Grand Rounds Recap 12/30/15

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Morbidity and Mortality Conference with Dr. LaFollette

Tracheoinnominate Fistula

One of the most dreaded days in the ED, a post-trach patient presents with a small bleed that stopped, is this one of 50% of patients with a TI fistula waiting to unleash?

  • 0.3% occurrence after routine tracheotomy
  • Incidence peaks 7-14 days after procedure

Once the patient starts massively bleeding - what's your next move hotshot?

  • If the trach is cuffed - overinflate the cuff and put external pressure on the trach, the maneuvers are about 80% successful at a tamponde
  • If not, replace the trach with an ETT, preferrably from the mouth if not a laryngectomy patient, again hyperinflating the cuff just above the carina
  • If bleeding is still not controlled, place your finger in the stoma and press anteriorly attempting to compress the artery on the manubrium

Success? Maintain whatever the effective method was successful until ENT is able to explore in the OR. Getting control of the airway is key - the' 75% mortality in these patients comes from respiratory compromise, rarely from exsanguination

Vital Signs = Vital

A young female was seen at another facility for shoulder pain now presents to you in cardiac arrest from a large empyema and sepsis. This is our nightmare as ED providers but fortunately is rare. 

Sklar et al looked at a cohort of over 380,000 patients and found a 7 day unanticipated death rate of 30.2 / 100,000 visits. 83% of those visits thought to be attributed to error had abnormal vital signs. 

Hypothermia

Although not this year, back when we were kids, winter used to involve cold and snow and people found themselves in it accidentally from time to time and so we discuss exposure hypothermia

The initial triage of these patients revolves around their mental status, vital signs and core temperature (rectal, esophageal and foley-based are all adequate)

  • Mild (32-35C) - you are at a Bengals game - get some warm, sweet hot chocolate, shiver and you will be fine
  • Moderate (28-32C) - shivering slows and mental status starts to wane
  • Severe (24-28C) - mental status is minimal and at high risk of cardiac instability and progression to ventricular fibrillation
  • Very Severe (< 24C) - lack of vital signs

The treatments are varied and will depend on your shop's capabilities. In any witnessed arrest known to be due to exposure, ECMO is the most effective means of rewarming (6 degrees C / hr) and should be activated as soon as possible. If unavailable, high/low chest tubes (3 degrees C / hr) are another effective adjunct along with warm IV fluids. 

Unclear if the patient's hypothermia is due to exposure? Warming rate > 1.8 C / hr has been correlated with cold exposure and the slower rewarmers are more likely to have systemic illness.

Brown et al. have a great summary in NEJM for a review of the topic

Physics and Physiology of Flight with Dr. Powell

There are people out there who's job it is to jump out of stratospheric helium balloons to see if the altitude kills you or not. And you thought what you did was bad$#@.

Henry's Law tells us that partial pressure of a gas dissolved in a liquid is directly proportional to the pressure above it. Decreasing pressure leads to decreasing partial pressure of gases i.e. they come out of solution easier without as much pressure "forcing" them into solution.

  • Henry's Law is the principle determinant of why decompression sickness occurs, both in the air and below sea. At high altitude and thus low atmospheric pressures, the gas constituents of your blood come out of solution. This is why you wear a fully pressurized suit at high altitudes and decompress when changing from sub sea level altitudes (high pressure) back to normal pressure.
  • Armstrong's Line=The limit of atmospheric pressure in which human's can live (~1/16th of sea level atmospheric pressure).  
  • The Bends. Decompression sickness typically precipitated by a less than adequate decompression time in divers transitioning from depth to sea level. Beyond a certain depth, divers should be spending a predetermined amount of time at a predetermined depth to allow the partial pressures of their blood gases to normalize (this is the purpose of dive tables and apps). If transitioned sub-optimally, blood gas bubbles everywhere that blood travels will increase in size and come out of solution, causing microvascular obstructive phenomenon throughout the body that can lead to ischemia. Joints are typically affected but the brain and spinal cord may be affected as well. Treatment is a hyperbaric chamber. 

Taming the SRU R3 Case Follow Up with Dr. DeVries

Middle aged female arrives hypotensive, hypoxic, and tachycardic after chest pain and a syncopal event. CTPA suggests massive PE. 

A qR wave in V1 is an ECG sign that may be associated with right ventricular strain secondary to pulmonary embolus (here is a link to the original article)

Massive PE: systolic BP<90 x15 min, significant HD compromise, refractory shock or pulselessness due to PE alone. Full dose TPA may be reasonable here. Half-dose TPA may be reasonable in sub-massive PE to mitigate right heart strain (2011 AHA Scientific Statement).  

Be careful with fluid resuscitation in the patient with HD compromise due to PE, as this could potentially cause increased right sided cardiac pressures, worsening septal bowing, and decreased left ventricular output. 

Bedside ultrasound, in practiced and credentialed hands, can be a powerful tool for emergency providers. The RUSH exam (Rapid Ultrasound in Shock) can be used in patients with undifferentiated hypotension as a means of evaluation and diagnosis of underlying pathology. 

  • For more info on the RUSH exam, check out this link from the folks at EMCrit to see the original publication, a podcast detailing its use, and additional links.

R2 Case Follow Up with Dr. Goel

Teenager on augmentin x several days presents with a diffuse maculopapular, erythematous rash. Upon presentation to our ED he has mucosal involvement and skin sloughing. The patient is admitted with a diagnosis of Stevens-Johnsons.

This is a critical disease pathology that the EDP has to be equipped to identify, as mortality is high, especially if diagnosis is delayed. 

  • Mortality correlates with degree body surface area involved.
  • Uveitis, corneal ulcerations, and blindness are important complications to remember associated with this disease pathology. As an inpatient ophthalmology consultation is warranted.
  • Treatment is supportive. IV steroids, IVIG, and cyclosporine therapies are all controversial and best determined by a dermatologist or inpatient team. The ED onus is detection. 

Medications are the usual inciting factors--most commonly penecillins, macrolides, sulfa drugs, anti-epileptic drugs and quinolones. However, the rash may start any time from days to weeks to months after initiating the medications.

Most cases (>90%) have mucosal lesions. This is the huge clinical clue. 

The disease pathology usually starts with a prodrome leading to cutaneous lesions followed by mucosal involvement (thought to be present in 90% of cases) and finally, skin sloughing may occur. 

Acute generalized exanthematous pustulosis is another high-mortality rash characterized by diffuse pustules, also often precipitated by drugs. 

R4 Case Follow Up with Dr. Denney

In evaluating your headache patients there are a few key historical features that may be useful in your decision, "to tap or not to tap?"

  • Does this patient normally get headaches, and, if so, is this headache the same or different? In patients who have new headaches or headaches with a changed quality, red flags should be raised. 
  • Knowing if the patient has recently been on antibiotics or had any recent facial infections (otitis, mastoiditis, cellulitis, sinusitis) is critical as well. New headache/changed headache + antibiotics or recent infection? In this provider's opinion that patient gets at least a discussion on the risks and benefits of LP if not the procedure itself. Partially treated meningitis can have an incredible variance in presentation and patients may appear benign and afebrile. 
  • Occupation, in general, is a good question to ask of all patients. Every once in a while you have a patient (as in ours) whose job is to sniff vats of international microbes. 

Beware of "the weird." If something is telling you your patient is "weird" but you just can't put your finger on it, consult the family. "Is this how your loved-one usually acts?" Weirdness, as with altered mental status and hypoglycemia, can be subtle. 

Reassess your patients and, if something happens that you did not initially anticipate (ie there temperature goes up and becomes a fever, their heart rate worsens with fluid administration) perform a HARD STOP and rethink your position and management pathway. 

Remember that response to therapy does not diminish the likelihood of significant illness in your headache patients (ie compazine making their pain better does not make meningitis/SAH less likely). However, non-response to treatment and refractory pain should raise another red flag and potentially another HARD STOP to rethink the patient. 

Clinico-pathologic Conference with Drs. Teuber and Hill

Neuroleptic Malignant Syndrome (NMS) can be a difficult diagnosis to make but should always be on your clinical radar for your undifferentiated altered mental status, toxicology, and febrile patients. 

  • Every patient with diagnostic uncertainty deserves a medication review. In an America that today is well-medicated, medications are an incredible source of pathology and complications in themselves and can have drastic effects on physiology even if they are not the etiology of dysfunction. 
  • Prolonged exposure to neuroleptics or withdrawal of a dopamine receptor agonist is usually the precipitating factor. 
  • Patients classically experience altered mental status, fever, "lead-pipe" rigidity, and fever and will have a CK elevation (rhabdomyolisis) on laboratory evaluation. 
  • Treatment is supportive and withdrawal of the offending agent. Resuscitation with aggressive fluids and intubation may be indicated. Bromocriptine, amantadine, and dantrolene are options though their efficacy is controversial. 
  • For a quick review, check out this LIFTL link