Grand Rounds Recap 6.19.2024

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Morbidity and Mortality- R4 Capstone - Traumatic Neck Injuries - QI/KT: Electrical Storm

Morbidity and Mortality WITH Dr. Stark

Diabetic Foot Infections

  • Diabetic foot infections are the most common diabetes-related complication leading to admission.

  • ED providers should determine whether the infection is complicated or uncomplicated to further guide management.

  • Early consultation of podiatry or other surgical service is warranted in all diabetic foot infections and can decrease rates of amputation.

  • Gram-positive organisms are the most likely pathogen, however those with moderate to severe infection should be covered for polymicrobial causes.

• MDRO UTIs

  • MDRO infections are increasing in frequency.

  • Risk factors include history of MDRO infections, recent inpatient stay, recent antibiotic use, and travel to endemic areas.

  • Previous cultures have been shown to predict both organism and susceptibility to antibiotics.

  • Consider fosfomycin or nitrofurantoin for patients with high risk for MDRO infection and always reference the antibiogram in your area.

• Esophageal Varices

  • Esophageal varices are a common but highly morbid complication of cirrhosis.

  • Prophylactic antibiotics have been shown to have a mortality benefit in patients with variceal bleeding due to the high rates of bacterial infections in patients admitted for variceal bleeding.

  • Other medical interventions include PPIs, octreotide, erythromycin, and blood transfusion as needed.

  • Early endoscopy is key to both diagnosis and therapeutics.

  • Patients with suspected variceal bleeding should be admitted to a higher level of care.

• Cardiac Arrest and LVADs

  • Cardiac arrest in patients with LVADs are most commonly due to changes in preload, afterload, native contractility, or device failures.

  • One should ensure that the device is plugged in and an audible hum is heard.

  • Unresponsive patients with undetectable MAP or EtCO2 less than 20 should undergo CPR.

  • LVAD patients should undergo typical ACLS including compressions and defibrillation.

  • TEE can be helpful in guiding resuscitation if available.

• Neutropenic Fever

  • Neutropenic fever defined by a single temperature over 101 or temperature of 100.4 sustained over the course of a one-hour period in a patient with an absolute neutrophil count of less than 1500.

  • Patients with AML and sepsis have a higher mortality than their otherwise healthy counterparts.

  • Gut translocation is a common etiology of sepsis in patients with AML.

  • Gram positive sepsis is more common, but gram negative sepsis carries higher morbidity/mortality.

  • Patients with AML may develop severe lactic acidosis called the Warburg effect, which carries a poor prognosis.

• Traumatic Arrest

  • Trauma is a common cause of death in persons under 40.

  • Factors that improve survival rates include cardiac activity on ultrasound, initial shockable rhythm,  witnessed arrest, extremity only trauma, and bystander CPR.

  • Hypovolemia is the most common reversible cause of traumatic arrest.

  • Blood transfusion may be useful in patients with penetrating trauma, although we must acknowledge when efforts are futile.

R4 Capstone WITH Dr. Smith

  • The most common bioethics framework taught in medicine is the four principles from Beauchamp and Childress: nonmaleficence, beneficence, autonomy and justice. 

  • Autonomy is formed from respectful personal interactions. Think of the locked-in patient - they can make autonomous decisions but have no autonomy as they cannot convey their thoughts to others. 

  • Providers should focus on shared decision making, only if the path forward is not clear from medical knowledge. Providers should not offer choices that are medically unreasonable. 

  • Evidence shows the ethical principles are not actually used from medical decision making. Instead, decisions are made from a bottom-up approach based on the facts of the case. 

r1 Clinical Knowledge: Traumatic Neck Injuries WITH Dr. Qin

  • Initial management depends upon recognizing impending airway obstruction and establishing a definitive airway

  • Patients with hard signs require emergent OR regardless of zone of injury

  • Consider early CTA for stable patients without hard signs, useful for a wide variety of injuries

  • Do not underestimate severity of blunt neck injuries and the consequences of sequelae

  • Many neck injuries can have delayed or subtle presentations, maintain a high index of suspicion 

  • When in doubt, err on the side of conservatism given the high mortality in missed or delayed diagnoses, utilize collaboration with surgical colleagues

QI/KT: Electrical Storm WITH Dr. Lott and dr. rodriguez

  • Electrical storm is generally defined as >3 episodes of ventricular arrhythmia within a 24 hour period

  • Pathophysiology = vulnerable heart + inciting trigger + sympathetic overdrive

  • Prioritizing an EKG is of upmost importance as management depends on presenting rhythm (i.e. mono vs polymorphic VT)

  • Management includes:

    • Tailoring antiarrhythmics to presenting rhythm with the use of amiodarone, lidocaine, procainamide

    • Cardioversion vs defibrillation depending on patient stability and presenting rhythm

    • Reduce sympathetic tone with esmolol and intubation/sedation 

    • Treat reversible causes such as electrolyte repletion, heart failure exacerbation, ACS with revascularization

    • Patients with an ICD should promptly have their device interrogated and EP consulted

    • If electrical storm degrades to cardiac arrest consider vector change, double sequential defibrillation, and eCPR