Grand Rounds Recap - 11/18

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Morbidity and Morbidity Conference with Dr. Denney

Case 1: RLQ pain in the young reproductive-aged female

  • RLQ pain can be a challenging complaint in the ED. Is it ectopic, torsion, TOA, PID, or appy? Five patients can present looking the exact same and have any one of these 5 different pathologies. How to proceed?  A few key concepts can help make the decision.
  • Assuming the urine pregnancy is negative, the decision of US vs CT can be made easier by keeping some points in mind:
    • CT is likely the more accurate test for every pathology other than torsion (in which US is best). This includes TOA (PID remains a clinical diagnosis as no imaging sensitive nor specific).
    • US limits radiation exposure in a population where this may be desirable
    • US is the test of choice for torsion. CT likely offers little to know benefit in its evaluation although it can detect masses/cysts which may predispose to torsion.
    • A reasonable approach: If sick->CT. If stable, rely on your best clinical guess taking availability of the tests into account. Starting with a CT is reasonable if you realize that you may need to then perform US if concern for torsion remains. Conversely, starting with US is reasonable if you realize you may need to follow up with CT for ruling out the appy.

Cases 2 and 3: Posterior Circulation Strokes

  • Consider acute ischemic stroke in your differential of severe headache + neurologic deficits
  • Headaches in stroke are common, estimated to be present in 20-25% of strokes and more common in posterior circulation strokes in particular as well as larger territory strokes
  • For ANY patient who arrives in the ED within the TPA window, this is a HARD stop: could this patient be having an ischemic stroke and are they a TPA candidate?
  • Last known normal is difficult to obtain both in real life clinical practice and as seen in the literature. Go the extra step to obtain an accurate last known normal time as it can have important consequences for your patient.
  • If the patient arrives within the TPA window and you are concerned primarily for SAH though ischemic stroke remains on the differential, consider CT/CTA as it may both work up the SAH and differentiate from acute ischemic stroke.
  • The posterior circulation perfuses essentially all CN nuclei AND all the of the cortical axons as they travel into the spinal cord. Accordingly, ischemic insults in this region may cause a huge array of signs and symptoms.
  • Remember "Dizzy plus." Plus what? Diplopia, dysarthria, dysphagia, disequilibrium, dysmetria, ataxia, visual field deficits, ophthalmolplegia, weakness
  • Basilar occlusion syndromes result from an occluded basilar artery. They can present as depressed mental status with few other concrete symptoms. Depressed MS + ophthalmoplegia should be evaluated for possible basilar occlusion if no other readily identifiable cause can be rendered. These patients are often misdiagnosed as status epilepticus. Also look independently for unilateral/bilateral flexur posturing which may be transient.

Case 4: Respiratory distress due to upper airway obstruction

  • Consider upper respiratory obstruction as a cause of fulminant respiratory failure (in this case, it was squamous cell carcinoma of the glottis), particularly if you are able to elicit stridor
  • Know the conditions that predispose you to anchor on a diagnosis. For many of us, a busy SRU is one of those.

Case 5: Hyperkalemia

  • There are no RCT-proven therapies shown to improve morbidity/mortality in hyperkalemic patients. Rather, evidence focuses on ability to decrease serum K.
  • IV insulin and albuterol (IV or inhabled) are proven therapies to acutely reduce serum K. These however are temporizing measures only and will require being redosed somewhere between 1 and 3 hours of initial dose.
  • Kayexalate is not indicated in the acutely hyperkalemic patient who is being admitted for hyperK. Its utility as a medication in general is questionable based on poor quality data.
  • Normal saline bolus may reduce serum K in select patients, particularly if they have a pre-renal AKI and are hypovolemic.
  • If the patient requires definitive serum K reduction, it is important to have a plan. That can be to temporize with medications and give fluid resuscitation with a recheck understanding that progression to dialysis catheter placement and HD may be necessary vs going straight to dialysis. Whatever the case, a plan needs to be in place that progresses to the next step in the event that initial steps are ineffective.

Cases 6 and 7: Retrobulbar hemorrhage and lateral canthotomy

  • If the patient arrives with significant facial trauma, ask yourself, could this patient have a retrobulbar hematoma? After examining to ensure there is no open globe, perform an exam looking for proptosis, resistance to retropulsion, and "hard" feeling eyes. If any of these exist, consider tonometry. If pressures>40mmHg, this is an indication for lateral canthotomy and catholysis--get optho involved but understand that you may need to operate in their absence as there is a limited time to act before irreversible vision loss (estimated to be ~100 minutes by some studies.)
  • Ocular trauma often travels together with depressed mental status. Some patients may not be able to give you the history of decreased vision or eye pain. These patients will rely on your physical exam and tonometry evaluations.
  • CT can help understand the pathology athough ultimately diagnosis remains clinical

Case 8: Boerhaave's Syndrome

  • This is also known transmural effort rupture of the esophagus, most commonly associated with emesis. However, 20-40% of patients do not recall vomiting. 
  • Remember to ask about difficulty/pain with swallowing in working up chest/epigastric pain
  • Diagnosis is made by CT chest vs esophagram (use gastrograffin as barium can cause a mediastinitus if it extravasates through the perforated esophagus). EGD can also make the diagnosis though insufflation may worsen injury. 
  • Time to surgical intervention is a key factor in mortality. <24 hours is 75% survival vs >48 is less than 10% mortality. 

EMS: AHA and IOM Updates on Cardiac Arrest with Drs. Benoit, Bohanske, and McMullan

The IOM just released their new guidelines about cardiac arrests

When looking at out-of-Hospital cardiac arrests, we can do better Cincinnati/world

  • 395,000 per year costing over $33 billion annually
  • 8/10 arrests occur at home yet <3% of the population trained in CPR
  • 70% of arrests are non-shockable rhythms and there is a 10% increase in mortality by minute

The AHA added some lofty 2020 goals of 2x bystander CPR rate, 2x cardiac arrest survival

How do we get there? Here's the new CPR guidelines

  • 100-120 compressions per minute
  • 2-2.5 inches (5-6 cm)
  • Continued focus on
    • Full recoil
    • Increase 'hands-on' time
    • Per-shock pauses (as short as possible)
  • Other tips - mechanical CPR devices are ok but manual compressions the 'gold standard'
  • Airway management - BVM/EGD/ETT. Your call
  • Vasopressin out of the algorithm
  • Prognostication with etCO2 < 10 is now acknowledged as part of the overall picture after 20 minutes of resuscitation
  • Prehospital cooling - ice packs are still recommended but large volume cold IVF are no longer recommended
  • Regional Cardiac Arrest Centers - this is a recommendation of the IOM but not yet hashed out - stay tuned
  • Cath lab activations
    • STEMI - Hard stop - Cath Lab
    • Non-STEMI - engage in all post-ROSC for multifactorial discussion that may lead to cath
  • Pregnancy
    • Manually move the uterus to the left (level I recommendation)
    • Peri-mortem C-Section by minute 4 of arrest and have the fetus out by minute 5
  • Lytics - if high pre-test for PE, ok to give but no recommendation on suspected STEMI or other cause of arrest
  • Tips
    • Pre-charge the machine for rhythm checks
    • Keep your fingers on the pulse
    • Eliminate ambiguity by limiting words to 'shock' or 'no shock'
    • Have your compressor hovering during pulse checks
    • Invest in mechanical CPR feedback
    • Have a 'Pit crew' mindset - everyone has a specific role that is pre-determined increases your team efficiency

Evidence Based Medicine on Anaphylaxis with Drs. Plash and Shah

The definition has significantly changed over the past 30 years and it is time to take a fresh look at anaphylaxis

The incidence has been increasing over the past 20 years - is it the hygiene hypothesis? definition change? more vicious bees?

Let's talk about the modern definition:

  1. Acute onset of illness (minutes to hours) involving skin/mucosa PLUS ONE of:
    1. Respiratory symptoms (wheeze, hypoxemia)
    2. Reduced BP or symptoms of hypoperfusion (syncope, incontinence, etc)
  2. Two or more of the following after likely exposure (minutes to hours)
    1. Skin/mucosal symptoms
    2. Respiratory symptoms
    3. Reduced BP or symptomatic hypoperfusion
    4. GI symptoms (abdominal pain, vomiting)
  3. Reduced BP after known allergen exposure
    1. SBP <90 or >30% drop from baseline

What is trying to kill us:

  • Medication (antibiotics, anesthetics, ASA, NSAIDs) - 31%
  • Food (eggs, milk, soy) - 31%
  • Insect Sting - 20%
  • Environmental allergens - 7.5%
  • Latex - 2.6%
  • Exercise - 1.2%
  • Unknown - 11%

Where to give the epinephrine? Stick 0.3-0.5mg in the lateral thigh. Stick to the intramuscular route

Biphasic reactions are a recurrence of anaphylaxis without additional stimuli, usually less severe

  • It can happen as early as 1 hour, as late as 72 hours
  • Studies evaluating predictors of biphasic reaction have been varied without reliable risk factors

Is there a role for steroids to prevent biphasic reactions?

  • Literature and practice recommendations vary on this and a burst dose is still recommended despite robust evidence

Taming the SRU Case Follow Up with Dr. Kircher

Intra-arrest management of the morbidly obese patient

  • CPR and Epi are what you do to support basic circulation while you work diligently to identify the cause of their arrest.  If you want ROSC in PEA you must look for a root cause, however this can be difficult to elucidate given the lack of availability of diagnostic studies (XR/CT/MRI/blood?)
  • Consider early endotracheal intubation in the ED for PEA arrest where hypoxia is the most likely cause of arrest or where you are concerned about the patient's respiratory mechanics with BVM or EGD.
  • For massively obese patients (BMI >50) - chest wall mass is your worst enemy.  It makes CPR technically challenging and requires extremely high driving pressures to properly oxygenate and ventilate.
  • There is emerging evidence that we might achieve ROSC in more patients if we work codes longer than traditionally done (>20 mins).  Patient selection is key.  Consider continuing resuscitation if you have a reasonable suspicion for a reversible cause of arrest and have minimal downtime before CPR was initiated in the prehospital environment.  Some of these patients will have an intact neurological recovery, even with prolonged resuscitation, but maintaining continuous high quality CPR and providing oxygen/glucose to brain is likely key.

R2 Case Follow Up with Dr. Ludmer

28y F abdominal pain in the left lower quadrant over the past week with associated diarrhea comes in tachycardic to 124 and respiratory of 20. Tender diffusely with multiple surgical scars on her abdomen. She forgot to tell you about her kidney transplant. And 3 immunosuppressive agents...

Solid Organ Transplantation and its Complications

>20,000 transplants per year with great life expectancy will increase the number presenting to the ED, it implores us to know a bit about it...

Rejection Types

  • Innate Immunity
  • T-Cell Mediated (Type IV Hypersensitivity)
    • MHC 1 Mismatch
    • Direct and Indirect Presentation of Antigen Via APCs 
  • T Cell Maturation/Differentiation
  • Co-Stimulation of B - Cells - Delayed antibody and immune complex mediated destruction

Immunomodulatory Agents

  • Antimetabolites (mycophenolate and azathioprine)
    • tops De-Novo Pathway of Purine Synthesis
    • Unique complications include leukopenia (34-43%) and GI upset
  • Calcineurin Inhibitors (cyclosporin, tacrolimus)
    • Decrease IL-2 production and signaling, stunting the T-Cell mediated response
    • Unique complications include nephrotoxicity, diabetes and GI upset
  • mTOR inhibitors (everolimus, sirolimus)
    • Bind mTOR (catalyst/enzyme required for cell proliferation/maturation) and prevent entry into cell cycle, prevent cytokine transcription
    • Unique complications include hypetension, hyperlipidemia, diabetes and GI upset