Grand Rounds Recap 10.9.2024
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Research Grand Rounds WITH dr. Freiermuth
Peer Review
Not common practice until the 1970s
Intent was to ensure scientific integrity
Equity
The Process
Read, summarize manuscript, comment on strengths and weaknesses, determine whether article fits with the priorities of the journal
Recommend action by the editor: accept, revise, reject
Re-review
Strength/Weaknesses
Significance
Innovation
Methods
Ethics
Clarity
Words Matter - be courteous and constructive
Major vs. Minor critiques
Institutional Review Board - duty is to protect participants
Representation
Scientific experts
Ethics
Lay members of the community
Gender and ethnic diversity
Commitment
Bimonthly meetings
Intermittent emails
Review of protocols and amendments
Training provided
CITI
FDA
Observation of at least two meetings prior to being named to the board
r1 core content: thromboembolic disease in pregnancy WITH dr. zinter
VTE (venous thromboembolism) is extremely common, consisting of both DVT and PE, and are a spectrum of diseases that you will come across it in your practice.
VTE is associated significantly with maternal mortality, and has been cited by the CDC to be up associated with 10.5% of all cases of maternal mortality.
Pregnant patients are inherently higher risk for VTE, and because of this are excluded from normal clinical decision tools like Wells Criteria that would normally be able to help guidance our clinical decisions.
However, this doesn’t mean you’re not alone. Alternative clinical practice tools exist to help you delineate who is higher vs lower risk for both PE and DVT, such as the LEFt Criteria for DVT and the YEARS Protocol for PE in pregnant patients.
D-dimer is a tool that can be used for both PE and DVT. The natural level of D-dimer rises throughout a normal pregnancy and thus the threshold we use to determine significance should also change. Using the YEARS Protocol and YEARS criteria can help you avoid unnecessary scans and radiation exposure safely by using a combination of the D-dimer and clinical signs/symptoms.
Low-molecular weight heparins, like Lovenox, are the workhorse of the anticoagulation options in pregnant patients. Warfarin and DOACs should be avoided in pregnant patients as they are not proven to be safe, or even teratogenic in Warfarin’s case.
Fibrinolysis and thrombectomy are both options for the unstable patient with VTE and pregnancy, and carry the same indications and contraindications are the non-pregnant patient.
r4 discharge/transfer/treat: hand injuries WITH drs. brower and glenn
Fingertip Avulsions/Finger Amputations:
Fingertip Avulsions involve soft tissue only and can managed by providing coverage with a non-adherent dressing or skin adhesive. Antibiotics are not indicated. ALiEM provides a great overview of how to manage these injuries here: https://www.aliem.com/trick-of-trade-dermal-avulsion-injuries-2-0/.
Amputations Distal to DIP may require revision amputation, which is in the purview of EM physicians. Rongeur bone until soft tissue is available for closure; close skin loosely with non-absorbable sutures. Consider antibiotics for high risk patients (e.g., vascular disease, T2DM, etc.).
Amputations Proximal to DIP should be evaluated by Hand Surgery and should be transferred for evaluation with consideration of reimplantation. Antibiotics are indicated in these injuries. When packaging an amputated digit for transfer, wrap it in sterile gauze soaked in saline. Place this in a plastic bag over a mixture of ice and water to keep it cool.
Pyogenic Flexor Tenosynovitis (FTS):
Commonly incited by local trauma such as bites or lacerations, pyogenic FTS is an infect of the flexor tendon sheath.
FTS is a clinical diagnosis based on the 4 Kanavel Signs: flexion posture at rest, fusiform swelling, percussion tenderness along the flexor sheath, and pain with passive extension (often the earliest sign). These findings are highly sensitive (91-97%).
X-ray imaging should be performed to evaluate for foreign body or bony injury. Ultrasound can be used to support the diagnosis by identifying anechoic or hypoechoic fluid within the flexor tendon sheath.
Labs such as WBC, ESR, CRP should not be used to rule out FTS given poor sensitivity (39-76%) and negative predictive value (3-13%).
Management involves broad-spectrum antibiotics and surgical debridement by Hand Surgery.
Common Hand Injury Quick Hits:
Skier’s Thumb (UCL Strain/Tear) typically occurs when the thumb is forced outward or backward causing strain or tear to the ulnar collateral ligament. Diagnosis is made by identifying laxity when applying radial stress to the thumb with the MCP in partial flexion (compare to contralateral thumb). Management involves placement of a thumb spica splint and Hand or Sports Medicine follow-up for likely outpatient MRI.
Jersey Finger typically occurs due to forced extension of a flexed DIP and results in the avulsion of the flexor digitorum profundus (FDP) from the distal phalanx. Patients are unable to actively flex their DIP and x-ray imaging often will reveal and avulsion fracture. Splint in slight flexion and arrange close Hand Surgery follow-up as these injuries require surgical repair.
Mallet Finger typically is caused by forced flexion of an extended DIP joint resulting in rupture of the extensor tendon in the area of the distal phalanx distal to the DIP joint. Patients present with DIP joint slightly flexed at rest with inability to fully extend about the DIP joint. X-ray imaging should be obtained to evaluate for avulsion fracture. Splint the DIP joint continuous slight hyperextension (trying to avoid splinting the PIP joint as well) and provide follow-up with Hand Surgery.
ED Discharge after trauma WITH rachael collman
In 2023, 1689 trauma patients were discharged from the University of Cincinnati Medical Center (UCMC) ED
Patients discharged from the ED after trauma have high rates of recidivism, poor pain management, and non-adherence with follow-up care (Battle et. al.)
Major contributing factors for poor outcomes in this patient population (Dalton et. al)
variability in discharge instruction
lack of referral to resources
poor patient awareness of diagnosis and follow-up expectations
Variability in discharge instruction, pain management, and follow-up care based on patient race and provider discretions (Chun et. al.)
Current discharge processes for truama patients lack critical information
Ineffective discharge leads to poor pain management, lack of resource utilization, and ED recidivism
Standardizing discharge to provide vital information will improve care and decrease recidivism
pediatric lecture: respiratory emergencies and airway management with cchmc colleagues Drs. Heckle and Chang
Respiratory Emergencies
Thinking about lung exam findings in buckets can be helpful in diagnosis (upper vs lower airway, inspiration vs expiration)
Croup gets weird with older kids (>6 years) and recurrence
Community acquired pneumonia can be a clinical diagnosis but CXR helps discern antibiotics or no antibiotics
Bronchiolitis requires lots (but not too much) of suction; not steroids or inhaled medications
Broncho-pulmonary dysplasia is stiff, large alveoli. Collaborating with parents is helpful
Asthma exacerbations are generally classified as mild, moderate, or severe and it is best to hit them early with lots of albuterol, ipratropium, and steroids
Airway Management
Airway Anatomic Features in Children
Everything is smaller, there is always less space
Teeth are easily avulsed or aspirated
Epiglottis is narrow and angled acutely with respect to the tracheal axis, hence the epiglottis covers the tracheal opening more than in an adult airway and harder to mobilize
Narrowest point is at the level of the cricoid (vs adults is the glottis)
Cartilage in airway is more collapsible, loose underlying tissue, more vulnerable to edema or multiple attempts.
Physiologic Differences in Children
Infants, younger children have fewer alveoli - thicker and less efficient in gas exchange
Infants have highly compliant chest walls, need to work harder to breath as their chest wall pulls inward to forceful inhalation
Higher oxygen consumption, even more if sick
