Grand Rounds Recap 2.21.24

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Morbidity & Mortality WITH Dr. Finney

  • Case 1: MVC​

    • AMA, especially in pediatrics, is a high-risk disposition that requires thorough discussion and documentation​

    • Approach pediatric blunt abdominal trauma with a thorough physical exam and consider decision making tools when applicable​

  • Case 2 & 3: Found down​ and Hypoglycemia​

    • Renal replacement therapy & bicarb drips can be useful in management of severe metabolic acidosis in the setting of AKI​

    • Be cautious when dosing bicarb as it has an effect on other electrolytes and volume status

  • Case 4: Groin Pain​

    • Spontaneous RP hematoma is rare, but frequently missed on initial presentation; it carries significantly morbidity & mortality​

    • Have a high index of suspicion in coagulopathic patients when having nonfocal abdominal symptoms and utilize CT for diagnosis​

  • Case 5: Altered Mental Status​

    • Acute on chronic liver failure is a severe subset of acute decompensated cirrhosis with intense systemic inflammation and high short-term mortality​

    • Cerebral edema is less common in chronic liver disease; manage ICP supportively and consider dialysis for severely elevated ammonia​

  • Case 6: Respiratory Distress​

    • SCAPE is a clinical diagnosis that requires prompt recognition and management​

    • Utilize high-dose nitroglycerin, as well as NIPPV with frequent hemodynamic reassessments

R1 Diagnostics and therapeutics WITH Dr. Snyder

  • NIBPs estimate blood pressure measurements based off proprietary algorithms 

  • The jury is still out on how accurate NIBP is compared to arterial pressures but is less reliable with higher doses of norepinephrine, lower MAP value, higher BMI, and increased patient age.

  • Central arterial lines are more accurate in critically ill patient and fail less often than peripheral lines  

    • Axillary arterial lines may be a good option to obtain central pressures in patients with high BMI 

  • Waveform morphology can help you identify a number of pathologic states 

  • Incorrect transducer placement and zeroing can overestimate MAP 

  • The fast flush test can help you assess if your system is appropriately damped and guide troubleshooting efforts

r4 Case Follow up WITH Dr. Wosiski-kuhn

  • Fat embolism syndrome happens 1-3 days after injury or procedure​

  • Nontraumatic causes of fat emboli exist, such as pancreatitis

  • AMS + respiratory failure + rash​ should make you concerned for this syndrome

  • Push for an MRI when concern for fat embolism is high can help elucidate the pathology

R2 clinical Pathologic Case WITH Drs. Wilson and Curry

  • Drugs are bad, but you should know how to use them safely

  • Ecstasy and MDMA like drugs cause hyponatremia via salt wasting, polydipsia and SIADH

  • Acute, symptomatic hyponatremia can be given up to 300 cc's of 3% NaCl over 30 minutes.

  • Urine drug screens might offer context to a clinical encounter, but are unlikely to change your management