Grand Rounds Recap 3.15.23
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tamingthesru: Massive bee envenomation WITH dr. Yates
Anaphylaxis
Pathophysiology
Type 1 Hypersensitivity Reaction
IgE-mediated
Mast-cell degranulation of vasoactive materials
Reaction occurs in minutes
Clinical Definition:
Acute onset of illness with involvement of the skin, mucosal tissue or both + one of the following
Respiratory compromise
Reduced BP
Or, acute onset of illness with at least two of the following in the setting of a likely allergen:
Involvement of the skin/mucosal tissue
Respiratory compromise
Reduced BP (including hypotonia/collapse, syncope, incontinence)
Persistent GI symptoms
Anaphylaxis criteria can also be met with hypotension alone as a symptom if exposed to a known allergen
Treatment
Epinephrine
Alpha-1 Agonism
Vasoconstriction and increased PVR
Beta-1 Agonism
Increased chronotropy and inotropy cardiac output
Beta-2 Agonism
Decreased mucosal edema via pulmonary smooth muscle relaxation
Administration
0.01mg/kg IM
Max dose 0.5mg
Given every 5-15 minutes
If refractory hypotension epinephrine gtt
Can give 5-20ug IV boluses if needed while setting up gtt
Positioning
Passive leg raise
Fluid Resuscitation
H1 and H2 antihistamines
Steroids
No high quality data
Inhaled Beta-2 Agonists
Other treatment Considerations
Scene safety
Stinger removal
Africanized Bees
1957 – escaped lab in Brazil, subsequently colonized majority of Americas
1 sting: 140-150ug median dose delivered
Systemic symptoms typically > 50 stings
Lethal dose: 2.8-3.5mg/kg in human
Requires >1000 to be considered lethal
Includes melittin, phospholipase A2, hyaluronidase
Melittin: mainly responsible for the pain reaction
Phospholipase A2: responsible for large portion of allergic reactions
Hyaluronidase: Leads to faster distribution of toxin, also responsible for some of the allergic reactions seen
Melittin and PLA2 when form complex with melittin hemolytic factor which cleaves cell membranes, particularly hemoglobin, leukocytes, vascular membranes
Also individually and synergistically work together to break down skeletal muscle
Massive envenomation
> 50 simultaneous stings
Vague systemic symptoms
Complications:
Myocardial injury
Hypertension
Hepatic Injury
Rhabdomyolysis
Alkalinization of urine
Hemolysis
Acute Renal Failure
Disposition should be admission for observation given complications can be delayed for several hours with > 50 stings
R4 Capstone WITH Dr. Mullen
Cases and rants:
Marginalized patient populations deserve equitable treatment in the ED
Understand the triage note, but interview the patient with a clean slate to limit triage bias
Someone who normally walks and is not not walking is not normal – you must try and walk patients before discharge
PEs can look like anything; Sometimes luck brings the diagnosis
“Uncooperative” patients are not always behavioral and may portend real physiological distress
Meet EMS at the bedside – hearing information directly from the source is critical
Respect electrolytes
Understand and acknowledge the admitting physician’s comfort with accepting patients
Every patient is someone’s loved one
Life can be meaningful at any age
Parents are allowed to be concerned about their babies
Know your team member’s names
Protect your team and their wellness on shift
Give praise; we hear constructive feedback often but deserve to celebrate our successes
Hydrocephalus WITH dr. Stothers
Anatomy
CSF is produced in the lateral and third ventricle
Drains through the cerebral aqueduct into the fourth ventricle, then into the subarachnoid space
From here, CSF is absorbed into the venous system by arachnoid granulations
Physiology
Obstruction of flow of CSF between its production and drainage can cause increased ICP and symptoms of hydrocephalus
Obstruction can occur from tumors, intracranial bleeding, decreased drainage by arachnoid granulations, increased rate of CSF production
Monro-Kellie Doctrine = sum of the brain, CSF and blood is contained within a fixed volume within the skull
Clinical Presentation
Headache
Vision changes
Diplopia
Papilledema
Gait disturbances
AMS, coma, seizure
Death
Normal pressure hydrocephalus
Gait disturbances (94-100%), incontinence (78-98%), cognitive impairment (60-92%)
Diagnostics
CT Head
Enlargement of ventricles
Disproportionately enlarged subarachnoid space
Corpus callosal angle < 90 degrees
Evan’s Index
Ratio of the maximum width of the frontal horns of the lateral ventricles and the maximal internal diameter of the skull at the same level
Rough estimate of ventriculomegaly in NPH patients
CSF Tap for NPH
Remove 30-50cc’s
Wait 3-4 hours to evaluate response to therapy
Therapeutics
VP shunt
Catheter placed in the lateral ventricle with valve that can measure pressure
Distal tip empties into the RA or peritoneum
CPC: Brain tumor WITH Drs. Glenn and irankunda
Case: Isolated aphasia in a female patient diagnosed with a R parietal brain tumor on CT head
Brain tumor
Patients less than 30 - primary > metastatic
Presentation
Headache (50% of patients)
Worse in morning
Tension type 40-50%
Migrainous in 10%
Seizure
50-80% with primary brain tumors
10-20% metastatic brain tumor
Elevated ICP
Nausea/vomiting
Vision changes
Headache
Diagnostics
MRI Brain to characterize lesion
CT Chest/Abdomen and Pelvis to evaluate for primary tumors
In a case series of 227 patients, ~60% of patients with brain tumor had an identifiable primary tumor elsewhere
Management
Dexamethasone
Seizure prophylaxis is not indicated, but treat if patient presents with a seizure
Hyperviscosity syndromes (HVS) WITH dr. beyde
Hyperleukocytosis
WBC usually > 100k but symptoms can occur > 50k
5-30% of adult leukemias
Patients are functionally neutropenic
Infections are a leading cause of death
Sickle cell disease
Misshapen RBCs predispose to hyperviscosity
Simple transfusion cannot provide sufficient number of RBCs to lower percent of HgbS without causing hyperviscosity
Transfusion increases risk for autotransfusion
Waldenstrom Macroglobulinemia
Most common cause of HVS (up to 90% of all cases)
Rare type of NHL
More than 30% develop hyperviscosity
Malignant B cells secrete immunoglobulins
Presentation
Hyperviscosity triad
Mucosal bleeding, vision changes, neurologic symptoms
Mucosal bleeding is the most common
Mucosal bleeding
Naso-oral is most common, though GI and vaginal bleeding can occur
Platelet dysfunction
Neurologic Symptoms
Headache, stroke symptoms, ataxia, vertigo, hearing loss, coma, seizure, tinnitus
Vision changes
Painless vision loss, blurred vision, diplopia, fundoscopic changes
Optic nerve edema
Sausage link retinal veins
Hemorrhages
Exudates
Cardiopulmonary
Shortness of breath
High output heart failure
ACS
Acute kidney injury
Venous thromboembolism
Clues to increase suspicion
Cancer history
B symptoms
Lymphadenopathy
Mucosal bleeding
Dehydration
Ruddy complexion
Advanced age
Evaluation
CBC with differential
Evaluate cell lines
CMP
DIC labs (d-dimer, fibrinogen, coags)
Uric acid, LDH, phosphorus
UA
Peripheral smear
Rouleaux Formation
Serum viscosity
3-5 day turnaround
SPEP-UPEP
Imaging (CT head, CXR, MRI)
Treatment
Temporary
IV fluids
Phlebotomy
2-3 units replaced by 2-3L IVF
Definitive
Emergent plasmapheresis
Leukapheresis
Plateletpheresis
Anemia
Avoid transfusion before plasmapheresis
Will worsen symptoms
Broad spectrum antibiotics
Infection is a leading cause of death
Risk of Tumor lysis (10%)
Screen and treat electrolyte derangements
Hydroxyurea
50-100 mg/kg
Shown to reduce WBC by 50-60% in 24-48 hours
Chemotherapy
Only treatment proven to improve survival
The Language of being well WITH dr. arlene chung
Being able to accurately pinpoint how we are feeling is important and precision language is key
Burnout has been a longstanding issue, predating COVID
46% of physicians reported 1 or more dimensions of burnout (Shanafelt et al 2012)
72% of EM physicians reported 1 or more dimensions of burnout
Physicians in specialties at the front line of care access seem to be at the greatest risk
76.1% of emergency medicine residents report 1 or more dimensions of burnout (Lin Annals Emerg Med 2019)
Moral Injury with COVID
“We pushed aside our fear and frustration to focus on saving the patients in front of us; we kept our eyes open, and our feelings closed. As with soldiers in war, we know that as soon as we stop doing, we will start feeling.” (Dean Ann Emerg Med 2020)
Emotional Agility by Susan David, PhD
Being in touch with our inner emotional experience allows us to be more in touch with our lives in a more complex and intentional way
The readiness potential in our brains is activated and allows us to take action
Emotions are data and allows us to respond to them
Knowing what you’re feeling and knowing what to do about it (Barrett, Cogn Emot 2010)
53 subjects kept a diary of emotions over 2 weeks and their response to emotions
Ability to differentiate emotions is correlated with better emotional regulatory response
This was only true with negative emotions
Postulated to be adaptive response
Does not correlate with positive emotions
Emotional differentiation is a simple, easily trainable skill that is frequently overlooked
Plutchik’s Wheel of Emotions
Burnout
A job-related experience, characterized by emotional exhaustion, cynicism and reduced professional efficacy. Refers specifically to phenomena that occur in the occupational context and should not be applied to describe experiences in other areas of life.
Many think of burnout as a medical disease; this was never the intended use.
There are some emotions that are “okay” in medicine
Insecurity, depression, etc may not be viewed as “okay” emotions in a professional setting but may be labeled instead as “burnout”
Specific use of language is important
How to proceed
Mindfulness
Reflection
2800 physicians at Mayo were surveyed and found that leadership qualities of physician supervisors appear to impact the well-being and satisfaction of individual physicians working in health care organizations (Shanafelt, Mayo Clin Proc 2015)
Leadership score associated with decreased likelihood of burnout
Increased satisfaction with the department
Statistically significant correlation
Telling stories of our experiences in medicine is important and helps us to reflect, process and share emotions
“Stories are the avenue toward telling and, therefore, knowing of the self. Narratives trigger changes of many kinds in both the teller and the listener, yielding meanings that are reciprocally produced by each teller-listener dyad.” (Charon, Academic Med 2012)
embracing fear in emergency medicine WITH dr. arlene chung
What is fear?
Basic emotion
Social construct
Survival response
Personality
Physical Fear
Fear of heights, death, pain
Can have physical fear for someone else
Identity Fear
Fear of sense of self
Friend, leader, father/mother, daughter/son
Social Fear
Fear of isolation or being cast out
Fear of belonging
Fixed vs Growth Mindset (Mindset by Dweck 2006)
Fixed Mindset
We are born with all the abilities that we will ever have
Failure is a value judgment
Growth Mindset
Failure is another learning opportunity
I failed vs. I am a failure
Residency is an excellent time to cultivate the growth mindset
Hidden Curriculum
Doctors do not show weakness
The three most powerful words in emergency medicine are “I don’t know”
It takes courage to acknowledge deficits and limitations
Imposter syndrome
Imposter syndrome is fostered by fear of failure, fear of success and low self esteem (Traut-Mattausch Front Psychol 2016)
Leads to decreased career planning, career development, strive to succeed
The Armory (Dare to Lead, Brown 2018)
Mechanisms for self-preservation in the face of fear
Perfectionism
Numbing
Being right
Crush or be crushed
Cynicism/sarcasm
Absence of feeling fear does not lead to feelings of joy
Armor must be removed before we can embrace all emotions
Bravery
Quality or state of having the mental or moral strength to knowingly face fear, danger or difficulty
“It is not the critic who counts: not the man who points out how the strong man stumbles or where the doer of deeds could have done better. The credit belongs to the man who is actually in the arena, whose face is marred by dust and sweat and blood, who strives valiantly, who errs and comes up short again and again, because there is no effort without error or shortcoming, but who knows the great enthusiasms, the great devotions, who spends himself in a worthy cause; who, at the best, knows, in the end, the triumph of high achievement, and who, at the worst, if he fails, at least he fails while daring greatly” - T. Roosevelt
Courage is not a fixed trait and can be learned
Show up every day and do it again and again
Be prepared
Box breathing
Be human
It’s okay to feel a range of emotions
Be vulnerable
This is how we change the hidden curriculum
Be empathic
Be there for each other
