Grand Rounds Recap 11.30.22

/

Morbidity & Mortality w/ Dr. Kimmel

Testicular Torsion

  • Typically presents as sudden onset unilateral scrotal pain due to twisting of the spermatic cord and resultant ischemia to the testicle

  • Testicular torsion affects 1 in 4000 males <25 years of age

  • It has a bimodal distribution, with peaks within the first year or life, and another around the time of puberty as testicular volume increases

  • Occurs less commonly in older men, but should be included on the differential diagnosis, as these patients have lower rates of salvage thought to be related to delay in diagnosis and higher degree of rotation/torsion

  • Risk factors: testicular mass and bell clapper deformity

  • History of onset may be spontaneous, often waking a patient from sleep, or with strenuous physical activity. In about 4-8% of cases, torsion is associated with trauma. This is thought to occur due to abrupt contraction of the cremaster muscle, which surrounds the spermatic cord, resulting in torsion. 

  • The spermatic cord contains the neurovascular bundle and the vas deferens

  • Pathophysiology: twisting of the spermatic cord leads to edema of the spermatic cord, followed by obstruction of lymphatic flow, followed by obstruction of venous outflow. This leads to equalization of the venous and arterial pressures, causing obstruction of arterial blood flow and resultant ischemia

  • There are two types of torsion that occur, which are named based on their relation to the tunica vaginalis

    • Intravaginal torsion: occurs due to an anatomical variant known as a bell clapper deformity, which is a congenital abnormality leading to inappropriately high attachment of the tunica vaginalis over the spermatic cord which leaves the testicle free to move around and twist within the tunica vaginalis (like the clapper of a bell). Occurs most commonly in pubescent males 

    • Extravaginal torsion: occurs in neonates prior to fixation of the tunica vaginalis within the scrotum, often scrotal swelling noted by caregivers during diaper changes, associated with low rates of salvage due to delay in diagnosis

  • Presentation: horizontal lie (due to bell clapper deformity), firm, high riding testicle (due to twisted and foreshortened spermatic cord), edema, inguinal fullness, overlying skin changes, absent cremaster reflex. 10-15% of patients may present with isolated lower abdominal pain, which is thought to be secondary to innervation of the testis by T10 and T11

  • The TWIST score has excellent positive and negative predictive value for the diagnosis of torsion

  • Diagnostic imaging is performed with color doppler ultrasound

  • Manual detorsion can be attempted in low resource settings where expeditious surgical intervention is unavailable, but should never delay definitive care

  • OR exploration with urology will determine viability 

  • Testicular salvage rates are 90-100% if surgery is performed within 6 hours of onset of pain

  • Patients with developmental delay or who are unable to verbalize pain have higher rate of adverse outcome due to delay in diagnosis


Acute Myeloid Leukemia

  • AML is the most common acute leukemia among adults, and makes up a large portion of all adult leukemias

  • AML is defined as a clonal expansion of immature myeloid cells, leading to ineffective erythropoiesis and bone marrow failure

  • Incidence is ~20k cases per year in the U.S. AML is more common in males, and has an average age at diagnosis of 68 years. Older age is associated with poorer prognosis

  • Risk factors: myelodysplastic syndrome, aplastic anemia, myelofibrosis, congenital disorders like Down syndrome or Bloom syndrome, environmental risk factors like tobacco use, benzene exposure, and radiation

  • Therapy-related AML can be seen after exposure to chemotherapy (i.e. alkylating agents like cisplatin or cyclophosphamide, or topoisomerase II inhibitors like etoposide)

  • There are several cutaneous manifestations of hematologic malignancy, and can be broadly categorized into 3 groups:

    • Neoplastic skin infiltration (i.e. leukemia cutis, Sweet syndrome, pyoderma gangrenosum)

    • Immune-mediated (i.e. erythema nodosum)

    • Related to therapy (i.e. GVHD, adverse drug reactions, infections secondary to immunocompromised state)

  • Factors Affecting ED Follow-Up

    • Lack of clear diagnosis, importance of follow-up not communicated, hopelessness, long wait times for appointments, issues with insurance (out of network, uninsured), forgetfulness

    • Many studies have demonstrated that simple interventions (scheduling follow-up while patient is in the ED, enrollment in automated text message appointment reminders) improve rates of ED follow-up

  • Patients with Limited English Proficiency

    • One large study noted that patients with LEP were less likely to receive specialist referrals upon ED discharge

    • Ask patient which language they prefer to speak during the encounter

    • Use an appropriate interpreter

    • Printed discharge instructions should be reviewed with the patient verbally in their native language with the use of an interpreter prior to discharge

Hypertensive Emergency in ESRD

  • Pulmonary edema can present with wheezing, known as “cardiac asthma” or “cardiac wheezing.” These lung sounds are caused by bronchial wall and intraluminal edema which cause narrowing of small airways

  • Patient with ESRD are at higher risk of developing hypertensive emergency

  • These patients have also found to have higher rates of cardiac arrest, acute pulmonary edema, and longer average length of stay during hospital admissions for hypertensive emergency

  • Management includes afterload reduction, with nitroglycerin being a good choice for venodilation. Diuresis can also be helpful in patients who produce urine. Dialysis should be performed if there are signs of volume overload. PPV can be used in the case of pulmonary edema and respiratory distress. 

  • Providers should be judicious with volume administration in these patients, and be mindful of volume administered in parenteral medications and IV contrast

  • Echocardiography can help assess volume status


Posterior Circulation Stroke

  • Posterior circulation stroke accounts for about 20–25% of all ischemic strokes

  • The incidence is roughly 18 per 100,000 person-years

  • Posterior circulation stroke is classically a difficult diagnosis to make

    • In the emergency department, posterior strokes are nearly 3 times more likely to be missed than anterior circulation strokes. Of these, those presenting with dizziness or n/v are more likely to be missed, which thought to be related to the nonspecific nature of these complaints

    • Patients may also have visual impairments that they are unaware of, making these difficult to diagnose 

    • Up to 25% of posterior circulation strokes may be caused by arterial dissection. Young patients, who may be more prone to trauma and dissection, have higher rates of misdiagnosis. This is likely because providers may be less likely to consider this diagnosis in young patients who lack traditional stroke risk factors

    • The NIHSS does not account for many of the disabling symptoms associated with posterior stroke

    • Noncontrast CT Head has very poor sensitivity for acute ischemic stroke, which is especially poor in the posterior circulation territories due to artifact from the bony skull base

  • Physical Exam:

    • Cerebellar

      • Gait: patients with mild vertigo may have profound truncal ataxia. It is imperative to walk these patients. Patients with cerebellar ataxia tend to fall toward the side of the lesion. 

      • Dysmetria: abnormal finger to nose or heel to shin

      • Nystagmus: bidirectional nystagmus and vertical nystagmus are more common among central causes of vertigo

    • Occipital lobe

      • Assess visual fields to look for visual field cuts. In patients who may not be able to follow commands, the examiner can assess visual fields to confrontation

      • Patients with occipital lobe lesions may also have difficulty naming objects or difficulty recognizing faces

  • Caplan et al divided the location of posterior circulation infarcts into 3 territories given the vastly different clinical presentations that result from ischemia in these areas:

    • Proximal: regions supplied by the intracranial vertebral arteries (ICVA): the medulla oblongata and the posterior inferior cerebellar artery (PICA)–supplied cerebellum

    • Middle: supplied by the basilar artery up to its superior cerebellar artery (SCA) branches: the pons and the anterior inferior cerebellar artery (AICA)–supplied cerebellum

    • Distal: territory supplied by the rostral basilar artery, SCA, posterior cerebral artery, and the penetrating branches of these arteries to the midbrain and thalamus

  • The addition of clinical information can improve the sensitivity and diagnostic accuracy of radiology interpretation of imaging


Occlusion Myocardial Infarction

  • This concepts acknowledges that the classic STEMI/NSTEMI dichotomy is prone to error

  • The OMI/NOMI classification aims to identify myocardial infarction caused by occlusion of the coronary arteries that would benefit from emergent reperfusion

R3 Small groups

Winter Pictionary w/ Dr. Diaz

  • High / Low Chest Tubes

  • indicated when hypothermic and peri arrest / arrest

  • Ideally would place bilateral (anterior can be a pigtail and posterior), left side first if coding, right side if alive (cardiac irritability)

  • Chest Wall Escharotomy

    • Procedure detailed under Aircare

    • Indicated when large full thickness (not necessarily circumferential) that leads to inability to ventilate

    • Mark, clean, cut down until fascia but do not cross it

    • Can use cautery or pressure for hemostasis, do not use cautery while flying

  • Segond fractures

    • Lateral proximal tibial fracture

    • Common in soccer, skiing, basketball and baseball

    • Pathognomonic for ACL tear

    • Consider tendon/ligamentous injury in ski injuries

    • Ensure good ortho follow up 

  • Skier's Thumb

    • Associated with UCL sprain / tear due to FOOSH with ski pole

    • Associated with chronic disability if not treated

    • Place in thumb spica and arrange ortho follow up

  • CO/CN poisoning

    • Indications for cyanokit - structural/house fire with AMS or if unstable. Can re dose 

    • Consider if VBG contains carboxyhemoglobin

    • Hyperbaric chamber indications: level >25 or > 15 in pregnant pts, with syncope/AMS/coma

      • Discuss with burn team prior to consideration for transfer to hyperbaric center

  • Nasotracheal intubation in inhalation injuries

    • Consider lidocaine 4 ways

      • Atomized

      • Topical

      • Nebulized

      • Transtracheal block

  • Median/Ulnar/Radial Nerve blocks

  • Don't forget the triad of death, remember to keep trauma patients warm!

Cold Weather Jeopardy Board Questions w/ Dr. Wosiski-Kuhn

“Heating Up”

· How to prevent the afterdrop phenomenon: by heating the patient’s core before the extremities

· Method to be used to rewarm a patient with a temperature of 30C (86F): any external warming method (including warm water immersion)

· What methods do you initiate at 28C (82F)? Any internal warming method

· The most rapid method for rewarming in hypothermia: cardiac bypass NOT ecmo! Fluid rate is faster in bypass than VA ECMO (BONUS how fast is bypass rewarming? 9C per hour)

· Rank the following methods from slowest to fastest rewarming: External warming = Warm IV fluids (1 to 3 C/hr) < Thoracic lavage (3 C/hr) < Hemodialysis (up to 4C/hr)

Hypothermia: EKG & Physiology

The finding indicated by these arrows that can also be found in subarachnoid hemorrhages, acute coronary syndrome, and be a normal variant. What is Osborne waves or J waves (BONUS – are these associated with the degree of hypothermia? Yes, they become more prominent)

· This is what you should expect for glucose levels in hypothermia. What is hyperglycemia (additional fact: this is because circulating catecholamines and cold temperature decreases insulin secretion from your body)

· The most common dysrhythmia that is seen in acute hypothermia. What is atrial fibrillation (additional fact: Typical sequence of EKG progression in hypothermia: sinus bradycardia, atrial fibrillation with slow ventricular response, ventricular fibrillation, and then asystole)

· Slowed impulse conduction through the potassium channels in hypothermia causes this EKG change. What are prolonged intervals (BONUS how does hypothermia affect the EKG of hyperkalemia? You won’t see the usual hyperkalemia- associated changes)

· This is how urine output is affected in hypothermia. What is diuresis (increased UOP)

Floods of Blood (get your nose a humidifier)

· These are your first line methods for treating epistaxis. What are topical vasoconstrictor sprays, like oxymetazoline, combined with direct pressure. (BONUS how long should you observe for rebleeding after removing pressure? 30 minutes)

· 90% of all nosebleeds originate from this anatomic area. What is the Kiesselbach plexus. (BONUS how do you position the patient? Have them lean forward so any rebleeding comes out the nose rather than down the throat)

· Epistaxis coming from bilateral nares are more likely to be this. What is posterior (BONUS what is the culprit artery? Nasopalatine branch of the sphenopalatine artery)

· If you can see the culprit vessel, use chemical cautery (silver nitrate). Tell me at least one caveat to using silver nitrate cautery on epistaxis. Never apply for >10 seconds, never use bilaterally (risk of septal perforation), it won’t work on an actively heavily bleeding surface

· Bleeding persisted despite cautery (or you couldn’t visualize it) so you placed anterior packing. This is the first choice of antibiotic to place these patients on. What is augmentin

It's not RSV for once

· The two most common causes of pneumonia in preschool aged children. What are viral and strep pneumo (Respiratory viruses are the main cause of pneumonia between 30 days and 5 years of age. However, between the age of 2 to 5, you will see an increase in Strep pneumo and H flu)

· The treatment for pneumonia in children 2 months to 5 years. High dose amoxicillin (remember, you’re covering strep pneumo) (BONUS: if the kid is actually allergic to penicillins what do you give? Azithromycin)

· The treatment for pneumonia in children 5 years to 16 years of age. What is azithromycin

· The most common pathogen for pneumonia in a patient who has or just had the flu? What is staph aureus

· Name at least 2 of the pathogens present in the birth canal that neonates with bacterial pneumonia need to be covered for. group B strep, Klebsiella, E. Coli, and Listeria

I'm cold (but it's not the weather)

· Your expected vital signs in severe hypothyroidism. What are hypothermia, hypotension, bradycardia, hypoventilation (BONUS: Treatment of severe hypothyroidism is to institute EARLY with Levothyroxine (T4) and Liothyronine (T3 – more rapid onset). T3 is more rapid onset)

· The most common cause of severe hypothyroidism/myxedema coma? What is abrupt cessation of medication in a hypothyroid patient

· The two most classic electrolyte derangements in severe hypothyroidism. What are hyponatremia and hypoglycemia

· This vital sign is directly related to mortality in severe hypothyroidism. What is hypothermia

· How TSH levels will be in central vs primary hypothyroidism. TSH can be normal in central hypothyroidism vs primary hypothyroidism where it is high

Cheers to the wrong alcohol

· This toxic alcohol leads to retinal injury and irreversible blindness. What is methanol. (BONUS what is the toxic metabolite? Formic acid)

· This toxic alcohol leads to rapid kidney failure and hypocalcemia with QT prolongation & tetany. What is ethylene glycol (BONUS what are the 3 toxic metabolites: glycolic, glyoxylic, and oxalic acids)

· Most places don’t have a rapid return on a volatile alcohol panel so what lab should you always include when you suspect a toxic alcohol ingestion, in addition to your usual BMP & VBG? What is serum osmolality (BONUS how do you use this? Look for an osmolar gap >25U early on)

· These are the two criteria for starting hemodialysis in toxic alcohol poisoning (the best method to remove the alcohols & their toxic metabolites). What are metabolic acidosis (ph <7.3) or any end-organ damage (i.e. renal failure or vision changes)

· These are the 3 cofactors to give to a patient with a toxic alcohol ingestion? Folic acid, thiamine, pyridoxine (BONUS: which go with which? Folic acid is methanol, the other 2 are ethylene glycol)

Hypothermia w/ Dr. Stark

  • Hypothermia is common and can be very dangerous to our patients.  It is very important to obtain a core temperature via rectal probe, esophageal probe or temperature sensing Foley.

  • Temperature may not be reflected in patient presentation.

  • Be sure to consider primary and secondary causes of hypothermia as rewarming will not occur and secondary causes of hypothermia, rather the etiology should be treated to improve temperature.

  • Be careful as to not agitate cold patients as it does increase the risk of arrhythmias.  Consider minimizing treatments including placing femoral CVC if needed as to not agitate the pericardium.

  • The HT staging of hypothermia can be used to help identify patient presentations as well as typical therapies for these patients.  

    • Mild hypothermia is defined as 32 to 35 °C and should be treated with passive external rewarming.  

    • Moderate hypothermia occurs at 28 to 32 °C and may present as a drowsy, not shivering patient and requires active external rewarming.  

    • Severe hypothermia is defined as 24 to 28 °C and patients often present as unconscious with fixed dilated pupils. They require a combination of active external rewarming as well as possibly active internal rewarming.  

    • Finally, pulseless patients at less than 24 °C should receive a combination of active external, active internal rewarming and likely ECMO if the patient meets criteria including potassium level that is less than 10.

Evidence-based nihilism w/ Dr. zalesky

 How to find the evidence

  • Have them sent to you

    • EMRAP

    • Journal Feed

    • Evidencealerts.com

    • Dynamed Plus

  • Seek them out

    • QxMD

    • Browzine

  • Track your papers

    • Zotero

  • Data paralysis

    • One study does not adequately represent the population and its results cannot be viewed as truth in isolation 

      • Systematic reviews have larger sample sizes and better approximate the true mean

    • Research rabbit

      • A tool that forms a knowledge graph with the papers that each study cites

      • Forms a visual representation of the network of knowledge around a topic

    • Example: Does ketamine cause hypotension?

      • 1996 - basic science study in the OR showed cardiac suppression with ketamine

      • 2009 - Multicenter RCT comparing etomidate vs. ketamine for RSI, showed equivalence in mortality but not powered for hypotension

      • 2012 - Patients in respiratory distress or with high shock index were more likely to suffer hypotension after RSI

      • 2015 - Case series of 2 cases demonstrating cardiac arrest following ketamine use in RSI in the ICU; retrospective case series showing equivalence

      • 2016 - Prospective observational study showing equivalence in outcomes in RSI, though focused on mortality

      • 2017 - Larger retrospective studies comparing ketamine vs. etomidate in RSI

      • 2019 - Prospective observational NEAR studies showing more hypotension in the ketamine group with large sample size with significant difference in all comers undergoing RSI and also in sepsis intubations

      • 2021 - Multicenter RCT for etomidate vs ketamine for RSI in ED and ICU looking at blood pressure outcomes, showed equivalence in blood pressure but higher short term mortality with etomidate

      • 2022 - Another retrospective review released evaluating etomidate vs. ketamine on hypotension in RSI – difficult to interpret given previous higher quality studies

Ethics in global health w/ Dr. gorgas

Conflicts in Conscience

  • All done in the name of hippocrates is not right

  • Physician centered paradigm can distort true health improvements

  • The brain drain

    • Significant diaspora of physicians in low income countries that move to high income countries

    • Projects can raise expectations without the means to correct manpower and technology deficiencies

  • “Do they want what we want?” – understanding cultural competency

    • Must understand how to attend to social justice and underlying factors of poor health

    • Understand cultural needs and local perspectives when providing healthcare

    • Must exert respect for emerging literature and research from abroad

  • NGO (non-governmental organizations) code of conduct

    • Recently developed 2007-2008, included APHA, PIH, Physicians for Human Rights, Save the Children, AMREF, GHETS, WHO, World Bank

    • There following areas are where NGOs can do better:

      • 1) hiring policies;

      • 2) compensation schemes;

      • 3) training and support;

      • 4) minimizing the management burden on government due to multiple NGO projects in their countries;

      • 5) helping governments connect communities to the formal health systems; and

      • 6) providing better support to government systems through policy advocacy

      • 7) providing transparency and inter-system linkages