Grand Rounds Recap 11.30.16

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Air Care Grand Rounds with Drs. Kircher & Hinckley

Caring for Impella Patients on Air Care with Dr. Charlie Kircher

http://www.abiomed-eu.com/products/impella-cp/

http://www.abiomed-eu.com/products/impella-cp/

The goal of the impella is to increase myocardial and tissue oxygen delivery while reducing work of the heart by reducing preload and after load. The device sits across the aortic valve with the inflow portion of the device in the left ventricle and outflow in the aortic root augmenting CO. The impella can also augment coronary arterial flow to improve perfusion of the myocardium, potentially reducing infarct size in the setting of MI.

Troubleshooting: Is it in the right spot?

  • The impella produces a waveform which should look like an arterial line waveform when it is placed properly. If you see a ventricular waveform it suggests that the impella is too deep and sitting in the ventricle. If you see a flat waveform, the device may have been pulled back and is likely sitting in the aorta.
  • Use bedside ultrasound to visualize the device directly, it should traverse the ventricle into the aortic outflow tract in a parasternal long-axis view.

Prevent migration of the device:

  • Immobilize the leg through which the device was placed, particularly when moving the patient. Knee immobilizers can be helpful.
  • Agitated or combative patients may need sedation.

Clinical Pearls:

  • Verify placement at the bedside before transport!
  • The device is preload dependent, if preload is too low the device may produce a "suction" alarm. Consider IV fluid bolus.
  • The device will not function well if after-load is too high. You may need to titrate down pressors for optimal augmentation.
  • You may find yourself titrating down drips as the device augments native cardiac function during transport.
  • If the patient codes, put the device in "P2" mode (lowest power setting while still providing some flow) and do CPR.
  • Ensure you have adequate sedation, consider pharmacologic paralysis if needed to ensure safe transport.

More info: https://www.abiomedtraining.com - Impella App for Android - Impella App for iPhone

Air Care Cases with Dr. Bill Hinckley

Case 1: Middle aged male picked up from the scene after his shirt became caught in an auger. He has complete amputation of his right arm at the glenohumeral joint - not amenable to tourniquet. His body had been slammed against the tractor during the event. He is in PEA with a GCS of 3 when the team arrives.

The MARCH algorithm in trauma:

  • Massive Bleeding
  • Airway 
  • Respirations
  • Circulation 
  • Head

Have a low threshold to bring the cooler with you from the aircraft to the scene.

Case 2: Elderly female, scene call for MVC. She was the restrained driver in a single vehicle MVC into a bridge abutment with airbag deployment with prolonged extrication. GCS 13 when the team arrived, LOC unknown. Seatbelt sign, unstable pelvis, 90% amputation of RLE with open tib/fib fracture.

Clinical Pearls
1.  Considerations in the single vehicle MVC: did the patient have a medical emergency that lead to the crash?
2.  Open Book Pelvic Fractures:

  • Physical exam is only 26% sensitive at detecting open book pelvic fractures
  • Some data shows that external pelvic compression device (we use the T-Pod) may reduce need for blood better even than a pelvic ex-fixator
  • When in doubt, place a T-Pod.

Case 3: Inter-hospital call for adult female, sepsis, intubated, on 4 drips. Found to have pyelonephritis with obstructing renal stone and renal abscess. Now s/p intubation with rocuronium.

Clinical Pearls:

  1. Intubated patients in septic shock - they likely need a lower EtCO2 to compensate for metabolic acidosis.
  2. Consider ketamine drip in hypotensive, intubated patients who need sedation.
    1. Take 200 mg of ketamine and inject into 100 mL NS (2mg/mL)
    2. Start at 10 mpg/kg/min = 0.6 mg/kg/hr
    3. Titrate to effect
    4. Unlikely that you'll need more than 20 mcg/kg/min
  3. Consider using the epoc to get more information if there is time in flight.

R2 Case Follow-Up with Dr. Isaac Shaw

HIV virion

HIV virion

The Case: Young, healthy male presents with sharp, RUQ abdominal pain which occurs after eating. Social history includes social alcohol use, marijuana use, one male sexual partner with consistent condom use. ROS reveals pain in right cheek over buccal mucosa which demonstrates one white, non-vesicular, papule on exam. Patient asks: "hey, do you think this could be HIV?"

Exam: Vital signs normal. Patient appears anxious but is not in obvious pain. Significant RUQ and epigastric tenderness without rebound or guarding. Normal GU exam. 

Work-up:
Labs - CBC, Renal, Hepatic, Lipase, Urinalysis all normal
RUQ Ultrasound - no stones or signs of cholecystitis

Patient goes home with diagnosis of likely gastritis. HIV test returns later that day and is positive, infectious disease follow up is arranged.

Visit #2: Patient returns for dysphagia and is found to have oral candidiasis and is treated with oral candidiasis.

Visit #3: Next day the patient returns because he is unable to swallow anything due to severe pain with swallowing and in his epigastrium. CT Chest is obtained which demonstrates esophageal candidiasis. Started on oral fluconazole.

At his infectious disease appointment his CD4 count is 56.

Challenges in the Diagnosis of HIV in the Emergency Department:

Epidemiology:

  • 1.2 million people have the disease and 15% are unaware of their diagnosis
  • 50,000 people contract HIV each year
  • Our population is especially at risk: Approximately 1% of patients in the emergency department were found to have a new HIV diagnosis on universal screening.

Presentation: Patients are typically symptomatic during the acute infection and then years later when they develop AIDS. Years of asymptomatic viral replication make it difficult to detect due to lack of suspicion on the part of the patient/provider.

Symptoms: Non-specific flu and mono-like symptoms

Diagnosis:

  • Day 0-10: No available test will detect infection
  • Day 10-14: RNA tests likely to be positive
  • Day 14-20: p24 antigen positive
  • RNA detection: not-rapid and expensive
  • Antibody detection: faster and cheaper but antibodies don't develop until around 4 weeks after infection, after the acute infectious symptoms
  • p24 antigen testing: fast and is positive earlier after the initial infection. Not always positive in chronic infection so it is usually combined with antibody testing.

What is the test we use?

  • HIV 1+2 antigen testing combined with HIV 1 Antibody testing for confirmation
  • If the antigen is positive but antibody is negative, the patient likely has an acute retroviral infection and western blot is run for confirmation.

Take Home Points:

  • Rapid HIV diagnosis is a top priority in public health.
  • Clinical presentation is challenging, symptoms are non-specific.
  • Know the window periods and know what kind of testing you're using at your clinical site.

R4 Clinical Soapbox with Dr. Kelly Thomas

Financial considerations in the practice of emergency medicine.

Terms:
Cost: What the healthcare system pays to provide a service.
Charge: What hospitals and providers bill the patient.
Out of pocket: Amount the patient pays towards their care.
Reimbursement: What medicare and medicaid pays the hospital for the care given.

Reimbursement comes in different forms from fee-for-service where payment is provided for each individual service to diagnosis-related groups where a single amount is reimbursed for the care of a specific diagnosis regardless of length of stay or services provided. Newly developing is reimbursement based on quality of care.

Charges and costs are not standard and vary widely even between hospitals in a same geographic region.

Reimbursement typically does not cover costs.

Patients often delay or avoid care when they suspect they cannot afford it. By age 25-54, medical bankruptcy makes up 1/4 of all bankruptcies in the US.

Smulowitz et al. A Novel Approach to Identifying Targets for Cost Reduction in the Emergency Department

Origins of Observation Medicine

In the late 1990s Medicare made a push to handle more care as "outpatient" which is where the observation status came from. Stays for observation are billed and reimbursed as an "outpatient" visit. This affects how the patient is expected to pay. For inpatient there is a set deductible and 20% co-pay for physicians fees, other facilities fees and charges are covered. For outpatient care the patient pays a 20% co-pay for all services, facilities, and physician fees and NO coverage for any oral, home medications they receive during that visit. Bottom-line: observation stays typically cost medicare patients more and reimburse hospitals less.

R3 Taming the SRU Case Follow-Up with Dr. Maika Dang

The Situation: It's a very busy day in the SRU, 2 patients intubated for respiratory failure, multiple GSWs, trauma patient via Air Care, tracheostomy patient in florid sepsis. 

Then Cincinnati Fire calls:
"Middle aged male in cardiac arrest at dialysis in PEA undergoing CPR with BVM"

Patient gets calcium and epi, intubation, defibrillator pads placed.
Wide complex tachycardia on the monitor shocked with 200J followed by ROSC.

Initial labs: pH 7.04, pCO2 96, HCO3 26, lactate 9.6
Potassium 4.6

Patient has a pacemaker in place, EKG shows ventricular pacing unchanged compared to prior.

Can you diagnose STEMI in a paced patient? Yes, Sgarbossa Criteria can be used.

What next? Cooling, CT Head are planned. However, 30 min later - pulses lost again with wide complex tachycardia. He gets more epi, amiodarone, bicarb, calcium, and lidocaine with multiple defibrillation and 20 minutes CPR. Bedside ultrasound showed no effusion and cardiac activity. Triple lumen and arterial line placed and patient goes to ICU.

What is the role of ultrasound in cardiac arrest?

1. Prognostication? The data is not quite there yet, however: patients who have cardiac activity on ultrasound seem to achieve ROSC more often than those that do not and may survive to hospital discharge more often.

2. Ultrasound may be used to determine if the patient is pulseless by visualizing a femoral arterial flow (which it is difficult to palpate).

3. RUSH exam can be used as an adjunct to diagnosis in PEA.

Pacemakers:

  • Sense cardiac activity
  • Stimulate electrical impulses

What does the pacemaker code mean?

  • I: What chamber is paced? 
  • II: What chamber is sensed?
    • O: None
    • A: Atrial
    • V: Ventricular
    • D: Dual (A+V)
  • III: What is the response to sensing?
    • T: Triggered
    • I: Inhibited
    • D: Dual (I+T)
  • IV: Rate modulation
  • V: Multisite sensing

Pacemaker arrhythmias: place a magnet over the pacemaker to see what's going on underneath.

  • Endless loop tachycardia: PVC conducts retrograde to atrium and is sensed by pacemaker resulting in ventricular contraction. Place a magnet over the pacer to break the loop.
  • Sensor-induced tachycardia: increased rate from pacemaker sensing changes in physiology but can also be induced by other external stimuli such as movement, loud noises.

CPR Point - Don't place defibrillator pads directly over the pacemaker box.

Airway Grand Rounds with Dr. Carleton

R-29 Soapbox: Committing to First Pass Success

Direct laryngoscopy (DL - without video assistant) has been shown to be inferior to video-assisted laryngoscopy (VL) time and again with good evidence.

1.  VL is better for the patient: fewer complications and a higher first pass success rate.
2. VL is better for the practitioners as it allows for direct instruction in technique by more experienced providers.

Predicting Difficult Video Laryngoscopy

  • While sniffing position reduces risk for difficult DL in patients who are obese, older, and male, however it makes acute angle video laryngoscopy more difficult.
  • Lip bite score
  • Altered head/neck anatomy
  • Small mouth opening
  • Sternothyroid distance
  • Liquids/debris in the airway

Golden Uvula Award

The Case: Air Care is called to the scene of a trauma in which a young male was impaled by a pipe which flew through the windshield into his face, coming out of the back of his neck. He is tachypneic. Vitals: 120/70, p 118, r 22, sats 92% on blow by from a non-rebreather. You can just see his palate above the pipe. He has to lay on his side as a full 6-8 inches of metal pipe are still protruding from the back of his neck.

Using the difficult airway algorithm:

  • This is going to be a difficult airway and you are the most advanced provider available to you.
  • Are you forced to act? Not quite, but the patient's GCS and respiratory rate are dropping. He's getting worse.
  • Can you use and EGD? No, you don't know the extent of the pharyngeal trauma and there's a good chance you'd make it worse.

What did the providers do? Awake look with ketamine while also having cricothyrotomy equipment readily available. 150 mg of IV ketamine given with patient in left lateral decubitus position followed by copious suctioning and a single look with the King Vision. Unable to visualize cords, they abandoned the attempt after 15 seconds and successfully performed a cricothyrotomy, stabilizing the patient!

Pearls after you successfully perform the cricothyrotomy:

  • Hold the ETT or device in place during transport. The balloon should be inflated only 1-2 cm after passing through the trachea making it very easy to displace.
  • Beware passing the ETT too deep, it is very easy to mainstem these patients.

Another case: 
Elderly female with history of asthma and COPD arrives in respiratory distress. She is agitated and unwilling to wear a CPAP mask per EMS. Attempt is made to wear a 60 LPM high-flow face mask but she continues to desaturate. She still refuses to wear a BiPAP mask.

What next? She is given 0.3 mg/kg of ketamine over 30 seconds. She calms and is placed on BiPAP at 15/5 however a minute later she slumps over, apneic but with a pulse. They attempted to set a rate but it did not work so they proceed to BVM. She undergoes RSI with succinylcholine and etomidate. EtCO2 immediately after intubation was 61, so it was unlikely to be a hypercarbic respiratory arrest.

Ketamine is a great drug, but remember it is not without harm: