Grand Rounds Recap 03.24.21
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MORBIDITY & MORTALITY WITH DR. MAND
Boerhaave’s Syndrome
Spontaneous esophageal rupture in an otherwise healthy esophagus caused by increased in intraesophageal pressure leading to complete transmural tear and gastric contents being expelled into the mediastinum
Mackler Triad: Chest, abd, and/or back pain (83% of cases); vomiting (79% of cases); subcutaneous air (27% of cases)
Excessive alcohol use was seen in 40% of cases per one study
Less than 50% of cases are diagnosed in the first 24 hours resulting in significantly improved mortality as compared to those diagnosed later
How to improve diagnosis:
Maintain a high index of clinical suspicion
Chest x-ray can have multiple abnormalities including: pleural effusion (L>R), pneumothorax, pneumomediastinum, surgical emphysema
Diabetic Ketoacidosis
A pH is of limited utility in diagnosing DKA; as Dr. Shaw would say, “Respect the bicarb.”
In a 2003 prospective observational study of 200 patients where ED physicians were asked to write down diagnosis and disposition after BMP but before VBG resulted, there was no change to diagnosis or disposition but providers were more likely to give SQ over IV insulin if the pH was higher than expected. Notably, a low pH correlated with a low bicarb.
While there is no data to support intermittent IV insulin, you can consider SQ insulin in mild DKA
If using SQ insulin, consider effectiveness of route of delivery, such as obesity as concomitant factor, and ensure appropriate response to therapy before determining level of care
Pediatric Cardiac Arrest
Epidemiology
Trauma is the #1 cause of death from age 1-21
One third of pediatric arrests are out of hospital
Less than 4% of ED deaths occur in patients less than 18
Based on 2 systematic reviews of out-of-hospital pediatric traumatic arrests, survival to hospital discharge ranges from 1.2% to 5.4% with even lower numbers for good neurologic outcomes
There is no definitive time criteria for termination of resuscitative efforts
Retrospective studies showed no survivors with CPR >= 15 minutes
European resuscitation council recommends stopping at >= 20 minutes
American Academy of Pediatrics recommends stopping at >= 30 minutes
There are no definitive medical criteria for termination of resuscitative efforts; factors that PEM physicians consider per one study:
Resuscitation-related factors: No termination until satisfied with quality of resuscitation
Parent-related factors: Parental insistence or expression of emotion; family presence
Patient-related factors: Age did not factor into PEM physicians decision to prolong resuscitative efforts but does impact general EM physicians, who are 2x as likely to prolong resuscitation beyond 25 minutes
Physician-related factors: Experience of providers
Fiberoptic Intubation Optimization
Glycopyrrolate is an anticholinergic agent used to reduce sialorrhea, bronchorrhea, and even bronchospasm; IV administration is preferred due to peak onset of 10-20 minutes as compared to 30-45 minutes for IM
Cho et al. Prospective double blind RCT of 78 patients showed shorter intubation times and improved airway secretions; application to ED population limited as these were healthy patients w/ normal anatomy in a controlled setting in the OR
Sub-total intubation for nasotracheal approach
Pre-load ETT to 12-15 cm at the nostril, which helps position the scope at the glottic opening and decreases secretions covering the screen; downside is increased risk of epistaxis
Reposition of patient with neck extension and vigorous jaw thrust
BRASH Syndrome
BRASH Syndrome is a combination of Bradycardia, Renal failure, AV block, Shock, and Hyperkalemia
Retrospective analysis reviewed >65K patients in Switzerland found only 8 cases that had all 5 criteria for a prevalence of 0.04%, though this is likely higher in the US due to higher rates of comorbidities
Bradycardia may occur at lower potassium levels and EKG changes can be atypical, such as lack of widening of the QRS
See images for pathophysiology & management
Choledocholithiasis
While thousands of patients have a cholecystectomy each year without any complications:
5% will have persistent symptoms, termed post-cholecystectomy syndrome, though it’s often discovered that symptoms are unrelated to biliary pathology despite the name
15% have an asymptomatic CBD stone, as intraoperative cholangiogram is not routine, but only 0.5-2% of those go on to have complications
Risk factors for residual symptomatic stone:
Longer operative time
Acute cholecystitis on initial presentation
Smaller stone (< 7 mm)
More stones (> 3)
Time to operation doesn’t matter with studies showing cases up to 18 years post-cholecystectomy
Review operative report to see if an intraoperative cholangiogram was performed
Test of choice is an MRCP if there is high clinical suspicion, given CBD dilation is expected after cholecystectomy
Wellen’s Syndrome
EKG findings, typically seen in V2-3
Type A = biphasic T waves (25% of cases)
Type B = deeply inverted T waves (75% of cases)
Signals critical stenosis of the LAD in a peri-infarct state
Early PCI has decreased rates of AMI and mortality
In the sentinel study, there were 145 consecutive patients admitted for unstable angina with 26 (18%) having an abnormal EKG consistent with what we now call Wellen’s. Nine were medically managed with 75% of those going on to have an acute MI within 23 days. None treated with early PCI went on to have an acute MI.
MED MAL PART 2 WITH DR. RYAN
Why do physicians get sued?
Failure to diagnose - the most common
Procedures performed improperly and/or medication errors
Delays in treatment (including those in the lobby), consultation, admission
Weak medical record
Overlooked labs/testing/orders and/or inattentive follow-up (pulmonary nodules, test results)
No informed consent
Poor discharge instructions
Turnovers
Medical malpractice defined:
The physician had a duty to treat, which starts at the moment the patient arrives on hospital grounds - including the parking lot
The physician breached that duty
There was harm to the patient
The harm was caused by the physician’s breach of duty
Logistics:
Case filing
Malpractice: One year from discovery to file (usually occurrence date in EM)
Wrongful death: Two years from discovery to file (usually date of death in EM)
Both can be extended by 180 days, which is very common
Timeline of case filing is why tail malpractice insurance, preferably for 2 years, is important when looking at job contracts
Types of courts
Court of common pleas: Criminal and civil cases; jury, non-teaching cases
Court of claims: Trial of fact; judge not jury, teaching cases
2005 Ohio Tort Reform
Limited non-economic damages (“pain and suffering”) to $250K or 3x economic impact maxing at $350K per injured, whichever is higher
Requires affidavit of merit, where a physician expert reviews the cases and opines that standard of care was breached
R1 CLINICAL KNOWLEDGE: HAND INJURIES WITH DR. STARK
Hand Exam
Inspect: Look for scissoring
Palpate: Joint tenderness, snuffbox tenderness
Assess tendons:
Flexor digitorum profundus: Flex DIP against resistance
Flexor digitorum superficialis: Flex PIP against resistance
Extensor: Lie hand on flat surface and lift fingers
Circulation: Allen test
Nerve exam:
Median: Okay sign; sensation to palmar aspect of first 3 digits
Ulnar: Peace sign, spread fingers, cross fingers; sensation to palmar aspect of digits 4-5
Radial: Thumbs up, wrist extension; sensation to dorsal hand
PIP Dislocation
Injury: PIP hyperextension leading to dorsal dislocation
Exam: Assess for lateral laxity while joint in extension and in 30 degrees of flexion; Elson’s test is to extend against resistant and is abnormal if DIP is in hyperextension
Dx: XR showing dorsal joint widening due to subluxation, “V sign”
Tx: Closed reduction, buddy tape
Boxer’s fracture
Injury: Fracture of 4th or 5th MCP from axial load
Exam: Volar angulation of MCP, may have associated fight bite
Dx: AP and lateral hand XR
Tx: Acute reduction if scissoring or angulation >30 degrees (more angulation tolerated as you go up in digits), immobilize in ulnar gutter though buddy taping has some evidence behind it
Lunate & Perilunate Dislocation
Injury: Lunate forced dorsally and carpus remains intact; perilunate is opposite, carpus dictated but lunate remains
Exam: Median nerve injury in 25% of cases
Dx: Commonly missed w/ lateral XR being key (ie. break in Gilula’s arc, piece of pie sign, spilled tea cup)
Tx: Urgent ortho consultation, immobilize in sugartong splint if reduced in the ED
Distal Radius Fractures
Injury: Bimodal, young with high energy mechanisms and elderly with FOOSH
Exam: Radial tenderness, swelling, deformity
Dx: AP, lateral, and oblique XR; CT may be needed if intraarticular
Colles’: Dorsally displaced extra-articular fx
Smiths: Volarly displaced extra-articular fx (fall on flexed wrist or blow to back of hand)
Die-Punch: Depressed fracture of lunate fossa of distal radius, which is intra articular (axial load injury)
Barton’s: Dorsally displaced intra-articular fx
Chauffer’s: Fracture of radial styloid
Tx: Closed reduction (hematoma block + manual traction, finger trap traction, or active traction/countertraction), immobilization with sugartong splint, some will need operative management based on various criteria
High Pressure Injuries
Injury: High pressure injury usually from a work/industrial-related incident -> chemical irritation -> inflammation -> secondary infection
Exam: Entry wound may look benign but do not be fooled
Dx: Clinical
Tx: Tdap, abx, elevation, immediate surgical debridement
Nailbed Laceration/Avulsion
Injury: Blunt trauma or crush injury
Exam: Laceration of nailbed, avulsion of nail
Dx: XR to evaluate associated fx
Tx: Remove overlying nail, repair with absorbable sutures, replace nail or foil to stent open nailbed
Subungual Hematoma
Injury: Blunt injury; if atraumatic, a/w Kaposi’s or melanoma
Exam: Collection of blood deep to mail
Dx: XR to evaluate for associated fx
Tx: Trephination if < 48 hours, warm water soaks BID for 7 days, avoid electrocautery if acrylic nail
R3 TAMING THE SRU WITH DR. HUNT
Resuscitative Hysterotomy
Indications: Maternal cardiac arrest, gestational age >20 weeks, classically within 4 minutes but clinical gestalt/decision is most important
Rose et al AJOG 2015: “If maternal condition is not rapidly reversible, hysterotomy with delivery should be performed regardless of fetal viability or elapsed time since arrest”
Pearls: Perform immediately upon arrival, should not be delayed to perform US, continue CPR if able to do so safely
Procedure steps:
Large midline vertical incision from xiphoid to pubic symphysis
Small vertical incision through the lower uterine segment with scalpel, then extend the incision with scissors
Deliver the baby and clamp the cord
DIC in Pregnancy
Systemic activation of coagulation leading to microvascular thrombi, which depletes platelets and clotting factors
Per one review of pregnant patients from 1980-2009, there was a prevalence of 3 in 10,000 cases
Not a primary disease process and not caused by hemorrhage alone
Etiologies: preeclampsia, eclampsia, HELLP syndrome, acute fatty liver, sepsis, amniotic fluid embolism, placental abruption, postpartum hemorrhage
Diagnosis is often clinical but can be made by laboratory abnormalities including thrombocytopenia, prolonged PT/PTT, hypofibrinogenemia, elevated D-dimer
Treatment is supportive (hemodynamic support & transfusion of platelets if <10K and FFP if prolonged PT/PTT or low fibrinogen) but ultimately requires treating the underlying cause
Final Pearls
Review autopsy reports, especially of difficult cases can be educational and provide closure
Take a moment on shift to decompress after difficult cases
