Grand Rounds Recap - 10/8/2014

Quarterly Sim with Dr. Frank Fernandez

82yoF with multiple medical problems including Grave's Disease who accidentally stopped her Synthroid arrives altered, hypothermic, and bradycardic.

Differential diagnosis for profound hypothermia is fairly short: Environmental vs. Hypometabolism (sepsis is typically a mild hypothermia)

• The typical myxedema coma precipitants are infection, medication changes, or cold weather
• Sepsis + bradycardia, should make you think about hypothyroidism
• Consider evaluating hypothyroid patients for other metabolic issues as they are often co-morbid, especially SIADH
• Tx for myedema coma is fluids (pressors may not be as effective), T4 bolus and drip, but it is important to search for the underlying reason and treat that as well.
• Disposition should be the ICU
• Consider steroids in the ill hypothyroid patient as there may be some element of hypopituitarism leading to adrenal insufficiency

Important tip! - Check a glucose in each and every altered patient immediately

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Oral Boards Cases with Dr. Brandon Conine

• Polytrauma can be tough to keep track of when not looking at the patient so use the body diagram provided to keep track of injuries and interventions
• A thorough exam is vital to every patient every time, especially if they've had a trauma
• Address the patient's pain in all cases even if it's to say you're too unstable for pain medicine (then again there's always subdissociative doses of ketamine...)
• CXR is vital in any STEMI as you have to rule out widened mediastinum/dissection
• Dissection management with a STEMI is still beta-blockage (typically esmolol) for HR control, nitrate (for afterload reduction) and discuss with the appropriate surgical service

By James Heilman, MD (Own work) [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

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Oral Boards Cases with Dr. Sarah Ronan

Sick septic patients on oral boards means you can quickly and efficiently move through Surviving Sepsis guidelines.  Fluids, antibiotics, more fluids, pressors, PRN blood, and PRN intubation...pretty simple, right?

• Always find a source in your septic patients

Old person + headache = Temporal arteritis

• Temporal arteritis is often co-morbid with polymyalgia rheumatica, thus make sure ROS includes myalgias
• Steroid dosing and disposition depends on the degree of visual involvement

Consider dislocation in folks with significant joint pain after a seizure, classically a posterior shoulder dislocation

• Traction-counter traction with external rotation is classically described as the reduction technique, but these have a higher rate of needing to go to the OR for reduction

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Oral Boards Cases with Dr. Bill Hinckley

Not every elevated temperature is an infection, so be sure to think through a DDx each time, especially the higher the hyperthermia as this can be more indicative of medication-induced reactions, such as NMS

• Check carefully for rigidity or clonus in altered patients
• Treatment includes aggressive attempt to lower the temperature of NMS patients and then discuss the appropriate antidotes, including dantrolene and bromocriptine

Don't forget about esophageal rupture as one of the 6 deadly causes of chest pain

• While esophageal rupture can be picked up on CXR with associated pneumomediastinum and pleural effusion, the definitive test for this is a Gastrograffin swallow (as gastrograffin is less caustic to the mediastinum)

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Pediatric Visual Diagnosis

By Okwikikim at en.wikipedia (Transferred from en.wikipedia) [Public domain], from Wikimedia Commons

• Every suspected nonaccidental trauma patient should get a skeletal survey and if they are < 12 months a head CT
• Neonates often have spells of periodic breathing which is normal (aka pauses of 2-5 seconds followed by tachypnea, apnea is defined as no breaths for >20 seconds)
• Grunting is a neonates way of providing PEEP and indicates pathology
• HSP treatment is typically supportive care, but assess for proteinuria as ~25% develop nephritis
• There is not enough evidence to support empiric steroids for HSP unless they have severe disease and then discuss with a consultant
• Hydroceles should transilluminate

While there are plenty of reasons for an infant to be fussy, our job is to rule out the life threats which include: (SPITFACE)

• S - SVT, SBI (sepsis)
• P - Physical Abuse
• I - Intussusception
• T - Torsion, Tourniquet (hair)
• F - Foreign Body
• A - Acute Abdomen
• C - Congenital Heart Disease, Corneal Abrasion
• E - Electrolyte disturbance

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Pediatric Oral Boards Cases

Don't forget that on oral boards (and in real life) a fingerstick blood glucose is essentially a vital sign (especially in an altered patient)

• You need to determine if neonatal hypoglycemia is the primary or secondary problem (i.e. has the patient been too sick due to sepsis to eat and thus is now hypoglycemic)
• Hypoglycemia in the Neonate Differential Diagnosis:
  • Sepsis
  • Non-accidental Trauma
  • Endocrine/Congenital abnormalities (specifically consider Congenital Adrenal Hyperplasia)
• Treatment of Neonatal Hypoglycemia: Glucose via the Rule of 50...D50 tends to be too concentrated for their veins so calculate the correct weight-based dose by dividing 50 by the concentration of glucose you are bolusing.  For example, if you're using D10, 50/10= 5 cc/kg for an appropriate dose 
• If the patient is not profoundly ill from the hypoglycemia consider pulling a red top and putting on ice so endocrine/metabolic labs can be sent as once you give glucose many of these values can be altered

Intussuusception should be considered in any young child with abdominal pain (clinically from 6 months to 3 years)

• If you have a low pre-test probability of disease consider a 3 view abdominal x-ray and if there is air in the ascending colon on all 3 views this should sufficiently rule out the disease if you are not at a facility with abdominal ultrasound capability.