Grand Rounds Recap 3.20.19

navigating frozen waters- brain death in the era of therapeutic hypothermia WITH DR. bonomo

Brain Death and Organ Transplantation

  • Brain Death is the irreversible loss of neurologic function, as defined by clinical criteria or adjunctive testing

    • Clinical criteria include loss of all brain-stem and cerebral function in the absence of factors that could confound the subsequent examination (shock, hypothermia, electrolyte derangement, paralysis, neurologically depressing agents)

  • The Dead Donor Rule specifies that organ donation must not cause death of the donor.

  • Brain death is an indicator of legal death in some jurisdictions, allowing for organ donation of life-sustaining organs in those affected.

  • History

    • Denise Darvall became the first person to become a donor for a heart transplant after being struck in a motor vehicle accident in 1967

    • She had some preserved brainstem reflexes before donation, so was not brain dead by modern definitions

    • The United States had the technology to perform a heart transplant at that time, but could not due to the dead donor rule

    • It wasn’t until 1981 that the United States adopted the Uniform Determination of Death, which states that a patient with 1) irreversible cessation of circulatory and respiratory function or 2) irreversible loss of function of the entire brain, including the brain stem, is dead.

    • This definition is different than the definition of brain death, as it is possible to have cessation of circulatory and respiratory function on life-support without evidence of brain death.

Therapeutic Hypothermia

Accessory testing in the determination of brain death

  • Accessory testing can help aid in the diagnosis of brain death, but must be used in conjunction with clinical exam

  • Cerebral angiography

    • There is no gold standard for the amount of force to apply to inject contrast

  • Cerebral scintigraphy

    • There is institutional standard for the time to re-image in nuclear medicine testing for nuclear studies for brain perfusion

  • CT angiography

The Future

  • Moving forward, we must consider how increasing medical complexity and improved medical technology will affect determination of brain death.

  • We must also consider the implications of the dead donor rule on the future of organ transplantation.

R4 Case Follow-up WITH DR. harrison

PEA vs. Hypotensive Bradycardia

  • These can be difficult to distinguish, as palpable pulses can be difficult to detect in profoundly bradycardic rhythms, especially in the prehospital setting

  • This has lead to study of “pseudo-PEA”, or patient’s falsely thought to be in cardiac arrest due to absence of a palpable pulse

  • Palpation of a pulse can be difficult due to a number of confounders, including body habitus, peripheral artery disease, and profound shock.

PEA prognostication


Taming the SRU: r3 case follow-up WITH DR. Nagle



  • Aortic dissection is dissection through the aortic intima, which leads to blood leaking into the media

  • This occurs in 3.5/100000 patients per year

  • Even when optimized, mortality is 30%

  • There is a 1-2% mortality for every hour of treatment delay

  • Patients have a 38% misdiagnosis rate

  • Risk factors include bicuspid valve, aortic coarctation, male gender



  • Type A dissection (ascending dissection) require surgical and medical treatment

  • Type B dissection (descending dissection) require medical treatment

  • Medical treatment

    • Control pain (ex. fentanyl) to decrease endogenous catecholamines

    • Control heart rate and blood pressure to limit aortic stress (target HR of 60 and SBP of <100)

    • Utilize the right arm or arterial line for blood pressure management because the left circulatory system is more commonly affected by dissection

R4 Case Follow-up WITH DR. summers

PRES Syndrome


  • The cause is controversial, but thought to be due to impaired cerebral autoregulation leading to cerebral perfusion deficits in patients with hypertension

  • This was fairly recently discovered and defined in 1988

  • PRES is a clinicoradiological diagnosis of HA, AMS, seizures, or vision changes in those hypertension and with posterior leukoencephalopathy on imaging

Making the diagnosis

  • 70% with have seizure, 50% will have impaired consciousness, and 50% will have headache on initial presentation before confirming diagnosis

  • Imaging will show focal symmetric edema in the watershed zones

  • In 90% of diagnosis, the posterior brain is involved

  • Common risk factors include female gender, hypertension, and use of chemotherapy agents



Wellness curriculum: Resilience WITH Dr. leenellett

Physician Burnout

  • Up to 50% of medical students and 70% of residents report burnout

  • Emergency medicine has one of the highest rates of burnout

  • This is different than stress, as stress will improve with recovery time

  • Burnout leads to depersonalization and a lack of enjoyment derived from work

Why does this matter?

  • Physicans with burnout have more medical mistakes

  • They also have increased rates of substance abuse, suicide, and depression

How can residents develop wellness?

  • Pursuit and achievement of goals (purpose)

  • Building competence in their specialty (mastery)

  • Strong social relatednes, sleep, and time away from work can help develop wellness

Fixed vs Growth Mindset

  • In a fixed mindset, you believe people are born with a certain amount of ability and talent, and most work to show these abilities

    • This leads to fear of failure and a focus on appearing an expert

  • In a growth mindset, you believe that your basic qualities can be cultivated through effort, strategy, and help from others

    • This causes a focus on development and learning rather than appearing an expert


  • Resilience is the process of shaping the way you adapt to challenges and failures

  • How do we do this?

    • Identify who you are and what gives you meaning in your work

    • Identify three things that you are grateful for and thankful for each day

    • Form social network as this leads to the dynamic spread of happiness

    • Take care of your basic needs (eat, drink, sleep)

    • Recognize when you are feeling stress, and reach out for help