Grand Rounds Recap 2.1.23
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R4 Case Follow-Up WITH Dr. Zalesky
Humility Hubris and Healing
Case 1
A case of a patient who presented during the height of covid with signs of sepsis. Patient was resuscitated and admitted. After they were admitted they were noted to have worsening shock and it was found that they had a necrotizing infection of their leg.
Learning points
Don’t anchor on pressure ulcers as they often are not the source of sepsis
Look at the feet of all sick patients as infections often can hide there
Be smooth and methodical in your clinical actions. Think about an economy of motion in all actions. Slow is smooth and smooth is fast.
Dogma
Rudeness has been shown to degrade team performance in the clinical setting. Creating a rude or hostile care environment can impact the quality of care delivered to patients. Seeking to avoid this and instead building an environment of collaboration creates a place that is better to work in and better for our patients
Case 2
Patient initially presented for back pain with a history of significant IVDU and discitis. After a prolonged ED course the patient eventually received a non-contrast MRI spine which was not the initial plan to evaluate for possible spinal epidural abscesses. This was negative. Patient was discharged. He returned a few days later in septic shock with endocarditis.
Learning points
Respect signout and ensure every patient still gets an honest moment of thought and review before final decisions are made.
Know your own biases and work to counterbalance them in the clinical environment. Don't let your pathology become your patients pathology
Closing
For this is the day you know too little
against the day when you will know too much
For you will be invincible
and vulnerable in the same breath
which is the breath of your patients
For their breath is our breathing and our reason
For the patient will know the answer
and you will ask him
ask her
For the family may know the answer
For there may be no answer
and you will know too little again
or there will be an answer and you will know too much
forever
- Excerpt from Gaudesmus Iggituar, John Stone MD
R2 CPC:Cecal Diverticulitis WITH Dr. Moulds and Dr. Goel
Diagnosis: Cecal Diverticulitis
Test of Choice: CT abd/pelvis - Cecal (right-sided) Diverticulitis
Accounts for 1.5% of diverticulitis in Western countries
Up to 75% of cases of diverticulitis in Asian countries
Initially thought to be separate disease process from left-sided diverticulitis
Pathophysiology
Fiber hypothesis
Genetic predisposition
Connective tissue degradation
Presentation
More common in younger patients
Less likely to be complicated than left sided
Differential: appendicitis, typhlitis, crohn’s disease, gynecologic, testicular torsion
Treatment
No clear treatment guidelines
Can be managed medically with antibiotics or surgically with colectomy or diverticulectomy with similar success rates
Recurrence risk is higher with medical management (16% vs 2%)
R1 Clinical Diagnostics: Lung Ultrasound WITH Dr. Artiga
Fundamentals
Artifacts depend on:
Hardware itself
Tissue harmonics
Spatial compounding
Frequency
Persistence
Post bandwidth
MI range
Operator-dependent factors
Use the correct preset
Use the correct probe
Linear probe
Superficial anatomy
Absolute best for PTX
Pleural line at 1/3-1/2 of screen
Curvilinear or Phased Array
Deeper structures to ~15cms
Adjust settings for gain and focal point
Image the correct area
PTX: One of each anterior lung
Pleural effusion: PLAPS-point of each lung
parenchymal disease: More views needed for localization
No standard protocol for every clinical context
Our protocol: 5 views + PLAPS
Anterior superior/middle/inferior
Lateral middle/inferior
PLAPS-point
Findings
A lines
Parallel to pleural line
Equidistant
Depth at multiples of distance between probe and pleural line
Attenuate
B-Lines
Originates at the pleural line
Does not attenuate
Traverses entire depth of scan
Moves synchronously with pleural sliding
Must obliterate A-lines
Evaluating B lines
Density
Semiquantitative: ≥3 within an ICS, ≥2 regions of lungs
Extent over lung surface
Laterality
Diffuse vs Focal
Sparing
Homogenous vs Heterogenous
Gradient
Gravitational-component
Intensity
No correlation to severity!
Pneumothorax
Look for Lung sliding or lung point
Linear probe
Pearls
M-mode
Subcutaneous emphysema
False lung points
Lung pulse
Pulmonary edema
Look for B lines
~6 views of the lungs total
Pneumonia
Newly infected tissue
Edematous → B-lines
Subpleural consolidations
~90% PNA involve visceral pleura
Shred sign
Consolidated lung tissue = subpleural hypoechoic region, irregular (shredded) border against normally aerated lung
Tissue-like sign
Hepatization
Air bronchograms
Static Air Bronchograms
Air trapped by fluid on both sides of a collapsed airway
Fluid bronchograms
Effusions
Effusion Types
Anechoic
Transudates
Homogeneously echogenic
Hemothorax
Complex non-septated
Complex septated
Pearls
Spine sign
Jellyfish sign
Plankton sign
Sinusoidal sign
R4 Simulation: THyrotoxicosis WITH Dr. COmiskey, Dr. Mullen, and Dr. Frankenfeld
Overview
Acute, life-threatening diagnosis of hyperthyroidism with multi-system involvement
Technically a clinical diagnosis
if the clinical suspicion is high enough, you should not wait to initiate treatment
Usually caused by a superimposed precipitating factors in the context of diagnosed or undiagnosed hyperthyroidism
Epidemiology
Rare presentation of hyperthyroidism, approx. 0.57-0.76 cases per 100,000 per year
Mortality estimated to be 8-25%
Most common with Grave’s disease
Pathophysiology
Underlying mechanism is not well understood, but thought to be caused by a surge of catecholamines and thyroid hormone
No correlation between the severity of disease and the level of hormone
Clinical findings
Hemodynamic consistent with sympathetic surge (tachycardia, hypertension, hyperpyrexia, tachypnea, may see hypoxia due to increased metabolic O2 demand and pulmonary edema)
Lab findings may be:
Hypercalcemia
Hyperglycemia (inhibition of insulin release and increased glycogenolysis)
Abnormal LFTs
Low or high WBC
Abnormal TFTs
· Several scoring systems: all based on clinical findings
Burch-Wartofsy Point Scale
>45 = thyroid storm
25-44 = less likely
< 24 = unlikely
Japanese thyroid association
CXR may help identify CHF/cardiomegaly
Head CT helps to rule out other CNS pathology
EKG useful to detect and monitor for arrhythmias
Treatment
Supportive measures
Treatment of underlying precipitating factors
Thyroid storm specific treatment:
1. Beta blocker
40-80mg of propranolol q4-6hrs
Chose cardiac beta-blockers in patients with underlying asthma (atenolol or metoprolol)
May also use diltiazem if there is an absolute contraindication
2. Thionamide
PTU: loading dose of 500-1000mg
Followed by 250mg q4hrs
Favored due to blocking of peripheral conversion of T4 to T3
Methimazole: 20mg q4-6hrs
Both drugs can cause agranulocytosis and should be monitored with routine CBCs
If initially started on PTU, the patient should be transitioned to methimazole due to hepatotoxicity of PTU
Pregnant women should be started on PTU and then transitioned to methimazole as well due to the teratogenic effects of methimazole in early pregnancy
3. Iodine solution
One hour after administration of thionamide, give 5 drops of supersaturated potassium iodide PO q6hrs
Must administer thionamide prior to iodine to prevent significant surge of thyroid hormone
4. Block peripheral conversion
Hydrocortisone 100mg IV q8hrs or Decadron 2mg q6hrs
5. Block enterohepatic recycling (severe cases)
Oral cholestyramine 4g q6hrs
Thyroidectomy may be the mainstay of treatment if the patient does not tolerate or has contraindications to medical management
Definitive treatment is radioactive iodine or surgical management
Will need to be treatment with exogenous hormone afterwards for iatrogenic hypothyroidism
Surgical complication of hypocalcemia (accidental removal of parathyroid glands)
Some refractory cases of been managed with plasma exchange
Disposition
Patients with confirmed or highly suspected thyroid storm should be admitted to the ICU for close monitoring
Will need frequent labs and medication administration
