Grand Rounds Recap 3.27.24
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Morbidity and Mortality learning points with Dr. Yates
Critical Limb Ischemia
Critical limb ischemia is a clinical diagnosis that needs to be recognized early to reduce significant morbidity and mortality
Diagnosis is primary clinical but can be enhanced with diagnostic studies such as ABIs, arterial duplex, CTAs, and/or MRA
Therapy should be initiated immediately, starting with heparin and a discussion with vascular colleagues for endovascular thrombolysis vs. surgical revascularization
Patients will likely require further specialists for wound debridement or amputation, infection control with antibiotics, and further management of underlying disease process
DRESS Syndrome
DRESS syndrome is a commonly missed diagnosis due to its latency period and many different potential causative agents
DRESS syndrome requires three different criteria to make the diagnosis: it must be associated with a drug reaction, the patient must have hematologic involvement, and internal organs must be involved
Management of DRESS syndrome must include prompt withdrawal of the causative agent along with additional supportive therapy and likely systemic corticosteroids
Arterial Lines
Intra-arterial blood pressure monitoring is favored when patient’s require continuous hemodynamic monitoring, repeat blood gases, and/or NIBP is not trusted for accurate blood pressures
Cannulation placement should be chosen carefully based on patient anatomy and potential complications
The modified Allen’s test has limited use and poor sensitivity in the emergency department for predicting likelihood of hand ischemia
Elderly Abdominal Pain
Elderly patients are more likely to present atypically, later in their disease process, and with less predictable vital signs
The most common surgical diagnosis for elderly patients is biliary tract disease, but keep in mind extra-abdominal etiologies such as MI or pneumonia as the cause of abdominal pain
History, physical exam, and laboratory assessment may be nonspecific or altered based on the patient’s chronic medical history and medications, so a low threshold for imaging should be used
Dabigatran Overdose
Dabigatran is a highly used NOAC that works on the common pathway of the clotting cascade
Dabigatran is greatly affected by renal clearance, and therefore concern for overdose should be high in cases of acute renal failure
In cases of intentional or accidental overdose and major bleeding/hemorrhage, Idarucizumab and dialysis have the most benefit, but may not be as readily available as PCCs which have limited effect
Fournier’s Gangrene
Fournier’s Gangrene is a rare but often fatal disease, with mortality rates staying largely unchanged for the past 25 years
Expeditious and appropriate antibiotics along with quick time to the OR significantly decreases morbidity and mortality
Systemic infections can be associated with acute myocardial ischemia, and should not always be attributed to type II ischemia
clinical pathologic conference: hypomagnesemia WITH drs. joshi and lang
Magnesium is a cofactor in >300 enzymatic reactions including nucleic acid synthesis and mitochondrial reactions.
Hypomagnesemia causes concurrent hypokalemia and hypocalcemia, which can present with tetany, muscle cramps, cardiovascular manifestations, and neurologic manifestations including psychosis/delirium and a stroke mimic: hypomagnesemia induced cerebellar syndrome
First time psychosis deserves a full medical workup prior to diagnosis. Avoid implicit and anchoring biases.
r1 clinical knowledge & THerapeutics: tracheostomy emergencies WITH dr. gallen
See Dr. Gallen’s full post here!
Not all tracheostomies are the same – it is imperative to communicate these details to ENT:
Size and type/brand of tracheostomy tube
Indication & date of placement
Whether or not the patient can be intubated from above
Note that different brands may have different inner cannula diameters (i.e. a 6.0 of one brand may not have the same inner diameter as a 6.0 of a different brand), which is important especially if the patient needs to be scoped
Total laryngectomy patients: a unique challenge from an airway management standpoint because their airways are not contiguous with their nose or mouth
The patient’s larynx, including the epiglottis, thyroid and cricoid cartilage, and vocal cords are removed, and the trachea is disconnected from the oropharynx and reattached directly to a skin opening in the anterior neck
These patients cannot be intubated nasally or orally
Mature tracheostomy tubes (~7-14 days or after confirmed trach exchange) can be exchanged/replaced in the emergency department
If a replacement tracheostomy is not available, an endotracheal tube can be used in the stoma
Placing the tube over a flexible scope can assist with confirming correct placement of the tube which is particularly helpful in tenuous circumstances
If unable to replace the tube in the stoma, intubate from above
Obstructed tracheostomies can typically be managed by deflating the cuff (if present), removing and cleaning the inner cannula, and suctioning through the tracheostomy to clear thick secretions or crust around the end of the tube
The National Tracheostomy Safety Project algorithms for tracheostomy and laryngectomy patients can help providers navigate emergency situations
Life threatening hemorrhage associated with tracheostomies secondary to a tracheoinnominate artery fistula is rare (<1% incidence) but highly morbid (85%)
Roughly half of patients will have a sentinel bleed, so it is important to have a high index of suspicion if this occurs
Emergency management of hemorrhage includes overinflation of the cuff and/or finger tamponade in the stoma with anterior pressure placed on the innominate artery. Definitive management is operative.
