Grand Rounds Recap 3.27.19

Morbidity and Mortality Conference WITH DR. MURPHY

Cavitary Lung Lesions

  • Definition- lucent area contained within a consolidation, mass, or nodule

    • Acute <12 weeks

    • Chronic >12 weeks

  • Risk Factors

    • IVDU/Homelessness/Travel to Endemic Areas

    • Immunosuppression

    • Structural Lung Disease

  • Basic Approach

    • Identify risk factors

    • Establish time course

    • If a new cavitary lesion in a patient with risk factors, treat for abscess and rule out TB

  • Differential

    • Acute

      • Mycobacterial disease- TB more common in at risk populations, MAC more common in those with structural lung disease

      • Abscess- Typically unilateral and solitary, involves multiple organisms including anaerobes, so treat with anaerobic coverage (Clindamycin/Augmentin)

      • Septic Emboli- Imaging will show cavitations in various stages of development, treat the underlying source

      • Nocardia- Gram positive bacteria found in the soil, which will develop in those with a deficiency in cell mediated immunity (Stem-cell transplant, AIDS, leukemia/lymphoma)

      • Fungal pathogens- In immunodeficient hosts, can present with more invasive and severe pathogens such as mucormycosis, cryptococcus, invasive aspergillosis

    • Chronic

      • Fungal pathogens- In immunocompetent hosts, can present more indolent and be treated as an outpatient. Examples include histoplasmosis (the OH river valley), blastomycosis, chronic aspergillosis

      • Paragonamiasis- found commonly in ingestion of crab/crayfish, treated with praziquantel

      • Echinococcus- tapeworm found in dogs that forms liver cysts and elsewhere throughout the body

      • Malignancy

      • Autoimmune- including but not limited to rheumatoid arthritis and granulomatosis with polyangitis

Chronic Pain Management

Neuroleptic Malignant Syndrome

  • Background

    • A syndrome characterized by hyperthermia, rigidity, and altered mental status in the setting of antipsychotic use

    • Most often is symptomatic within the first 2 weeks of starting or up-titration of a antidopaminergic medication

    • Affects all age groups

    • Pathogenesis is unknown, but thought to be due to dopamine regulation in the brain of heat dissipation in the hypothalamus and rigidity in the corpus striatum

  • Diagnosis

  • Treatment

    • Stop the causative agent

    • Supportive care

    • Targeted therapy- no good evidence to support typical use of these

      • Dantrolene- skeletal muscle relaxant that inhibits calcium release, but can be associated with hepatotoxicity

      • Bromocriptine- dopamine agonist

      • Amantadine- has some dopaminergic and anticholinergic effects

    • Mean recovery time is 7-11 days with a 5-20% mortality

  • Clozapine

    • Typically used in the case of treatment resistant schizophrenia

    • 1-3% of patients will have neutropenia

Graft Versus Host Disease

  • Definitions

    • Allogenic Transplantation: transplant of cells to a recipient from a genetically non-identical donor

    • Graft Versus Host Disease: T-cells in the donated tissue recognize the recipient as foreign and therefore attack it

  • Risk Factors

    • 30-50% of those with allogenic cell transplantation have GvHD

    • Higher degree of HLA mismatch leads to higher likelihood of disease

    • Receipt of transplant from an unrelated donor increases the likelihood

    • Donor/Recipient gender disparity leads to higher likelihood

    • GvHD risk can be minimized by limiting risk factors, and starting patients on immunosuppression

  • Presentation

    • Maculopapular rash or bullae, skin sloughing

    • GI symptoms such as diarrhea with bleeding, mucositis, and nausea/vomiting

    • Liver disease and ascites, with lab testing showing early bilirubin and alkaline phosphatase elevations more typically than transaminitis

  • Treatment

    • Grade 1: Skin Involvement <50% TBSA

      • Topical steroids

      • Ensuring adequate underlying immunosuppression with methotrexate or mycophenolate and tacrolimus or cyclosporine

    • Grade 2 and up: anything else

      • IV Methylprednisolone 2mg/kg/d in divided doses

      • PO Beclomethasone/budesonide for GI involvement

Sepsis Without a Source

discharge, transfer, or admit: ENT/Ophtho/Dental  WITH DR. Lafollette

Quincke’s Edema

  • Swelling of the uvula, in the abensce of systemic infectious symptoms should be considered angioedema and treated as a Type 1 hypersensitivity reaction with (H1 and H2 blockers, steroids)

  • Disposition: Warrants observation, so consider transfer to a facility with ENT capabilities

Complicated Facial Lacerations

  • Exam- do a thorough neurologic exam to ensure no cranial nerve involvement

  • Anesthesia- use long acting anesthetics (bupivacaine) as more complex repairs typically take longer than one hour when solo coverage

  • Evaluate for need for muscle repair to ensure the subcutaneous layer approximates

  • Ensure adequate outpatient follow-up

Dental Fractures

  • Ellis System

    • Ellis 1- enamel involvement only, does not require coverage

    • Ellis 2- dentin involvement, requires coverage with calcium hydroxide paste

    • Ellis 3- pulp involvement, requires coverage with calcium hydroxide paste and may require root canal for pulp necrosis

    • All require rapid referral to dental

Transfusion reactions WITH DR. hunt

Febrile Non-hemolytic Transfusion Reaction

  • 0.1-1% of all transfusions, more commonly in children

  • Present with a fever of at least 1 degree celsius, thought to be due to cytokines

  • Products stored for more than 48 hours are more susceptible to this

  • Starts within 1 to 8 hours of transfusion

  • Management includes acetaminophen and supportive care

  • No role for acetaminophen or diphenhydramine premedication, as this can mask fever and more insidious transfusion reactions

Hemolytic Transfusion Reactions

  • 1 in 70k transfused units lead to these

  • Typically due to ABO compatibility, where the host’s immune system attacks the donor red blood cells

  • Presents with fever, renal failure, hypotension, tachycardia, and signs of DIC

  • Management involves halting the transfusion and supportive care

  • If oliguric, consider using furosemide to maintain UOP 1cc/kg/hr

Anaphylactic Transfusion Reactions

  • 1.7-4.3 per 100k blood transfusions

  • Due to some allergen in the transfused product, commonly in IgA deficient patients reacting to IgA, though has been seen in those who have peanut allergy post transfusion

  • Presents with rapid onset of shock, hypotension, lip swelling, respiratory distress, and GI symptoms

  • Stop the transfusion and treat with typical anaphylaxis medications (epinephrine, steroids, histamine blockers)

Urticarial Transfusion Reactions

  • 1-3% of transfusions

  • Present with isolated hives, but no fever or other system involvement

  • This is well tolerated, and the only transfusion reaction that does not require you to stop the transfusion

Transfusion Associated Lung Injury

  • Occurs in 1 in 5000 transfused units, and the leading cause of transfusion related mortality in the US

  • Occurs due neutrophil accumulation within the lungs that are activated during transfusion

  • Usually occurs in 1 to 2 hours, but up to 6 hours after transfusion

  • Presents with pulmonary infiltrates and hypotension

  • Manage with supportive care including airway management and halting the transfusion, paying attention to low tidal volume ventilation, similar to ARDS management

  • Daily breathing trials has been shown to decrease the time on the ventilator

Transfusion Associated Circulatory Overload

Transfusion Associated Sepsis

  • 1 in 30k RBC and 1 in 2k platelets have some level of bacterial contamination

  • Bacterial contamination is more common in platelets as they are stored at room temperature

  • Present rapidly with fever, rigors, tachycardia, and hypotension

  • Treat as you typically would treat sepsis (fluid challenge, pressors as needed, broad spectrum antibiotics, blood cultures)

Clinical pathologic conference WITH DRs. HALL And plash

Non-Convulsive Status Epilepticus

  • Presentation

    • On-going alteration and EEG confirmed seizure activity for at least 30 minutes

    • No major motor signs or symptoms (there can be some subtle motor signs of twtiching, eye deviation)

    • Changes in behavior or cognition (mild confusion to coma)

    • This is very difficult to diagnose. Of the 23 patients who were diagnosed with status epilepticus, only 13 were diagnosed within 23 hours in a retrospective review

  • Etiology

    • Acute events such as metabolic abnormalities, infections, structural lesions, medications and intoxication can cause this

    • Chronic insults such as remote history of stroke, head trauma, or anoxia can be susceptible to this

  • Diagnosis

    • Requires a high index of suspicion

    • EEG is the gold standard of diagnosis

    • Can do a trial of benzodiazepines if EEG is not immediately available, but not alway definitive

  • Treatment

    • No randomized controlled trials to guide our treatment

    • Should follow general seizure treatment protocols for status epilepticus

    • Identify and treat any underlying causes (medications, infection, intoxication)

Alternative ekg lead placement WITH Dr. Connelly

See Dr. Connelly’s Introduction post Here

 taming the sru: Refractory Septic Shock WITH DR. klaszky