Grand Rounds Recap 9.20.23

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Universal HCV Screening WITH Justin Campbell, Pharm. D. and Kathleen Hildreth, Pharm. D.

  • Statistically, 1/10 patients who present to the emergency department have hepatitis C, with an estimated 2.5-3.5 million Americans living with HCV. Unfortunately, about half of those individuals are unaware that they have the disease. 

  • Approximately 15,000 people die per year due to HCV, even though there is a cure. 

  • Screening for HCV will lead to earlier identification and connection to treatment for these patients.

Sports medicine: Concussions WITH Dr. Gawron

  • There are around 2 million ED visits per year for head trauma, with approximately 75% of those visits being related to mild TBI or concussion. 

  • It is important for emergency physicians to be able to differentiate concussion from a more serious TBI that may require additional imaging or intervention. 

    • Clinical decision rules exist, however it is important that providers know how to use these rules appropriately to guide decision making. 

    • Sport Concussion Assessment Tool (SCAT) can be helpful in the assessment, especially in real time including athletic events.

  • It is important to appropriately educate patients and family on anticipatory guidance at disposition. 

  • It is important to appropriately educate patients and family on anticipatory guidance at disposition. 

  • Most patients can follow up with their PCP as an outpatient.

R1 Clinical Knowledge: Nonconvulsive Status Epilepticus with Dr. Guillaume

  •  The presentation of NCSE is variable, ranging from coma to mild confusion +/- subtle motor symptoms.

  • Patients with a history of seizures, supratentorial structural brain pathologies, post-arrest, or unexplained altered mental status should prompt suspicion for NCSE.

  • The diagnosis of NCSE is rarely made in the ED as it requires cEEG monitoring. However, Ceribell is a useful technology to help detect seizure activity and affect disposition.

  • Follow the same stepwise approach for the treatment of both convulsive and non-convulsive status: benzodiazepines, followed by AEDs, and in rare cases, followed by anesthetic agents.

Taming the SRU with Dr. Shaw

  • PRES is a clinical + neuroradiographic diagnosis that consists of acute neurologic symptoms such as headache, visual disturbances, seizure, or encephalopathy in addition to findings on CT head or MRI consistent with PRES. 

  • Two main theories behind the development of PRES. (1) acute increase in blood pressure overcomes the body's ability to regulate cerebral blood flow via autoregulation leading to inappropriate arteriole vasodilation and hypoperfusion causing vasogenic edema  (2) exposure to drugs are toxins which causes endothelial dysfunction leading to leaky capillaries and vasogenic edema. 

  • PRES most commonly occurs in the bilateral parieto-occipital region given the posterior circulation has less sympathetic innervation and is more susceptible to hyperperfusion. 

  • Emergency physicians should consider PRES in patients with altered mental status, seizures, and neurologic deficits who have risk factors for PRES. Heightened suspicion should be raised in those patients who are on immune-suppressive medications, those with renal disease and acutely elevated blood pressure

  • While non-contrast CT scan can show signs of vasogenic edema, expeditious MRI should be performed as this is the most sensitive and specific imaging modality for PRES

  • Seizures are often the presenting symptom of PRES and occur in a majority of cases. These are often seen as generalized tonic clonic seizures but can also be seen as non-convulsive status epilepticus. 

  • Treatment is focused on seizure management, blood pressure control, and removal of offending agents

R4 Simulation WITH drs. Diaz, Fabiano, And martella

  • The presentation of adrenal crisis is often nonspecific, so it is important to keep a broad differential in cases of undifferentiated shock.

  • The workup can and often reveals hyponatremia, hyperkalemia, and hypoglycemia, which should aid in making the difficult diagnosis.

  • Although adrenal crisis is rare, fluid non-responsive shock is not, and one should have an approach that aims to manage these patients, often including pressors and steroids.

oral boards cases

  • Beginning in 2023, the Oral Exam will have 5 standard single-patient cases and 2 structured interview cases.

  • Structured interviews are designed to assess the candidate's thought processes. You will be asked scripted questions to assess why you take certain actions, how you develop a differential and final diagnosis, and how you transition the care of the patient.

  • Sub-massive PE

    • Sub-massive PE is an important diagnosis to make in the emergency department, as it directs both ED and inpatient management of the patient such as anticoagulation vs thrombolysis, possible intervention, and level of care

    • Sub-massive PE can be diagnosed with findings of RV dysfunction including elevated troponin or BNP, new full or partial RBBB on EKG, or RV dilation or systolic dysfunction on TTE

  • Tumor lysis syndrome

    • Tumor Lysis Syndrome is most common in blood borne cancers, especially during the induction phase of chemotherapy.

    • It is important to recognize the associated laboratory findings including hyperphosphatemia, hyperuricemia, and hypocalcemia with an associated AKI.

    • Emergency providers should be familiar with the following treatments and their indications:

      • Rasburicase if uric acid > 8

      • Dialysis for AKI or renal failure

      • Calcium for EKG changes and/or severe symptoms including tetany