Grand Rounds Recap 12.11.24

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Mastering minor care: Low back pain WITH Dr. Lang

  • Red flags for low back pain include:

    • Fever

    • IVDU

    • Diabetes

    • LE weakness

    • Incontinence

    • Anticoagulation

Spinal Epidural Abscess (SEA)

  • WBC elevated in ⅔

  • ESR >20 in 100%

  • CRP- similar

Management of musculoskeletal back pain

  • Bed rest vs normal activity

    • Cochrane review 2010

      • Moderate quality evidence in favor of resuming normal activity

      • Low quality in favor of those with sciatica

  • Steroids

    • Small study (67 total patients)

    • No benefit

    • Prednisone group much more likely to have second health care visit 40%

    • Radicular pain?

      • Moderate evidence it helps in a Cochrane review in 2022

  • NSAIDs

    • Cochrane review 2020

      • Acute pain: effective but small change

      • Sciatica: no effect

  • Tylenol

    • BMJ Meta-analysis 2015

      • Tylenol NOT effective

  • Muscle relaxers

    • 2017 Meta Analysis

    • Effective for acute LBP, unclear for chronic

    • No evidence for benzodiazepines

qikt: Acute limb ischemia WITH Drs. boyer and segev

  • Acute Limb Ischemia (ALI) is a sudden decrease in limb perfusion with symptoms lasting < 14 days. ALI classically presents with the 6 P’s: pain, pulselessness, pallor, poikilothermia, paresthesias, paralysis.​

  • The presence of neurologic symptoms or absence of ALL distal pulses indicates a threatened limb that requires prompt heparin anti-coagulation and revascularization by vascular surgery to salvage the limb.​

  • Chronic limb ischemia (CLI) is a decrease in limb perfusion due to underlying peripheral arterial disease (PAD) with symptoms lasting > 14 days. When CLI progresses to rest pain, it is termed chronic limb threatening ischemia (CLTI) and requires prompt revascularization to salvage the limb​

  • Identifying underlying CLI is critical as the physiology and management of CLTI differs from that of ALI.​

  • When consulting vascular, be prepared with the following information 1) pertinent PMH 2) vascular exam including the most distal dopplerable pulse 3) focused neuro exam of the threatened extremity.

Taming the Sru WITH Dr. Hajdu

  • High quality cardiopulmonary resuscitation (CPR), administration of epinephrine and defibrillation on rhythm changes when indicated should be the mainstay of treatment for cardiac arrest caused by nonshockable rhythms including pulseless electrical activity (PEA) and asystole. Though we have many medications, procedures, and adjuncts to advanced cardiovascular life support (ACLS), the data does not support that we employ these for all comes of cardiac arrest from non-shockable rhythms.

  • Medications such as sodium bicarbonate and calcium chloride are frequently utilized medications for cardiac arrest, but per guidelines should only be considered use for hyperkalemia and their corresponding toxicities (TCA-toxicity for sodium bicarbonate and calcium channel blocker toxicity for calcium). Literature demonstrates that use of these medications for all comers of cardiac arrest do not improve outcomes and may be associated with worse outcomes.

  • Thrombolytics such as tenecteplase (TNK) or alteplase (TPA) should be used for treatment of cardiac arrest when pulmonary embolism (PE) is the suspected or confirmed cause of death. It is generally accepted that thrombolytics are given as quickly as possible and that the code should be ran for at least 30 more minutes, however there is no standardized recommendation for which medication or dosing strategy to employ, and how long the run resuscitations for after administration.

  • Similarly, in the United States there is no standardized recommendation for when time of death should be called for patients undergoing ACLS for nonshockable rhythms. This decision should be made on an individualized basis when no clear reversible causes of death have been identified.

  • Running ACLS, or any high stakes resuscitation, in a small team setting where the number of advanced providers is limited poses many challenges including with how one should task prioritize. Physicians who practice in resource rich settings, particular where there are multiple physicians participating in running codes or doing procedures, should reflect on how their management would change were they alone.

  • Patients with nonshockable rhythms often have bad outcomes. Our jobs as emergency medicine physicians are incredibly difficult as we often encounter tragedy and death. To help build our resilience and find hope, we should find creative ways to connect with our patients and their families efficiently and effectively.

R1 Core Content: infectious diseases of the pelvis and perineum WITH Dr. guay

  • Urinary tract infections are a common infection that can be treated in the outpatient setting with short antibiotic courses, but complicating factors such as immunosuppression, history of MDRO infections, functional/anatomical abnormalities, or infection recurrences all necessitate a nuanced approach to their management.

  • Pelvic inflammatory disease is a clinical diagnosis based on patient risk factors, symptomatology, and physical that should not be delayed as high risk complications can develop quickly.

  • Epididymitis/orchitis can be a sequelae of STI’s and UTI’s in men, but a diagnosis of testicular torsion must be first ruled out in patients presenting with acute scrotal pain.

  • Have a low threshold to initiate IV antibiotics in patients who present with a fever after prostate biopsy as bacteremia can develop very quickly.

  • Fourniers gangrene can initially present very quietly, such as asymptomatic redness, itching, or unexplained vital sign changes. A heightened clinical awareness and thorough physical exam can shorten time to diagnosis and OR management, thereby significantly reducing mortality in this patient population.