes voice is different and he notes some difficulty swallowing.  Seen by multiple previous providers for same.  Vitals normal except for mild tachycardia.  Exam notable for tenderness to palpation in trapezius distribution, known heart murmur.  Labs are unremarkable.  Xray with small effusion.  Started on cefdinir, neck pain improved with hydrocodone-APAP.  Discharged home.  Returns the next day for positive blood cultures of gram positive cocci in clusters and pairs.  Repeat labs and CXR unremarkable.  Admitted for IV antibiotics.  TTE shows mild mobile mass on mitral valve consistent with endocarditis.  MRI neck shows vertebral osteomyelitis with epidural phlegmon.  

Vertebral osteomyelitis:

  • 50% hematogenous spread from another primary infectious source (batson’s plexus with no regurgitation valves allows for reverse spread of bacteria)
  • 50% direct instrumentation, contiguous spread, or unknown
  • 11% in cervical spine, 30% in thoracic, rest in lumbar
  • 50% misdiagnosed on first presentation
  • Fever in only 35-60% (often masked by over the counter medications)
  • Weight loss, nausea, vomiting, anorexia, lethargy are common
  • Tenderness to palpation is uncommon
  • For diagnosis: CBC, ESR, CRP, plain films, MRI
  • Blood cultures are only 58% positive
  • Complications
    • epidural abscess
    • retropharyngeal abscess (dysphagia or swallowing difficulty)
  • IV antibiotics for 6-8 weeks
    • If stable, ok to delay antibiotics for biopsy etc.
    • MRSA+ or history - gram negative coverage needed
  • Surgical consultation for epidural abscess, neurologic symptoms, or significant destruction leading to spinal instability

Concurrent endocarditis is present in - 30% of patients with osteo

  • oral flora are more common
  • worse outcomes
  • more common to have epidural abscess

Case 3

Young  female with brown vaginal discharge x2 weeks, found on exam with clear bloody discharge, positive IUP noted on ultrasound, discharged home.  Returns with worsening bleeding, rh negative, got rhogam with no subsequent complications

Rhogam

  • For prevention of rh alloimmunization
  • Likelihood of alloimmunization from threatened Ab is very low and practice varies by country

Case 4

A male patient presenting for accidental heroin overdose, recovered with narcan.  Now stating that is unable to move his feet or legs and is having trouble hearing.  Abdomen is diffusely tender to palpation, patellar reflex present on right, absent on left, diminished sensation bilaterally, bilateral weakness.  EKG with some lateral lead T wave inversions, possible T wave peaking.  Labs notable for renal failure and metabolic complications thereof including hyperkalemia.  CT and MRI of spines negative.  Troponin 0.40, total CK 11,000.  Repeat troponin 0.74.  Repeat EKG with ST elevation in leads V1 and V2, peaked T waves diffusely, pattern a bit concerning for brugada syndrome vs hyperkalemia.  Cardiology performing TTE showing diffuse hypokinesis and right ventricle dilation, suspect heroin induced cardiomyopathy.  Admitted to cardiology for cardiomyopathy, admitting team initiates hyperkalemia treatment as it was worsening with EKG changes, eventually placing dialysis catheter and still needing scheduled dialysis

Rhabdomyolysis

  • Muscle breakdown, release of potassium, myglobin, phosphates and LDH
  • Nephrotoxicity occurs
  • Causes
    • Physical (exercise)
    • Hypoxia
    • Chemical (statins)
    • Biologic (hereditary vs infectious myositis)
  • Workup
    • CK
    • Renal panel (hyperkalemia, creatinine)
    • Ionized calcium
    • Coagulation studies (can be prone to DIC)

Study of 16 crush victims

  • 4 required dialysis
  • Dialyzed patients got first fluids in ~ 9 hours vs 3.7 hours for non-dialyzed patients

Systematic review of treatment for rhabdo

  • Early and aggressive fluid administration (first 6 hours)
  • Aggressive goal urine output of 200-300 cc/hr
  • Other therapies for urine alkalinization, mannitol and furosemide for high urine output don’t seem to have enough evidence for routine recommended use
  • Dialysis
  • Don’t necessarily need to treat hypocalcemia as this will often self correct

In IVDU: consider rhabdo for prolonged down periods, also some evidence that heroin may be directly myotoxic.

Quinines are often used to cut heroin due to similar taste, may affect hearing and result in temporary deafness.

Case 5

Middle aged male patient taken to outside hospital for AMS after being picked up by friends, taken to the ED and by report 2 bottles of organophosphates (malathion) found in patient’s home.  Patient with pinpoint pupils, tachycardia, smells of gasoline, large white colored bowel movement in ED that smells of gasoline.  EKG with some concerning morphology of inferior leads with ST elevation.  CXR with bilateral infiltrates.  Head CT negative.  Patient received 2-PAM, minimal atropine due to concern for heart, decontaminated, cardiology consultation with cath lab activation, patient to MICU following cath lab which showed clean coronary arteries.  

Organophosphate poisoning

  • Prevalent in suicides
  • Chemical warfare agent
  • Exposure:
    • Inhalation (frequently rapidly fatal)
    • Ingestion
      • 30 minute onset to several days 
        • May be lipophilic, leading to delayed release
    • Dermal
      • Local symptoms immediate
      • Systemic toxicity up to 48 hours for onset
  • Organophosphates bind and eventually irreversibly bind to acetylcholinesterase, preventing its degradation and allowing for continued acetylcholine excitement
  • Muscarinic findings
    • - DUMBBELLS
  • Nicotinic
  • Respiratory arrest is most common fatal cause (secretions)
  • Diagnosis is clinical and based on symptoms and history
  • Management
    • Decontaminate, PPE
    • Manage airway compromise
      • Succinylcholine is not contraindicated, but non-depolarizing agents preferred
      • Effects of succinylcholine will be prolonged
    • Atropine
    • 2-PAM
    • Benzodiazepines
  • Atropine
    • Give as 1-2 mg initial bolus, escalate q5 minute
    • Clinical goals of HR >80, SBP >80, dry lungs
  • 2-PAM
    • Works to dissociate organophosphate from acetylcholinesterase enzyme
    • Some organophosphates bind irreversibly more quickly than others, if patient has symptoms important to administer quickly

Case 6

Middle aged male MVC after heroin overdose, confused, laceration to forehead, seatbelt sign, labs notable for acidosis, elevated lactate.  CXR negative, pelvic X-ray negative.  Positive FAST in RUQ.  Agitated, unreliable vitals, DSI with ketamine for further assessment, product resuscitation due to hypotension, heads to OR.  Complete small bowel and colon transections.  Bucket deformity as well.  Taken to CT, more bleeding and hematoma with bleeding from mesentery, back to OR.  

Blunt intestinal injury

  • rare, <1% of blunt trauma
  • retrospective study found the following CT findings (2 or more), resulting in DPL if not frank criteria for OR
    • pneumoperitoneum
    • unexplained fluid (most sensitive)
    • bowel wall thickening
    • mesenteric fat stranding
    • mesenteric hematoma

CPC Drs. Merriam and Curry

Young female with past history of sickle cell trait, rapid response from parking lot after being discharged from trauma service after treatment for a retroperitoneal hematoma.  Imaging possibly looked like mass, maybe trauma causing some bleeding in mass.  Stable serial labs and exams.   Patient now back complaining of severe low back pain and SOB after becoming confused and collapsing.  Tachycardia, rapid respiratory rate, diaphoretic, distressed, intermittently falling asleep and snoring loudly, diffuse abdominal tenderness consistent with previous exams.  Labs show hemoglobin stable anemia from discharge, bedside FAST negative, unable to obtain EKG.  Became hypotensive and more tachycardic, started administering product.  Concern for PE due to syncope, shock, possible malignancy, and immobilization during hospital stay.  CTPA confirms massive PE. Patient got catheter directed tPA.

Treatment options for massive or submassive PE

  • PE responsible for 13.5% of sudden death
  • only ~10% of PE will present in shock
  • abnormal presentations of PE
    • syncope (19%)
    • fever (13%)
    • AMS (10%)
    • Wheezing (9%)
    • STEMI
    • Abdominal pain 
  • Classification
    • Low risk (hemodynamically stable, no findings of right heart strain)
    • Sub-massive
      • Hemodynamically stable, but findings of right heart strain
        • RV dilation on echo or CT
        • pulmonary HTN
        • elevation of troponin or BNP
        • RV strain pattern on EKG
          • incomplete or complete RBBB
          • S1Q3T3 pattern
          • T wave inversions in leads V1-V3
    • Massive
      • hemodynamically unstable (SBP <90, shock, pulseless, etc)
      • 58% mortality rate in first hour of presentation
  • Treatment options
    • Systemic thrombolytics
      • reduces mortality by 56%
      • 5x risk for massive hemorrhage
      • 10x risk for ICH
    • Embolectomy
      • Mortality for procedure is up to 27%
      • Reserved as second line treatment
    • Catheter directed thrombolytics (EKOS catheter)
      • has ultrasound capability, breaks up fibrin layer and increases clot surface area for more effective thrombolytic administration
      • First studied in ULTIMA Study
        • Randomized controlled trial, randomized to EKOS plus heparin vs heparin alone
        • Study group had 23% reduction in RV/LV ratio vs 3% in heparin group
        • Safety profile deemed adequate
      • Validated in SEATTLE II study
        • 25% reduction in RV/LV ratio
        • 30% in PA pressures
        • no cases of ICH

ACEP Open Mic

  • Calcific tendinosis: refractory to physical therapy.  Calcified tendon isn’t going to get better by muscle strengthening and range of motion exercises. 
  • Some new oral solutions for potassium removal to replace kayexelate may be coming to an emergency department near you.
  • ST/T ratio in pericarditis.  Ratio of >0.25 in a case series of 18 people was 100% specific for pericarditis.
  • Medial tibial stress syndrome: shin splints.  Important to get imaging with X-rays up front as syndrome can progress to require surgical intervention if not recognized and treated appropriately.
  • For every hour an ICU boarder stays in the ED, mortality increases by 1.5%
  • For dizziness in the ED:
    • Standardize the approach
      • Stop asking “what do you mean by dizzy”
        • Reliability for consistency on this history is very poor
      • Instead, focus on timing, triggers, and exam
    • The HINTS exam
      • assesses the vestibulocular reflex
      • Pearl: in the head impulse test, fast motion towards midline, easier to see overshoot at your nose
      • Pearl: record in slow motion on your phone, can pick up more subtle findings
      • Bidirectional fast saccades are concerning for central source for vertigo
  • Volume responsiveness
    • passive leg raise and EtCO2 in intubated patients
      • within 60 seconds, increase in end tidal CO2 by 5%, 100% specific for volume responsiveness (not very sensitive though)  

Dental Emergencies/Urgencies with Dr. Shewakramani

  • Visits to emergency department for dental pain have been steadily rising
    • Significant cost burden as compared to preventative dental care
  • The basics
    • Anatomy
      • 20 “baby” teeth/ Primary (A-T)
      • 32 “adult” teeth/ Permanent (1-32)
      • Can also be addressed descriptive terms (left maxillary canine, etc)
      • Describe surfaces
        • lingual
        • buccal (labial)
        • occlusal/incisal
        • mesial (front or middle)
      • Crown of tooth is ~1/3 of tooth length (important when performing individual tooth block, you’ll aim for a depth of ~ double the depth of the crown to reach the base of the root)
      • Layers
        • enamel
        • dentin (less mineralization, tubules, connection between pulp an enamel)
        • pulp (nerve fibers, blood vessels, almost no minerals)
      • Periodontal ligament to connect tooth to alveolar bone
  • Easing dental pain
    • Dental blocks
      • Benefits of complete anesthesia, avoiding narcotics, and allow for procedures
      • Risks of failure (~20%), Hematoma, nerve injury
      • Inferior alveolar nerve block
        • most common block
        • wide coverage for entire mandibular side
        • what you need:
          • +/- topical anesthetic for injection site
          • 5 cc syringe
          • 25-27g needle
          • 2-4 ml bupivicaine (with epinephrine if possible)
            • 2-3 hours pulp anesthesia with 6-9 hours soft tissue anesthesia
          • lingual nerve is anterior to inferior alveolar nerve, may get anesthesia to lateral tongue as well.
      • Supraperiosteal block
        • injection at base of tooth
        • insert needle at buccal fold, 45 degree angle with bevel facing periosteum of bone, once you hit bone, withdraw slightly and inject 1-2 cc of anesthetic
      • Anterior superior alveolar nerve block, middle superior alveolar nerve block, etc.
        • Look them up if you want to perform them, when in doubt it is ok to use a search engine for reference.  Online videos can be helpful (click for link here)
      • Don’t forget these nerve blocks for the soft tissue coverage they provide for facial lacerations.  
  • Ludwig’s angina
    • THE dental emergency
    • Signs you’re looking for
      • trismus
      • drooling
      • sublingual or oropharyngeal edema
      • dysphagia
      • fever
    • uncommon
  • Other dental infections
    • Dental caries (41% of ED dental visits)
      • Caries that reach dentin can cause reversible pulpitis
        • Results in cold sensitivity, sensitivity to sweets which is transient and goes away when stimulus is gone (~30 seconds)
        • Generally not tender to percussion
      • Caries that reach pulp causes irreversible pulpitis, sensitive to both hot and cold, pain lasting longer after stimulus or permanently, tender to percussion
        • bacteria can trace down root canal and set up periapical abscess
        • From periapical abscess infection can spread contiguously anywhere it wants
          • concern for orbital or maxillary sinusitis in maxillary teeth, progressing to cavernous sinus thrombosis
          • Mandibular teeth can result in spread to cause ludwig’s angina
    • Periodontal disease (gingivitis)
      • Severe end of spectrum can reach acute necrotizing ulcerative gingivitis/gingavostomatitis
        • Acute onset of pain (acute bacterial superinfection of existing gingivitis)
        • Ulcerations, necrosis, sloughing
        • Fever/lymphadenopathy
        • Often need IV antibiotics and admission
      • Pericoronitis
        • Inflammation of gingival flap overlying wisdom tooth
        • Chronic pericoronitis may only need better dental hygiene
        • Acute pericoronitis
          • inflamed, beefy red, acute infection
          • Consider irrigation with syringe to clear out food and such caught under flap
  • Treatment options for infections/dental pain
    • NSAIDs
      • First line (anti-inflammatory)
    • Narcotics
      • yes, sometimes they may be indicated in careful usage
    • Dental blocks for temporary relief
  • Antibiotic therapy
    • Penicillin VK
      • first line for the majority of dental infections 
      • consider clindamycin for second line
    • Not needed for:
      • enamel caries
      • reversible pulpitis
      • chronic pericoronitis
      • gingivitis
    • Indicated for:
      • periapical abscess
      • irreversible pulpitis
      • acute pericoronitis?
      • severe peridentitis
      • ANUG
  • Other considerations
    • Cement for dental caries
      • temporary
      • some with antibiotic properties
      • protection from painful stimuli
      • How to:
        • perform dental block
        • mix catalyst and base
        • dry tooth
        • apply
        • allow to dry, keep mouth open for 10 minutes
    • Peridex
      • Does nothing for plaque or tartar
      • helpful for gingival problems
      • use immediately after brushing
      • swish for 30 seconds and spit
      • don’t eat or drink anything for 2-3 hours afterward
  • Dental trauma
    • Dental fractures (70-80% are incisors)
      • Ellis classification
        • Type I: through enamel
          • Pain free
          • Cosmetic
        • Type II: through dentin
          • Painful (tubules)
          • control pain, consider calcium hydroxide paste/dermabond
            • don’t use commercial superglue, it is toxic to the nerve
          • consider antibiotics
        • Type III: through pulp
          • painful and some bleeding (pulp exposure)
          • antibiotics
          • calcium hydroxide paste
          • immediate dental referral
            • recommendations range from 3 hours to 24 hours
            • If you have an ellis III fracture, talk to a dentist to solidify plan
      • Luxation and Subluxation
        • Concussion: not mobile, not displaced, tender
        • Subluxation: mobile, not displaced
          • soft diet 1-4 weeks, close dental followup
        • Luxation: +/- mobile, displaced
          • extrusive (out), intrusive (smashed in), or lateral (side/side or front/back)
          • block, reposition, and splint
      • Avulsion
        • <20 minutes: 98% salvage rate
          • Death of periodontal ligament at 60 minutes
          • Re-implant immediately
        • Storage solutions
          • Hank’s salt solution > milk > saline > mouth > water
        • Dental bridge for splint
          • dry avulsed tooth surface
          • coat metal bridge from O2 mask with dermabond and attach to avulsed tooth and adjacent teeth

R4 Clinical Soapbox with Dr. Scupp

Acid Base Balance in Fluid Resuscitation

  • Strong ions approach to acid/base
    • Fixed ratio of sodium to chloride
      • strong ions such as these have very poor buffering capacity
      • increasing chloride mandates a change in other substances to balance charge (increase in H+ or decrease in bicarb)
  • Crystalloids in Resuscitation
    • Normal saline (0.9%)
      • 9 g of NaCl dissolved in 1L
      • MYTH: 0.9% NS is “acidic” so infusion of acidic fluid makes the patient acidotic
        • Any change to patient pH consider from strong anion difference rather than pH of the fluid itself
    • Ringer’s lactate
      • Can’t administer in conjunction with blood products due to blood product preservation process
    • Normosol
  • Does chloride matter?
    • Physiologic effects of using normal saline compared to balanced solution in small animal studies
      • decreased renal artery flow
      • decreased renal cortical perfusion
      • increased coagulopathy
      • increased cytokines/inflammatory markers
    • Observational reviews in humans, use of balanced solution compared to NS resulted in:
      • decreased mortality
      • decreased complications in surgical population
      • increasing Cl- correlated with increased mortality
        • trend of mortality found to be independent of volume administered
    • Meta-analysis of multiple small studies with similar results
      • Most data from large ICU/ED based study, 1500 patients
        • Reduced renal injury and failure from 14% to 8.4% when comparing NS vs balanced solution
        • No difference in mortality
    • SPLIT trial
      • Randomized clinical trial in New Zealand, ICU based study
      • Plasmalyte vs normal saline
        • No difference in AKI, RRT, or mortality
        • However:
          • 70% of patients were from OR (58% elective), only 15% of patients were from ED
          • Pre-enrollment fluids were on average 1.5 L of balanced solution and only 500 cc of NS, got relatively little resuscitative fluids overall
  • Debate between balanced solutions and NS is still hotly debated
  • What is the cost difference? 
    • Manufacturing and base cost is the same (couldn’t say how it’s charged though)
  • Take home points:
    • Normal saline is neither physiologic nor normal
    • Consider early use of balanced fluids in the ill patient that’s going to need a lot of it
    • Target your therapy