Grand Rounds Summary - July 29th, 2015

Morbidity and Mortality Pearls with Dr. Curry

Nephrolithiasis

© Nevit Dilmen [CC BY-SA 3.0 (http://creativecommons.org/licenses/by-sa/3.0) or GFDL (http://www.gnu.org/copyleft/fdl.html)], via Wikimedia Commons

Incidence in the US is 0.5-1% (lifetime risk 10-15%). There is a 2:1 male predominance and the recurrence rate is fairly high (37% at 1 year, 50% at 10 years and 75% at 20 years).

Patients at risk for poorer outcomes with ureterolithiasis are those with risk factors for diminished renal function, history of difficulty with stones/urologic intervention and symptoms of infection.

Urinalysis 

• UA is only up to 90% sensitive for nephrolithiasis (with 0 RBC cutoff on microscopy)
• Sensitivity increases with higher RBC threshold, but specificity decreases precipitously

Abdominal Plain Film (KUB)

• Moderately specific (82%) but poorly sensitive (69%) for nephrolithiasis.

Ultrasound

• Moderately sensitive (88%) and moderately specific (85%) for hydronephrosis when compared to CT.
• Has the advantages of decreased cost, no radiation and improved patient progression.
• Disadvantages are that it doesn't give information about stone size or location, can be somewhat user dependent.

Ureteral stones up to 5 mm have a 68% spontaneous passage rate, whereas >5 mm this rate decreases to 47%.

American Urologic Association recommends that in selected patients who have stones <10 mm, no evidence of renal failure or infection, good symptom control and the availability of close outpatient follow up, a trial of medical expulsive therapy may be indicated.

“In a patient who has a newly diagnosed ureteral stone <10mm and whose symptoms are controlled, observation with a periodic evaluation is an option for initial treatment.””

— American Urologic Association. 2007 Guideline for the Management of Ureteral Calucli (http://www.ncbi.nlm.nih.gov/pubmed/17993340)

Bacteremia in OHCA

According to a 2014 study in the journal Resuscitation, 38% of patients with OHCA presenting to a single center were noted to be bacteremic. (http://www.ncbi.nlm.nih.gov/pubmed/24128800)

There was no difference in 28-day mortality, though patients who were bacteremic were more likely to die in the ED than their nonbacteremic counterparts.

The most commonly isolated species were Streptococcus and Staphylococcus species. 

In a different study in Resuscitation in 2013, they retrospectively evaluated the mortality of patients admitted to an ICU after OHCA depending on whether or not they received antibiotics. They postuled that post-ROSC syndrome and therapeutic hypothermia could easily mask symptoms of infection and that antibiotics could confer a survival benefit. All patients underwent therapeutic hypothermia. They report a statistically signficant improvement in survival at 30 days for patients who received antibiotics compared to those who did not. (http://www.ncbi.nlm.nih.gov/pubmed/23153650)

Bottom Line: Select patients with risk factors (immunosuppression/immunocompromise or chronic indwelling catheters) may warrant empiric antibiotics in the post-ROSC period if no other cause of arrest can be found. This area needs more research including prospective trials of empiric antibiotics.  

Malignancy with SIRS

Don't think febrile neutropenia, the patients neither need to be febrile nor neutropenic to warrant empiric antibiotics. A better term (and the name of our internal protocol) is malignancy with SIRS.

UCMC Protocol: http://www.emergencykt.com/extern/Febrile%20Neutropenia.pdf

Goal time to antibiotic administration is <2 hours.

Start with empiric Gram negative coverage. Add Vancomycin if there is a clinical indication. 

Clinical indications for the addition of Vancomycin

• Clinically apparent serious catheter related infection
• Blood culture positive for gram positive bacteremia
• Known colonization with PCN/Cephalosporin resistant pneumococci or MRSA
• Hypotension or septic shock
• Soft tissue infection
• Pneumonia

“Goal time to antibiotic administration: <2 hours
Empiric Gram negative coverage with Cefepime or Meropenem.
Add Vancomycin if there is a clinical indication.”

Post-Traumatic Seizures

Post traumatic seizures (PTS) can be divided into early (<7 days) and late (>7 days). 

Early PTS can be further delineated by immediate seizures which are defined either as seizure at the time of injury or within 24 hours. Early PTS is considered to be provoked, whereas late PTS is considered to be unprovoked. 

Prophylactic AEDs are indicated for the prevention of early PTS in sTBI patients, though they have no proven effect on outcomes. 

PTS is very rare in mild TBI. One study indicated the overall rate of seizures in mild TBI was the same as the baseline population without brain injury. 

Procedural Complications/Sterile Cockpit

Maintain "sterile cockpit" procedures in even the most emergent cases by trying to minimize distractions as best you can.

Resuscitative Thoracotomy

New EAST guideline released this month: http://www.ncbi.nlm.nih.gov/pubmed/26091330

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CPC with Drs. LaGasse and Bryant

Elderly female presents with tingling and progressive weakness over 5 days, legs >> arms

Differential diagnosis boiled down to Guillain-Barré Syndrome (GBS) vs Tick Paralysis vs Transverse Myelitis

Test of choice is lumbar puncture, diagnosis is GBS, indicated by cytoalbuminologic dissociation

GBS is thought to be immune mediated, often triggered by preceding infection (classically campylobacter)

Subtypes include demyelinating (N America & Europe) vs axonal

Management dictated by respiratory status, intubate for NIF < 20 cm water pressure

Treatment: plasma exchange (plex) or IVIG, performed within first 4 weeks of symptoms. Plex may work more rapidly

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R4 Case follow up with Dr. Loftus

42 yo male with headache for 6 days that is bifrontal, fever and neck pain developed today

Classic triad of meningitis are fever, headache, and neck stiffness

Absence of all 3 signs of the classic triad of meningitis indicates 0-1% of meningitis, anything more than this may require a lumbar puncture

Kernig, Brud, Nuchal rigigity are individually 5-30% sensitive

Physical exam findings can increase suspicion of meningitis but can not exclude the diagnosis

Ultrasound guidance may increase success rate of LP in obese patient

Bacterial Meningitis Score of zero may allow us to predict pediatric patients that are appropriate for discharge with presumed viral meningitis

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The Neurologic exam with Dr. Zammit

We must distinguish level of consciousness (arousal) vs content of consciousness (awareness)

Arousal is related to RAS or a global cerebral process, thus patients can be aware but not arousable, the classic example is "locked in syndrome"

Neurological Exam Pearls

• Mental status: Orientation, Attention, Front Lobe Signs
• Describe patient's mental status instead of assigning a broad label. Abulia: frontal lobe injury leads to preserved LOC but diminished motivation
• Gaze deviation:typically taught that gaze towards hemiplegia results from seizure and gaze towards unaffected side = ischemic stroke. The exception is a pontine stroke in which the gaze may be to the weak side
• Forced downgaze: dorsal midbrain compression

Herniation

• Uncal herniation results in classic unilateral dilated pupil
• Central hernitation can result in direct brainstem ischemic 2/2 torsion
• Tonsillar herniation can result in isocoria

Dysarthria: difficulty annunciating

Aphasia: deficits in understanding or expressing language

Pronator Drift: it can be subtle and manifested by finger spread, then curl, then pronation

Neglect/Inattention: evaluate confused patients from both sides to eval for inattentiveness

UMN/LMN: UMN hyperreflexic, LMN hyporeflexic. Clonus in UMN. 

Coordination/Cerebellar Exam: FTN go all the way to patient's arm length. Eval for both appendicular and truncal ataxia. ALWAYS walk your patients

Romberg: Tests cerebellum and proprioception

Asterixis: sign of encephalopathy- not specific to hyperammonemia

Tremor: Consider NCSE with subtle rhythmic movements

Vertigo: Clinical features can indicate peripheral vs. central vertigo. Peripheral usually has more nausea and vomiting. Central vertigo usually has more difficulty with ambulation. Peripheral vertigo should fatigue. 

HINTS Exam: "Verified" in a single center study with all exams performed by a single neuro-ophthalmologist. This is not verified for your average practitioner and cannot dependably rule out acute ischemic stroke.