Grand Rounds Recap 1.17.18

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LEADERSHIP CURRICULUM: LEADERSHIP AND FINANCE WITH DR. STETTLER

Definitions:

  • Return on Investment (ROI):  A way of comparing cost vs gain
    • (Gain from investment - Cost of Investment) / Cost of Investment
    • Example:  You sell a painting for 20 dollars.  It cost you 2 dollars to make
      • ROI = (20 Dollars Gain - 2 Dollars Cost) / 2 Dollars Cost = 9 (High)
      • This would be a good investment
  • Capital Budget:  Fixed amount of capital available over a dedicated period of time (Usually a year)
  • Fiscal Year:  Period used by governments / organizations for accounting and budgeting purposes.
    • Variable by organization

Approach to New Investment / Project - Things to Consider:

  • Cost of Investment
    • Consider capital required up front
    • Consider time and opportunity cost
  • Gains of Investment
    • Direct revenue
    • Indirect revenue
    • Intangibles
      • Education
      • Wellness
      • Personal investment/commitment of those involved

R1 CLINICAL DIAGNOSTICS:  THYROID STUDIES WITH DR. MAKINEN

For an Introduction, See Dr. Makinen's post from earlier this week

Thyroid Axis.png

Assessment:  Laboratory Studies

  • Thyroid Stimulating Hormone (TSH)
    • Highly sensitive
      • Responds rapidly to feedback mechanisms
    • 1st Line test
      • If normal, patient is almost always euthyroid
      • No need to order further studies unless convincing clinical scenario
  • Free T4
    • Reflective of global thyroid function
      • Important to interpret in context of TSH
    • Also considered 1st line test (Not necessarily as reflex after TSH depending on your local logistics of ordering)
  • Free T3
    • Use when concerned for hypothyroid
    • Study takes longer, not often in real time
    • Considered 2nd line test due to cost, access and typical relation to T4
  • Total T3, Total T4
    • Not as useful clinically due to multiple variables (protein, acute illness, etc)
    • Usually not helpful in ED setting

Diagnostic Algorithm:

ThyroidStudiesAlgorithm.png

Sample Cases:

  • Sub Clinical Hyperthyroidism
    • Symptoms:  Palpitations, mildly increased BP
    • Labs:  
      • TSH low  (Increased negative feedback)
      • Free T4 Normal
    • Diagnosis:
      • Sub-clinical hyperthyroidism
    • Management:
      • Symptomatic management
      • Outpatient follow up
  • Thyroid Storm
    • Symptoms:
      • Altered mental status.
      • Seizure-like activity lasting 2 minutes which abated with 10 mg IM Versed. 
    • Exam:
      • Vitals:  HR 130, BP 180/110, RR 22, SpO2 99% on RA, T 103.2 F.
      • Diaphoretic, tremulous and agitated.  Eyes are open, moving all extremities but does not follow commands or respond to questions. Exam is otherwise normal.
    • Labs:
      • TSH:  < .01 (Normal = 0.5-5)
      • Free T4:  6.8  (Normal = 0.61-1.76)
    • Diagnosis:  
      • Thyroid Storm
      • Use Burt-Wartofsky Scale
        • >45 indicative of thyroid storm
    • Management
      • Stop production
        • Prophylthiouracil (PTU)
          • Preferred outside of pregnancy
          • Still OK in 1st trimester
          • Can cause liver damage/liver issues
          • Avoided in 2nd and 3rd trimester
        • Methimazole
          • Preferred in 2nd and 3rd trimester of pregnancy
          • Available in IV form
        • Lugol's Solution (Iodine)
          • Only after PTU or Methimazole
      • Stop conversion
        • Propranolol
      • Block peripheral effect
        • Propranolol
      • Steroids
  • Euthyroid Sick Syndrome
    • Symptoms
      • Elderly patient comes in altered/obtunded
      • Chart review reveals a history of HTN, HFrEF (40%), hypothyroidism. Her medications are carvedilol, losartan and levothyroxine
    • Exam
      • Vitals:  HR 90, BP 90/50, RR 22, SpO2 85% on RA, T 93.0 F
      • Exam:  Oriented only to self. She is otherwise neuro-intact. She has increased WOB. Exam is otherwise normal.
    • Labs:
      • TSH 0.4 uIU/L (Ref 0.5-5.0)
      • Free T4 0.3 ng/dL (Ref 0.61-1.76)
    • X-Ray:  Pneumonia
    • Diagnosis:
      • Sepsis secondary to pneumonia
      • Euthyroid Sick Syndrome
        • Characterized by clinically euthyroid patient with decreased levels of thyroid hormones
    • Management:
      • Levothyroxine not indicated
      • Treat underlying condition
  • Myxedema Coma
    • Symptoms:  
      • Elderly patient comes in altered/obtunded
      • Chart review reveals a history of HTN, HFrEF (40%), hypothyroidism. Her medications are carvedilol, losartan and levothyroxine
    • Exam:
      • Vitals:  HR 60, BP 90/50, RR 10, SpO2 85% on RA, T 93.0 F.
      • Exam:  Altered mental status
    • Labs:
      • TSH 12.0 uIU/L (Ref 0.5-5.0)
      • Free T4 0.3 ng/dL (Ref 0.61-1.76)
    • Diagnosis
      • Myxedema Coma
        • Epidemiology
          • Usually older women
        • Symptoms
          • Hypotension
          • Hypothermia
          • Bradycardia
          • Shallow respirations
          • AMS
        • Common precipitants
          • Drugs (Amiodarone, lithium)
          • Levothyroxine non-compliance
          • MI/CHF
          • CVA
          • Bleeding
          • Trauma/Burn
        • Treatment
          • IV Levothyroxine
          • Steroids
  • A-Fib 2/2 Hyperthyroid
    • Diagnosed on EKG
    • Epidemiology
      • 10% of new A-Fib associated with hyperthyroid
      • Increased risk of stroke/hypertension
      • 50% convert back to sinus rhythm once thyroid is controlled (euthyroid)
    • Managment
      • Many suggest anticoagulation while patient is hyperthyroid, as CHADS VASC still seems to have validity in this population

CPC WITH DR. GAUGER AND DR. LOFTUS

Case: 

  • Hx:  Patient presented following an episode of syncope 3 days prior, with chief complaint of left shoulder pain.  Had an episode of syncope, fallen onto left side.  Endorses not feeling well, lightheaded, and shortness of breath with exertion. 

  • PMHx:  Previous DVT
  • Exam:
    • Vitals: All within normal limits
    • Exam:  Unremarkable
    • Labs:  CBC, BMP, Troponin all normal
    • CXR:  Normal
    • EKG

      • Rate of 100.  Sinus rhythm.  Up in 1 , down in AVF.  Borderline Left axis.  Likely normal though.  Intervals normal except maybe prolonged.  No ST elevations.  Borderline R wave progression.  T wave inversions in V1-V6, more in V1-V3.  Precordial and inferior T wave inversions.

Faculty Approach:

  • Summary:  
    • Episode of syncope
    • Maybe lightheadedness/orthostasis
    • Dyspnea on exertion
    • Concerning EKG
  • Differential
    • VINDICATE
      • Vascular
        • Aorta (Dissection)
        • Pulm Vasc (PE)
        • Carotids (Stenosis)
        • Coronaries (MI)
        • Vertebral Arteries (Dissection)
      • Inflammatory
      • Neurologic/neoplastic
        • Seizure
      • Drugs
      • Infection
      • Congenital 
        • Long QT
        • Brugada
        • ARVD
        • WPW
        • Vascular malformation
      • Auto-immune
      • Traumatic
        • Internal bleeding
        • Sub-diaphragmatic injury
      • Endocrine/Metabolic
        • Potassium
        • Calcium
    • Pain, dyspnea, and syncope helps narrow differential
      • PE
      • Dissection
  • Diagnosis
    • CTPA:  Assess pulmonary arteries and aorta
    • Found PE!

PE and Syncope

  • Background
    • Syncope is a common complaint in the ED
    • Represents 1-3% of all ED patients
    • Prevalence of PE in syncope is debated
      • PESIT Trial
        • Found 97 of 560 had PE (17.3%)
        • Much debated
        • Unrealistic patient profile in study
          • Elderly (Mean age 76)
          • 11.6 had active cancer
          • All had signs and symptoms concerning for PE
      • Zardahst et. al Meta-analysis
        • Pooled a total of 7583 patients
        • Found prevalence of 0.9% of PE in patients with syncope

CLINICAL SOAP BOX:  SHOCK WITH MICHAEL MILLER

Definition

  • "Shock is best defined as a life-threatening, generalized form of acute circulatory failure associated with inadequate oxygen utilization by the cells. It is a state in which the circulation is unable to deliver sufficient oxygen to meet the demands of the tissues, resulting in cellular dysfunction." - European Society of Intensive Care Medicine
  • Definition by numbers
    • Systolic BP < 90
    • MAP < 65
    • Drop in SBP > 40 from baseline
  • Types of shock
    • Septic:  MOST COMMON.  Separated from other forms of distributive shock because it is the greatest single entity we see causing shock
    • Hypovolemic:  SECOND MOST COMMON
    • Distributive
    • Cardiogenic
    • Obstructive

Evaluation of shock

  • "Windows" of shock:  Signs an symptoms
    • Neurologic
      • Obtunded?
      • Clammy?
      • Altered?
    • Peripheral
      • Cool skin
      • Clammy
      • Mottled
      • Flushed
    • Renal
      • Poor UOP
  • Biomarkers
    • Lactate
      • Most useful in septic shock
      • Best non-invasive marker for assessing severity of illness
        • ex.  MAP < 64 and lactic acid >4 portends a higher mortality
    • ScvO2:  Central venous oxygen saturation
      • Can be drawn from a central line
      • Helps assess balance of O2 consumption and demand
      • Interpretation 
        • Normal oxygen extraction is 25–30% which leads to a ScvO2 >65%
        • ScvO2 < 65% May signify:
          • Flow is poor
          • Increased oxygen demand in tissue
        • ScvO2 > 80%
          • Microcirculatory shunting
            • Severe sepsis
            • Liver failure
    • Veno-arterial carbon dioxide gradient (VA-PCO2)
      • Calculated by PcvCO2 – PaCO2
      • Measure of the ability of CO to diffuse across tissue
      • Helps estimate tissue perfusion
      • Normal is <6
      • Large gradient/gap may signify a shock state that could benefit from increased perfusion
  • Hemodynamic monitoring
    • Arterial pressures (A-Line)
      • Allows for repeat arterial blood gases
      • Continuous pressure monitoring
      • Assess pulse pressure variation
    • ECHO
      • Rapid evaluation of shock etiology
      • Proposed 1st line modality
      • Advanced monitoring
      • May be able to help guide inotropy use, though this is debated in the literature
    • Blood pressure monitoring
      • Goal MAP >65
      • However, patients with baseline HTN may benefit from a higher goal MAP

What the future holds / things to look forward to

  • Continual non-invasive monitoring
  • Ergonomic monitoring tools
  • Wireless adaptable sensors/wearable sensors
  • Smart software, algorithms that change in real time

Dr. Miller's 10 lessons learned:

  1. Clacium Chloride:  Works well as a temporary pressor
  2. 1/2 dose ketamine works well as an induction agent in tenuous patients
  3. Usually better to shoot broad on sepsis workup  (May include cross sectional imaging)
  4. Arterial lines are helpful
  5. Call ECMO team early if the patient is a candidate
  6. Push dose epinephrine is handy in the crashing/peri-arrest patient
  7. Hemorrhagic shock can be hidden.  Consider it in the patient that does not improve with standard interventions
  8. ECHO early and often
  9. If considering gram negative sepsis, cover for it early
  10. 500cc bolus: Great fluid challenge to assess for responsiveness.  Rarely will 500cc cause significant harm.

TAMING THE SRU:  BLEEDING FOLLOWING NECK SURGERY IN A LARYNGEAL CANCER PATIENT WITH DR. TIM MURPHY

Procedures performed in laryngeal cancer:

  • Endoscopic/Laryngoscopic
    • Visualization with endoscopy or laryngoscopy
    • Local excision only
  • Cordectomy
    • Removal of vocal cord if tumor involves vocal cords
  • Pharyngectomy
    • Removal of pharynx
    • Often create a neopharynx
  • Laryngectomy
    • Parial
      • Several variations
    • Total
      • Remove entire larynx
      • Attach trachea to stoma in neck
      • 2 types
        • Primary:  Removal of larynx prior to chemo or radiation
        • Salvage:  Chemo and/or radiation first to shrink tumor, then laryngectomy
  • Neck Dissection
    • Radical neck dissection:
      • Removes lymph nodes in zones 1-5
      • Removes internal jugular vein
      • Removes sub-mandibular gland
      • Removes sternocleidomastoid
    • Modified
      • Varies
      • Spares some non-lymphatic structures

Complications of laryngectomy

  • Early complications
    • Bleeding/hematoma
    • Carotid artery blowout (hemorrhage of any part of the artery)
      • Types
        • Type I:  Exposure of artery
        • Type II:  Minor bleeding that resolves (Sentinel bleed)
        • Type III:  Acute carotid blowout
      • Risk factors
        • Radiation therapy
        • Wound infection
        • Flap necrosis
        • Fistula
        • Tumor invasion
        • Trauma
        • Extensive surgery
      • Management
        • Reverse any anticoagulation
        • Give blood/resuscitate as needed
        • Take to OR if unstable
          • Worst case, ligate carotid
          • Other options
            • Destructive:  Vessel embolizaion  (May be able to embolize specific branch and spare carotid)
            • Constructive:  Stenting  (Higher risk of re-bleeding)
        • If stable, consider CTA
    • Infection
    • Wound breakdown
    • Pharyngeocutaneous Fistula
      • Abnormal fistula between pharynx and skin
      • Common complication (15-35%)
      • Usually 1-2 weeks post op
      • Risk factors
        • Poor wound healing (Salvage, extended or radical neck dissection)
      • Management
        • Conservative
        • NPO
        • Wound Care
        • Antibiotics
        • May need surgery at some point to correct
  • Late Complications
    • Stomal stenosis
    • Pharyngeoesophageal strictures
    • Hypothyroidism

Learning points

  • Step by step approach to patient with bleeding post laryngeal or other ENT surgery
    • Call for help (Consult appropriate surgical service / mobilize possible operative need)
    • Assess the airway
    • Assess hemodynamics
    • Consider if you are able to stop the bleeding
    • Be prepared for common complications
      • Pharyngeocutaneous fistula (1-2 weeks)
      • Carotid artery blowout = most feared

MASTERING MINOR CARE: EPISTAXIS WITH DR. WOODS CURRY

Epistaxis

  • Background

    • 90% are anterior bleeds (Kesselbach's plexus is most common source)
    • 10% are posterior bleeds (Sphenopalatine artery)
    • Common age groups:
      • <10 yo and >70 yo
  • Approach to epistaxis
    • Gather equipment
      • PPE
      • Light
      • ENT Cart (Suction, packing materials, speculum, etc)
    • Blow out nose
    • Topical vasoconstrictor
      • Oxymetolazine (Consider mixing with lidocaine)
      • Cocaine (Anesthetic as well as vasoconstrictor)
    • Direct pressure

                     REASSESS:  IF BLEEDING CONTINUES...

    • Anesthetize
      • Lidocaine (4% atomized with MAD, viscous 2%)   Mix with afrin!
      • Cocaine 4%
    • Cautery
      • Only in anterior bleeds
      • Only if source is visualized
      • Must keep field dry while cauterizing
      • DO NOT:
        • Use electrical cautery
        • Cauterize both sides of septum
        • Repeat cautery within 4-6 weeks of prior cautery
      • Downsides
        • Painful
    • Packing
      • Anterior bleeds
        • Nasal tampon (Rhino rocket is example)
          • Polyvynal acetate sponge
          • Expands when wet
          • Contains hemostatic properties
          • Consider moistening/soaking with TXA for additional benefit
          • May dry, be painful to remove
        • Rapid rhino
          • Balloon that inflates to tamponade bleeding
          • Types
            • 5.5cm anterior
            • 7.5cm anterior/posterior
            • 9cm with 2 balloons for significant proximal sphenopalatine bleeding
        • Additional/supplemental hemostatic agents
          • TXA
          • Thrombin
      • Posterior bleeds 
        • Risk factors
          • Elderly
          • Coagulopathy
        • Diagnosis
          • Significant hemorrhage out of oropharynx
          • Pouring out of bilateral nares
          • Failure to control with anterior approach
        • Posterior packing
          • Can use foley
            • Tip is to cut distal portion beyond balloon to prevent gagging, vagal reflex
            • No more than 10mls into balloon
          • Dual balloon catheters exist
  • Dispo
    • IF successful with Afrin and pressure =>  DC to home with afrin and return precuations
    • IF successful with anterior packing =>  Plan for discharge with follow up in 48-72 hours
    • IF successful with posterior packing => Admission and observation, usually with antibiotics (Augmentin)