Grand Rounds Recap 02.03.2021
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Anatomy of a Research Project WITH Dr. Freiermuth
What’s your question?
PICO (population, intervention, comparison, outcome)
Searching for answers
Be mindful of who is synthesizing the evidence for you when using some of these resources
Pubmed
ACEP clinical policies
Journals
Cochrane Library
Uptodate
Hierarchy of Studies
High level to lower level evidence
Meta-analysis
Takes all evidence and tries to combine them all to find the net effect of all the studies
Randomized controlled trials
Experimental
Cohort studies
Analytical, longitudinal
Case control studies
Analytical, retrospective
Cross-sectional studies
‘Snapshot in time’
Case report series
Observational/descriptive
Case reports
Observational/descriptive
What did the study find?
Treatment effect
Associations
Descriptions
Hypothesis
Generating
Testing
Critiquing the Literature
Strength of evidence
Numerical system
Letter system
Very low to high
Bias
Selection
Performance
Detection
Attrition
Reporting
Conflict of Interest
What’s the next step? How to move your project forward?
Designing your own study
Starting with equipoise
Consideration of ethics
Logistics
Time, money, equipment, patient population
Get your info out there!
Results should be published, positive or negative
Be up front and explain limitations
Think about the next step
Please check out this resource! It is a website that Dr. Freiermuth shared. You can plug in your abstract and it helps guide you towards journals who may be amenable to publishing your research
https://jane.biosemantics.org
R1 Clinical Treatments: Open Fractures WITH Drs. Tillotson and Makinen
Open fracture = skin disruption that exposes environment to the bone
Common pathology (trauma)
About ⅔ blunt trauma
About ⅓ penetrating
Osteomyelitis - the overarching concern
Infected bone
High mortality disease
Systemic infection
Long antibiotic course
Loss of function or limb
High Incidence (2-55%)
Initial EM management can change outcome
Early antibiotic therapy
Wound debridement
What do you do first?
Trauma resuscitation (ABCs, MARCH)
Assess limb circulation
Immobilize
Neuro exam
Pain control
Gustilo-Anderson Classification
Developed in the 60-70s at Hennepin, modified in 80s
Risk stratification of open fractures
Type 1 = small skin violation, <1 cm
Type 2 = Laceration >1 cm, minimal soft tissue damage
Type 3 = extensive soft tissue damage
3a = high energy trauma, regardless of wound size
3b = extensive soft tissue injury with periosteal stripping and bone exposure, major contamination and bone loss
3c = open fracture with an arterial injury requiring repair
Alternatives to this exist but are not validated
Grade can predict organisms
Culture data from 60-70s
Type I and II = gram positive
Type III = gram positive and gram negative
Antibiotic choice
Standard therapy
Type I and II = 1st gen cephalosporin (Cefazolin)
Type III = 1st gen cephalosporin and gentamicin
EAST Guidelines recommends this
Gentamicin has ototoxicity and nephrotoxicity
Type III monotherapy
Emerging evidence to use ceftriaxone (Rodriguez et al, 2014)
Therapy duration
Type I/II = 24 hr
Type III = 72 hr, or 24 hr after closure
Irrigation/debridement
Saline, low pressure>high pressure, high volume
Remove obvious contaminants
Water contamination
Fresh water = zosyn
Salt water = zosyn and doxycycline
Soil/fecal contamination
Add metronidazole or zosyn for clostridium coverage
Can you have compartment syndrome with an open fracture?
YES! ‘Incomplete fasciotomy”
10% open tibial fractures can develop compartment syndrome
Ortho attendings / senior residents have 24% sensitivity and 55% specificity with palpation of legs in a study with cadavers
Traumatic arthrotomy
Joint capsule violation
Exam may have fluid seeping from joint
Most common joints are knee and elbow
Traditional diagnosis: saline load
Needs at minimum 50cc load, knee up to 200cc
40-50% sensitive, 95% specific when using 150-200 cc
Emerging evidence that CT can be a great tool for knee traumatic arthrotomy
Tetanus
Immunization status
Never = immunoglobulin + toxoid (and complete the series)
>5 years ago = give toxoid
<5 years = they are ok
Finger specific injuries
Tuft fracture = irrigation, no antibiotics necessary
Seymore fracture = IV antibiotics, hand surgery
R2 CPC: ITP WITH Drs. Ramsay and Nagle
Young adult male with a past medical history of substance use disorder and HCV presents from the justice center for epistaxis for 12 hours. He also reports a new onset rash on bilateral lower extremities. He notes gingival bleeding, joint pain, and BRBPR.
VS: temp 98.1, HR 82. BP 116/52, RR 16
Exam: Mild blood oozing at right nare, petechiae on palate and in lower extremities
Labs notable for Hgb 8.7 and Plt 3
BMP, LFT, coags normal
Differential
Thrombocytopenia
Increased destruction
Microangiopathy (DIC, TTP, HUS, HIIT, PNH, Scleroderma, APS, vasculitis, drugs)
Antibody mediated (ITP, HIT)
Autoimmune (SLE, APS)
Mechanical (prosthetic valve)
Decompensated liver disease
Vasculitis NOS
vW disease
Contaminated drugs/tox
Nutritional deficiency
Endocarditis
Congenital Disorders
Immune Thrombocytopenia
Primary - autoimmune platelet destruction without trigger
Secondary - autoimmune platelet destruction with trigger
HIV, HCV, HBV, Zika, Covid, H pylori, SLE, Malignancy
ITP testing
CBC, smear, coags, HIV, HCV, H pylori, Direct antiglobulin test, ANA/RF
The ED test: HIV
The diagnosis: ITP 2/2 acute HIV
ITP
Platelet count <100k
Platelets are being removed from circulation rather than clumping
50 case reports in literature of Covid Associated ITP
ITP could be early hematologic manifestation of undiagnosed HIV infection
ED treatment
Asymptomatic, platelets >30k, observation
Active bleeding, platelets <30k, steroids, IVIG
HIV
HIV test is recommended to be part of ITP workup
Acute HIV can have viral syndrome, but not all patients experience this
There are many shared challenges and shared solutions between HCV and HIV
R4 Simulation: Nicotinic Poisoning WITH Drs. Iparraguirre, Li, Makinen, and Mand
Simulation: Pediatric Nicotinic Poisoning
Case: 7 year old male presents via EMS to ED with chief complaint of seizures.
Initial Vitals: BP 100/65, P 131, RR 26, T 99, O2 Sat 93% on RA
History: Aunt found the patient seizing. Patient is generally healthy and aunt is unsure if patient took anything.
Exam: Appears postictal, diaphoretic, diarrhea, increased oral secretions, tachycardic
Lab work consistent with a seizure, negative ingestions, CT head negative
Patient Course: Patient seizes again, requires intubation, has increasing secretions, mom arrives with concern that patient drank vape fluid (nicotine), patient becomes more hypotensive and bradycardic, atropine is given and titrated for control of secretions and bronchorrhea, vitals slowly improve and patient is admitted to the PICU
Nicotinic poisoning appears similar to a cholinergic toxicity
It often presents biphasic: with initial tachycardia and hypertension and then hypotension and bradycardia
Secretions are increased everywhere: sweat, diarrhea, saliva, bronchorrhea
Atropine can be given, multiple doses often needed until secretions improve
2-PAM/pralidoxime unlikely to be beneficial in nicotinic toxicity
2-PAM is indicated in organophosphate toxicity
With the increasing vaping, nicotinic poisoning can become more common and ED providers should be able to recognize and treat this condition
Practice Oral Boards Cases
Thyroid Storm
Will often present with altered mental status, hyperthermia, and tachycardia
High mortality if unrecognized and untreated
Resuscitate, cool for temp control (central anti-pyretics will not work), beta blockers (propranolol), and thioamides (PTU or methimazole)
Will require ICU level of care
Afib WPW
WPW is a congenital pre-excitation syndrome
Atrial fibrillation can occur in up to 20% of symptomatic WPW patients (most will never have s/s)
Presents with wide complex, irregular rhythm
If wide complex, avoid AV nodal blocking agents
Avoid adenosine, beta blockers, calcium channel blockers, digoxin
Can decompensate into vfib/vtach
Procainamide is an appropriate antidysrhythmic agent
Synchronized cardioversion may be necessary
Ischemic/Low flow priapism
Urologic emergency
Can use penile ABG for diagnosis
Acidosis, hypoxia, hypercarbia
Penile nerve block can be used
Aspirate 25cc x2 from cavernosum or until detumesced
If persists, can irrigate cavernosum with cool saline, 10-20cc
If persists, can inject 100-200 mcg phenylephrine every 3-5 min
Consult urology if persistent
Be sure your patient can urinate prior to discharge
Pediatric Hair Tourniquet
Search for this on a fussy baby
Often on digits or penis
Depilatory cream (such as Nair) can be used to try and break tourniquet
May require cutting the tourniquet
If deeply embedded on digits, may require a dorsal slit procedure to remove
Appendicitis during pregnancy
This is the most common non-obstetric surgical emergency during pregnancy
Ultrasound can be used for diagnosis
Though often it is hard to visualize the appendix
MRI can be used for diagnosis
This is considered an emergent reason for MRI
