Grand Rounds Recap 12.8.21
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Morbidity and Mortality WITH Dr. Frederick
Vertebral Osteomyelitis
Vertebral osteomyelitis is rare, with an incidence of 2.4 cases per 100,000 people. The lumbar spine is the most common site (57%), followed by the thoracic (35%), and cervical spine (5.9%). The risk of cervical involvement is increased to 27% in patients who use intravenous drugs.
Overall, diagnosis is difficult and it can take 8-16 weeks of symptoms before it is found. Presentation varies, and can include:
Back pain in 86% of patients
Fever in 47% of patients
Neurological impairment in 33% of patients (this often suggests concurrent spinal epidural abscess)
Spinal tenderness in 20% of patients
Risk factors include:
Elevated CRP and ESR (OR 1.8)
Spinal surgery within 3 months (OR 2.4)
Fever (OR 4.9)
Urinary incontinence (OR 5.2)
Abnormal neurologic exam (OR 15.3)
Bacteremia (OR 26.2)
Serum Markers:
CPR has a half-life of 4-7 hours and rises 6 hours after inflammation starts. Levels peak at 1-2 days and return to baseline in 2-3 days following a minor infection or about 1 week after a major infection. CRP is elevated after surgery, but levels > 100 mg/L after POD 4 are suggestive of infection. Notably, CRP is produced by the liver and may be misleadingly low in hepatic failure.
ESR measures the Rate of RBC sedimentation and is affected by constituents of the serum, largely fibrinogen. ESR increases at 24-48 hours after onset of inflammation, peaks at 5 days, and can remain elevated for weeks (half-life is 100 hours). Falsely low ESR can be seen in blood cell dyscrasias.
In patients with a history of IVDU the ESR is 85-91% sensitive and CRP is 71-84% sensitive for detection of spinal infections. Notably WBC, ESR, and CRP are lower in patients with history of IVDU.
Imaging Modalities:
CT is 67% sensitive and MRI with contrast is 96% sensitive for vertebral osteomyelitis. Changes are seen on MRI earlier in the course of disease than on CT.
Skip lesions affecting multiple spinal levels are common and full spine MRI should be considered in high risk individuals.
Intracranial Hemorrhage in Hypertension
Hypertension accounts for 1% of ED encounters, with 8% of those encounters resulting in hospitalization. Stroke is the most common subsequent complication, though it occurs in less than 1% of these patients per year.
In a 10-year observational study of almost 160,000 hypertensive patients, 742 developed intracranial hemorrhage. Further analysis showed an increase in ARR of 2.73 among men and 3.15 among women for every 20 mmHg elevation in blood pressure.
Patients with stage 2 HTN are at the highest risk of ICH (HR 12.4), followed by patients with stage 1 HTN that was increasing (HR 9.66), patients with stage 1 HTN that was decreasing (HR 6.79), and prehypertensive patients (HR 3.11) when compared with normotensive controls.
African-American patients under 50 years old are at the highest risk of intracranial hemorrhage in hypertension.
Predictors of serious intracranial cause of headache:
Abrupt onset (OR 7.96)
Headache greater than 1 week (OR 10.6)
Pain on awakening (OR 3.14)
Fever (OR 6.0)
Worst headache (OR 12.95)
Altered consciousness (OR 13.55)
Focal neurologic deficit (5.28)
ACEP Recommendations regarding headache management in the ED:
Pain response to therapy should not be used as a sole diagnostic indicator of an underlying etiology of an acute headache (Level C)
Who should get imaging:
New neurologic findings (Level B)
New, sudden-onset, severe headache (Level B)
HIV positive patients with a new headache (Level B)
Consider imaging in a patient > 50 y/o with a new HA but with a normal neurological exam (Level C)
Pulmonary Embolism
Multiple modalities exist for diagnosis of suspected pulmonary embolism, with differing test characteristics:
Age adjusted D-dimer: sensitivity 99%, specificity 47%
Lower extremity compression ultrasonography: sensitivity 49%, specificity 96%
V/Q scan: sensitivity 58%, specificity 98%
CTPA: sensitivity 94%, specificity 98%
CTPA is the test of choice for diagnosis of pulmonary embolism, but concern for contrast induced nephropathy is a barrier to testing in patients with chronic kidney disease. Multiple recent meta-analyses and a joint statement from the American College of Radiology and National Kidney Foundation do not support contrast induced nephropathy as a significant risk when compared to a life threatening diagnosis. They do recommend peri-contrast administration of normal saline in patients with CKD 4 or 5.
There is increased risk of pulmonary embolism in patients with chronic kidney disease (66/100,000 patients with normal renal function vs. 527/100,000 patients with ESRD) that is likely due to protein wasting.
Delays in diagnosis and anticoagulation lead to adverse outcomes:
Adverse events are increased when diagnosis of PE is delayed until hospitalization (30%) compared to initiation in the ED (8.5%).
Mortality is increased when initiation of anticoagulation is delayed until admission (6.7% in hospital and 15.3% 30-day) when compared to initiation in the ED (1.4% in hospital and 4.4% 30-day).
European Society of Cardiology and American Society of Chest Physicians guidelines recommend immediate empiric anticoagulation in the following scenarios:
Wells > 4 using the two-tier criteria (28% risk of PE)
Wells > 6 using the three-tier criteria (37.5% risk of PE)
Modified Geneva score of 11 or greater
If definitive diagnosis cannot be made within 4 hours, patients should be anticoagulated if:
Wells 2-6 using the two-tier criteria
Modified Geneva score of 4-10 or greater
A recent study shows that only 2% of ED patients who were high risk received empiric anticoagulation, even though 32% of them had a preexisting reason for anticoagulation.
Additional findings suggestive of pulmonary embolism, include:
Syncope (+LR of 2.38)
Shock (+LR of 4.07)
Ultrasound findings:
TAPSE < 17 (+LR of 3.9)
D Sign (+LR of 7.8)
RV:LV >1 (+LR of 8.2)
Positive DVT study (+LR of 13.2)
McConnell’s Sign (+LR of 20.8)
Capacity
Capacity consists of: understanding, appreciation, reasoning, and communication
How common is incapacity?
Patients with learning disabilities: 65%
Patients with alzheimer's disease: 54%
Nursing home residents: 44%
Healthy elderly adults: 2.8%
Capacity is complex and dynamic:
Capacity can vary over time, even within an encounter
Capacity is situational; a patient can have capacity to agree to a simple treatment, but not a complex care plan.
Cognitive impairment or mental illness do not necessarily indicate incapacity.
Capacity requires information.
Patients exist outside of our world, and we are generally seeing a brief snapshot.
In the Emergency Department, capacity assessment is done simultaneously with the clinical assessment. Unless a patient is obviously impaired or incapable the EP proceeds with the clinical encounter as if the patient has capacity.
The CURVES mnemonic can be used to guide capacity assessment:
Communication: provide information to the patient, to make an informed decision
Collateral is invaluable for assessing a patient's baseline. If you obtain contact information for collateral, please place that info in the chart for future providers.
Understand: the patient must have an understanding of their condition and the proposed treatment, and be able to explain this in their own words.
Reasoning: the patient should be able to explain how they arrived at the chosen option, and what the alternatives are.
Values: understanding a patient’s values helps to understand their reasoning and what additional information may be needed.
Emergency: decision making may fall on the physician in a true emergency (life or limb threat)
Surrogate: if the patient does not have capacity, attempts must be made to contact a surrogate.
Using the EHR to improve care
Chart review has been demonstrated to improve care and accuracy of diagnosis in the ED. Studies have shown a significant increase in diagnostic accuracy when physicians were allowed to review a patient's medical record, when compared to seeing patients without a medical record. Char review also reduced unnecessary CT scans, allowed more appropriate disposition of patients, and decreased malpractice claims.
The following schema can be used to develop your own chart review practices:
On every patient, review PMHx, medications, most recent discharge summary, and any medical encounters within the last 4 weeks
For specific presentations, review:
Cardiac: most recent cath, echo report, and EKG
Seizure: last neurology note and AEDs
Oncology: oncology notes, recent CBC, chemotherapy history
HIV: most recent CD4 count and viral load, ID notes
Surgery: operative note, with attention to any complications
Ultrasound Grand Rounds: Femoral Nerve Blocks with Drs. Stolz, Minges, Mand, and Koehler
Femoral Nerve Blocks:
Primary indication is for hip or femur fractures
Useful in the ED, as osteoporotic fractures (largely of the hip and femur) comprised >40% of hospitalizations of elderly women in a 11 year retrospective study.
As this is a disease process that primarily occurs in the elderly, our typical solutions of parenteral opioids and procedural sedation carry greater risk.
Does it work?
A study of peripheral nerve block vs. sham for hip fracture in adults showed a reduction in pain at 30 minutes, reduced confusion during hospitalization (NNT 12), and reduced risk of pneumonia during hospitalization
Is it within our scope?
ACEP policy statement release in 2021 states that ultrasound guided nerve blocks are a core skill of emergency physicians.
The AMerican Association of Orthopedic Surgery and American College of Surgeons support use of regional analgesia for perioperative pain control in hip fractures.
How do we perform it?
A detailed description of the procedure can be found here: Scanning School - Nerve Block — Taming the SRU
In-plane technique significantly reduces nerve contact when compared to an out of plane technique (64% vs. 9%). No increase in adverse events was found, but theoretical risk of nerve injury exists.
As of right now this protocol only applies to UC, but after a brief trial, we will investigate expanding to our other sites
