Grand Rounds Recap 6.26.19

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Morbidity and Mortality WITH DR. Colmer

Case 1: Meningitis

  1. The Classic Triad: Fever, Neck Stiffness, AMS

    • This study showed that in patients with meningitis, the classic triad was present in only 44% of cases

  2. Timing of Antibiotics

    • This study showed a delay of >6h conferred an 8.4 fold greater risk of death in patients with meningitis

    • Give effective dosing of those antibiotics as early as possible

  3. Steroids

    • This Cochrane Review showed reduced mortality with steroids only in cases of meningitis caused by Strep Pneumo. They also saw lower rates of severe hearing loss and neuro deficits in patients who received steroids.

Case 2: Return Precautions

  • Patients listen to return precautions. Take some time in writing these and make sure they are given verbally as well. Make sure you use simple, clear language. Be vague enough to be comprehensive, but specific enough so that patients know what to look for.

Case 3: Chronic Nausea and Vomiting

  • Haloperidol:

    • The HUGS trial showed that patients with gastroparesis who got haloperidol showed decreased rates of admission (10% vs 27%) with no adverse events

    • This trial compared conventional therapy to haloperidol, this also showed decreased rates of hospital admission and improvement of symptoms with no increased adverse events

  • Droperidol:

    • Black box warning does not apply to doses we typically use in ED (<2.5mg), see this post for more information

    • This study showed reduced nausea when given droperidol vs metoclopramide, prochlorperazine, or placebo

Case 4: Compartment Syndrome

  1. Opioids As a Risk Factor:

    • This study showed that 22/213 cases of compartment syndrome had heroin intoxication/overdose as cause of their compartment syndrome

  2. Reliability of Exam:

    • 6 P’s are classically taught in medical school. However, this study showed that many of these individual signs/symptoms are specific, but not sensitive

    • This study showed that overall sensitivity and specificity of orthopedic surgery physicians of detecting isolated elevated compartment pressures was 24% and 55%, respectively

    • Exam not as reliable as we may think

Case 5: Psychiatric Holds and Decisional Capacity

  1. Psychiatric Hold: important to know the various laws in the state you are practicing in. This is somewhat variable state to state.

  2. Decisional Capacity:

    • Definition via ACEP (patient must meet all of these):

      • Ability of understand information relevant to treatment decisions

      • Ability to appreciate the significant of the information

      • Ability to weigh treatment options and demonstrate reasoning

      • Ability to express a choice

CPC  WITH DRs. Jensen and Stolz

Infectious Mononucleosis:

  • Background:

    • Caused by Epstein Barr Virus, it is a Human Herpes Virus, there is a 90% prevalence by age 20

  • Transmission/Timeline:

    • Spread through oropharyngeal secretions (kissing disease)

    • Patients asymptomatic for 4-8 weeks

    • Triad of fever, lymphadenopathy, pharyngitis

    • 30% coinfection with GAS

  • Pathophysiology:

    • The virus enters B cells, this then changes the B cells in several ways

      • It can cause B cells to become atypical and make heterophile antibodies. These atypical cells are recognized by the rest of the immune system and eventually cleared

      • In rare cases the cells can become malignant (Burkitt lymphoma, T cell lymphoma, Nasopharyngeal Carcinoma)

  • Workup:

    • Monospot sensitivity: 40-60% in week 1 of symptoms, 80-90% in week 3-4 of symptoms

    • If treated with beta lactams (amoxicillin), can develop a rash

  • Liver Pathology

    • Mechanism generally unknown

    • In patients who have liver dysfunction, they typically have mild (3-5x normal) AST/ALT elevations (80-90% of patients)

    • Rarely (5% of patients), patients can have an obstructive pattern with elevated alk phos, direct bilirubin

    • These changes typically self-resolve without specific treatment

    • Liver failure is exceedingly rare

Platelet Function Testing WITH DR. Urbanowicz

Platelet Function Assays have been around since the 1960’s. However, many of these early tests were slow, and so were not helpful in the emergency setting. Platelet function can be assessed using TEG/ROTEM but they cannot discern what the cause of platelet dysfunction is. This is why tests were developed to discern dysfunction related to ASA or P2Y12 receptor inhibitors.

These three tests are TEG-PM (platelet mapping), VerifyNow, and Multiplate Aggregometry. This study compared these three tests. All three tests were able to successfully identify the presence of anti-platelet agents in patients on known anti-platelet agents.

But what do we do with this information? The Patch Study showed that those with ICH on anti-platelet agents who received platelets had worse outcomes than those who did not receive platelets. In general, platelet transfusion is not recommended in this population unless they are going for an intervention. Administration of DDAVP can be considered in patients on anti-platelet agents. However, this is still very much based on local practice patterns.

For more information, please see this post.

Tamingthesru: Severe Hypothermia and Rewarming WITH DR. Murphy Crews

  • Severe Hypothermia (<28 degrees Celsius)

    • Dysrhythmias (bradycardia, atrial fibrillation, ventricular fibrillation)

    • Hypotension

    • AMS

    • Coagulopathy

    • Hyperglycemia

  • Rewarming:

    • External

      • warm environments, warm blankets, bair hugger, arctic sun

    • Internal

      • warm IV fluids, warmed humidified air, thoracic lavage (right chest), IV catheters (Quattro), V-A ECMO

      • conflicting data on how quickly these measures work

    • If not rewarming as fast as expected: Consider other diagnoses

      • Myxedema Coma

      • Hypoglycemia

      • Adrenal Crisis

      • Sepsis

  • Can you pronounce someone who is hypothermic?

    • Yes, if one of the following conditions are met:

      • Temp >32 degrees Celsius

      • K>12

      • Frozen solid

      • Clear history of death before cooling