Ground Rounds Summary 8/19/15

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Simulation - Clonidine Overdose

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  • 30 yo FM presents after having taking a handful of pills with the following VS: HR 45, BP 83/60, RR 8, 100% RA, T 98.  FS101. It gets better—there's a baby behind that baby bump.  
    • Ddx for AMS, hypotension and bradycardia? Tox, hemoperitoneum, spinal shock, myxedema coma, and a quite atypical sepsis. 
    • By EMS report this lady reportedly took a handful of unknown pills in an effort to harm herself. Remember to consider clonidine overdose in addition to beta blockers and calcium channel blockers. This lady found herself a bottle of clonidine and a near successful suicide attempt.
  • Clonidine by design obstructs sympathetic outflow centrally. The only way to keep these people alive is by giving catecholamines back ie epinephrine/norepinephrine drips.
    • Remember, beta blockers antagonize beta receptors and blunt the body's stress response including glucagon, epinephrine, cortisol, somatostatin levels. These now blunted endocrine responses cannot do their usual job of stimulating glucose availability (which they usually do in a shock state). Thus, beta blocker overdose results in hypoglycemia or normoglycemia. In contrast, calcium channel blockers will result in normoglycemia or potentially hyperglycemia.
    • Calcium channel blockers and beta blockers: Give calcium (Ca channel blockers specifically), glucagon, high dose insulin, intralipid, norepinephrine for hemodynamic support

Oral Boards with Dr. Hinckley

  • Case 1: 59 yo M p/w vomiting after a steak dinner that evolves into severe epigastric pain 
    • VS: T 101.4F, BP 94/54, HR116, RR26, 100%RR
    • Physical examination is significant for Hamman’s Crunch: a raspy heart sound synchronized with the heart beat that results from the heart beating against mediastinal air. Pathognomonic of the dreaded Boerhaave's Syndrome: esophageal rupture in this case due to recurrent vomiting
    • CXR: a large consolidative process and near white out of the left lung helping to confirm your suspicions
    • CT scanner down? No worries. Consider a gastrograffin swallow study. The sensitivity is slightly worse than barium, but there are less complications. This shows extravasation...
    • Time for treatment: IV antibiotics, NG tube (actually preferred if it goes through the defect) and a cardiothoracic surgeon. You may need a helicopter as well…
  • Case 2: 27 yo FM @ 34 wks pregnancy by US presents with fall onto abdomen with a fishy, inconsistent story of how she tripped over a toy... she has several recent ED visits for seemingly minor complaints.
    • Remember to screen for domestic violence and physical abuse, interviewing the patient alone if necessary. If you never ask, you may never know and never be able to give your patient the help they need.
    • Trauma in viable pregnancy (>24 wks) must be taken seriously regardless of relatively minor mechanisms and well appearing patients. Falls and other abdominal trauma can place the mother and fetus at significant risk of abruption. These patients need a pelvic exam to check for bleeding and cervical dilatation (remember to check that last US for signs of previa) and at least a period of observation in the hospital with continuous fetal heart monitoring under obstetrician supervision. 

Oral Boards with Dr. Stettler

  • Case 1: 24 yo FM p/w vomiting, abdominal pain, headache x 2 days.
    • BP 168/76, HR 122 RR 24, T 98.2, O2 98% RA
    • Don't forget to ask about LMP and/or hospitalizations. Nine months after this little lady's LMP she gave birth to a full-term, spontaneous vaginal delivery complicated by gestational hypertension. That was 6 days ago...
    • Exam: uncomfortable appearing, vomiting, moderate bleeding from cervical os, peripheral extremity edema, hyperreflexia
    • Labs: Proteinuria, transaminitis, thrombocytopenia
    • Sound familiar? She has postpartum pre-eclampsia and HELLP Syndrome (Hemolysis, Elevated LFTs, Low Platelets).
    • Pre-eclampsia/eclampsia can occur for up to 6 weeks after delivery. In this case the treatment is not delivery.
    • Rather: Give 6 g IV magnesium sulfate for neuro-protective properties and treat the blood pressure (labetolol and hydralazine are the classics). Admit these people to a high level of care with continuous monitoring under supervision by an obstetrician. 
  • Case 2: You respond to the cab of a truck in your ambo bay to find a new Mother bewildered to realize that her ever distending belly, significant weight gain, and abdominal pain was not merely something she ate--there's a fresh baby on the floor and it's still connected to an umbilical cord. Even more suprising is its floppy appearance and unsettling vital signs...
    • BP 40/palp, HR 50, T 97.2, O2 sat 75 %, RR undetectable
    • Step one: Soil yourself.
    • Step two: regroup.
    • A quick survey of the mother reveals a very well appearing slack-jawed look of confusion that is, aside from being attached to a body that is attached to a baby, overall quite reassuring. Ask your nurse to collect vitals, place an IV, draw blood, ensure she is not hemorrhaging and keep an eye out for changes in status. Your focus turns to the sick person amongst the two.
  • On to the main event. Oh, baby. Remember your neonatal resuscitation algorithm. The first steps are detaching from mother, stimulating, drying, warming and assisting respirations. Neonates and children are particularly prone to respiratory arrests and initial efforts (first 60-90 seconds of life) should be focused on airway and breathing.  Consider intubating between 60-90s post birth.
  • If, at 90 seconds post-birth, that heart rate remains anywhere from 0-60 after taking steps to optimize ventilations (~90s from birth) you should initiate compressions, administer epi, and consider hypovolemia and PTX.
  • For the purposes of oral boards, know your resuscitation algorithms front to back, back to front
  • Check out this link to the American Family Practitioners website to find an in-depth walk through of the neonatal resuscitation algorithm including a PDF of the algorithm itself
  • Finally, don't forget to check a FS! This child had a mother with DM and the child’s BS was 13. 

Oral Boards with Dr. Powell

  • Case 1: 67 yo male presents via EMS with AMS. The patient is obtunded and was found in a bathtub with a bottle of whiskey nearby.
  • VS: BP 110/54, HR 48, RR 9, T 82, 100% RA
  • This patient has profound hypothermia with a core temp of 82. Interestingly, in accidental hypothermia patients who have no other ongoing process (ie sepsis), vitals usually meet metabolic demands and the most important intervention by far is re-warming. 
  • Early, aggressive warming is warranted based on the degree of hypothermia.
  • Dysrhythmias are common and often refractory to interventions including defibrillation and cardioversion. You can try, and it is reasonable, to shock Vtach at least once and administer ACLS drugs (recommended at most half the frequency of normal ACLS administration) although again this may be refractory until the patient is rewarmed ie the old saying "they are not dead until they are warm and dead."
  • Methods of aggressive rewarming include high-low chest tubes, intraperitoneal lavage, and ECMO.
  • Active rewarming though less aggressive: Bladder irrigation, warmed IV saline, Bair hugger.
  • Yet again we will refer you to a summary of the approach to accidental hypothermia from a prior, incredible Grand Rounds lecture given by Drs. Mudd and Riddle (coming to a CPQE near you).

R1 Clinical Knowledge on ACS Guidelines and Updates on ACS with Dr. Colmer

  • EKG should be obtained within first 10 minutes of arrival
  • Fibrinolytics. Pulling this trigger should occur within 30 minutes of first medical contact
  • If concern for inferior STEMI, don't forget the right sided EKG
  • STEMI treatment: ASA, NTG, morphine, heparin, anti-platelets, beta blockers (beta blockers within 24 hours--not necessarily in the ED as they can precipitate hypotension, CHF, and… wait for it… death)
  • Clopidogrel: At some institutions loading in the ED has been controversial based on the concern that, if the patient has triple vessels disease, CABG is not optimal under its anti-platelet effects. This controversy may still exists at some institutions, but ours is no longer one of them. Clopidogrel. Fire away.
  • TIMI is valuable as a prognostic tool in patients who have non-STEMI ACS. The utility in the ED is difficult to ascertain because we do not always know the diagnosis. The usefulness in evaluating patients with diagnostic uncertainty is arguable and argued. 
  • The term Unstable Angina is currently under revision and will likely go away altogether… stay tuned. The current AHA term is non-STEMI ACS which includes NSTEMI and UA.
  • If employing an invasive strategy to manage non-STEMI ACS, ticagrellor has greater evidence of efficacy than clopidogrel and receives a higher recommendation from the AHA.
  • CK-MB for dx of MI? It’s dead. Don't use it. 
  • BNP has a 2BA recommendation as a prognostic tool for patients with ACS. 

R1 Diagnostics with Dr. Bernardoni on TEG/Coagulation Studies

  • INR of 3.0 corresponds to 30-35% of factors functioning vs 5-6 (10%) and >6 (a little less than 10%). The clinical implications of this however may be able to be presumed but have not been well characterized
  • TEG:
    • R time: How long it takes to form fibrin. Prolonged->give FFP
    • K time: time for fibrin to cross link caused by fibrinogen and achieve a certain kinetic strength. Prolonged->give cryoprecipitate
    • Alpha angle: measures the speed at which fibrin builds and cross links. Low angle->give cryoprecipitate.
    • Max Amplitude: Highest vertical amplitude of TEG corresponding to strongest platelet aggregation. Low amplitude->give DDAVP or platelets
    • Ly30: Amplitude at 30 minutes corresponding to clot lysis at 30 minutes. Low->TXA
    • Check out this awesome TEG review from LifeInTheFastLane
    • Our institution uses 55 as a guide to your transfusion triggers (R time>55, Alpha angle<55, MA<55)

R4 Capstone on Tactical EMS with Dr. Strong

  • Step 1 in the ED: ABCs. Step 1 in the field: Make sure your patient doesn’t kill you.
  • Drs. Selvam and Niziolek: great doctors. Poor law officers.
  • Participation with local law enforcement as a tactical EMS provider can be invaluable to the team and a great way to be involved in the community.

One Simplified Approach to Hyponatremia in the ED with Dr. McDonough

  • Step One: Determine the patient’s volume status via H&P + help from a BMP, serum osm, and urine osms (UCr and UNa helpful as well in order to calculate FeNa)

    • Normal urine osms: 250. 300+=concentrated. 200 and below=dilute.
    • Eg: High Uosm + normal to high serum Osm->hypovolemic
    • Eg: Normal to high Uosm + normal to low serum Osm-> euvolemic or hypervolemic
    • Eg: Low Uosm + High serum osm->Hypovolemic (diuresis vs diabetes insipidus)

  • Step Two: Are my patient's symptoms severe (seizures) or not (asymptomatic to mild confusion).  If severe Start with 1-2mEq/L/hr for a few hours. Once sx improving, can back off and resume 0.5mEq/hr, which is the non-severe goal.

    • 1LNS will change serum sodium in most adult patients max 1.3 mEq and most likely less so you can likely give with impunity. 250cc of 3% should not change more than 2mEq.

  • Case 1: Elderly gentleman from nursing home comes in smiling with a chief complaint of hiccups.

    • Serium Na 96, Serum osm 195, Uosm 250

    • This gentleman has a hypotonic dilutional hyponatremia with Uosms suggesting euvolemia. What's he got? Psychogenic polydipsia.  Apparently hiccups made this young man quite thirsty and he had been drinking a ton of water to get rid of them.

    • Treatment? Fluid restriction.

  • Case 2: 50 yo alcoholic arrives in the ED actively seizing

    • Serium Na 121, Serum Osm 220, Uosm 600.

    • This patient has a hypotonic dilutional hyponatremia and is euvolemic presumably with SIADH

    • Treatment? This man needs salt. 250cc 3% is a reasonable approach.

  • Case 3: Known alcoholic presents responsive to pain only

    • Na 117, Serum Osm 300, Uosm 650

    • This person is not hypotonic but is significantly hyponatremic as well as hypovolemic. They require not only salt (250cc 3%) but volume as well (1L NS)