Grand Rounds Recap 3.30.22
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MORBIDITY AND MORTALITY CONFERENCE WITH DR. LOGAN WALSH
Abdominal Aortic Aneurysm
The classic triad of abdominal pain, pulsatile abdominal mass and hypotension is overall less common than we’d like, occurring in only 25% of patients
Of the individual characteristics, abdominal pain is most common (61%)
Misdiagnosis is very common
40% of ruptured AAAs are misdiagnosed
Carries a 74.6% mortality compared to 62.9% if accurate diagnosis occurs on first visit
Common ICD-10 codes when missed: renal colic, MI, nausea and vomiting
Aortic Ultrasound Review
Use curvilinear probe, can use phased array in thin patients
Requires 4 views: proximal, mid, distal and longitudinal
Steady probe pressure displaces bowel gas and is overall shown to not affect diagnostic performance
Measure outer wall to outer wall
Abnormal = >3cm for abdominal aorta with >5cm warranting urgent intervention
>1.5cm at common iliacs is abnormal
US is 99% sens and 99% spec detecting presence of AAA by ED bedside providers
Detects AAA alone, not great at assessing for rupture
US findings concerning for rupture (specific but not sensitive)
Thrombus inhomogeneity
Interruption of mural thrombus
Floating thrombus layer
Peri-aortic hypoechoic focus
Visible interruption of AAA wall
Adjacent hematoma
US cuts time to diagnosis nearly in half compared to CT
Unclear if associated with a survival benefit
Why does vascular still want a CT scan? For EVAR planning
EVAR with significantly lower in hospital mortality, respiratory complications, renal failure, mesenteric ischemia, blood product administration compared to open AAA repair
Pulmonary Embolism in Renal Transplant Pts
Kidney transplants have more than 2x risk of PE than the general population
40-60% of these PEs occur in first year after transplant
Early PE increases risk of graft failure
Why are they at such high risk?
Still have underlying conditions which are often prothrombotic
CKD at baseline has increased risk of thrombotic complication
Immunosuppressants carry increased risk of VTE, especially MMF and steroids
After transplant, patients develop relative erythrocytosis and nephrotic syndromes
Contrast in Transplanted Kidneys
Transplanted kidney are not just regular kidneys
Recipients have increased GFR at baseline and multiple comorbid conditions which will affect the transplanted organ (CHF, DM, etc)
Calcineurin Inhibitors (like tacrolimus) increase effects of vasoconstrictors
Not all contrast is the same: low or iso-osmolar contrast mediums carry less risk of CIN
3-6 % risk of CIN in renal transplant patients after contrast administration based on two studies
Used low osmolar contrast, relatively large recovery rate (71%)
Ultrasound for Diagnosis of PE
2019 ESC Guidelines have a 1C recommendation for use of bedside echocardiography in PE diagnostics and a 1A recommendation for presumptive diagnosis of PE in patients with high clinical suspicion and proximal DVT on ultrasound
Early Diastolic Notching
Easier and more specific than many other sonographic signs/tests (McConnell’s, 60/60, RV dysfunction)
Measurement of outflow velocity at level of pulmonic valve
Obtain from the Right Ventricular Outflow Tract view
From parasternal short view, slide/rock probe proximal
If “notch” in flow occurs within first half (i.e. starts <50% of way through total ejection time, is positive
92% sensitivity and 99% specificity for massive or submissive PEs
97% specificity in another study with all comers PE
High interrater reliability (K 0.87)
Fat Embolism
Incidence 0.17% in any fracture, 0.57% in femur fx, 1.29% in polytrauma
Usually occur 12-72 hours after injury
Other causes besides trauma
Sickle cell disease
Alcoholic liver disease
Liposuction
Bone marrow biopsy and transplant
Pancreatitis
Pathophysiology: fat cells from marrow transmitted into bony venous sinuses then systemic circulation which triggers platelet aggregation and fibrin generation
Do not follow typically anatomical distribution of venous extremity clots (i.e. end point in pulmonary vasculature) because fat molecules can pass through all capillary beds then into arterial circulation
After lodging in tissue, require breakdown by tissue lipases who byproducts cause vasogenic and cytotoxic edema
No good diagnostic test or score to identify fat embolism syndrome and remains largely a clinical diagnosis
Mental status changes (MRI w/ DWI changes)
Hypoxic Respiratory Failure
Usually seen as patchy infiltrates due to small alveolar hemorrhage
Not seen as a “PE” on CTPA imaging
Petechiae
Rarest finding, often in non-dependent areas
Treatment is supportive care
Low mortality (<10%), most recover fully
Anticoagulation not effective and is often contraindicated in these patients
ECMO can be considered in severe cases
Prevention: if traumatic injury-associated, operative fixation within 25hrs of injury substantially decreases incidence
Cardiac Tamponade
Occurs as a spectrum of disease related to timing and volume of effusion
Diagnosis by physical exam
Beck’s Triad performs poorly (10% sensitivity)
JVD is individual component that performs best (76% specificity)
Pulsus paradoxus is most sensitive and specific physical examination finding (82%)
Diagnosis by bedside ultrasound
US signs of tamponade
Right atrial systolic collapse
Plethoric IVC - most sensitive but not specific
Right ventricular diastolic collapse
Mitral valve inflow variation >25%
Ultrasonographic version of pulsus paradoxus
Obtaining the image: pulsewave doppler measurement from AP4 view of mitral valve comparing tallest and shortest spikes. If >25% variation, is positive
Most cardiac US packages have calculators for this
Must increase sweep speed to capture more beats
75% sensitivity, 91% specificity
Special Population: Pulmonary Hypertension
Mortality in pHTN pts w/ any effusion is higher than no effusion alone, even in absence of tamponade physiology
Carries higher associated risk of mortality than any other predictors commonly evaluated including gender, age, 6min walk test, Mean PAP, RAP
May not show many of the sonographic signs of tamponade due to increased right-sided cardiac pressures (especially RV free wall diastolic collapse)
MV inflow variation >25% still performs well and can be diagnostic in this pts
Acute Chest Syndrome
Sickle cell pts have markedly shorter life expectancy regardless of sex
Major causes of morbidity and mortality
Stroke - more common and at younger ages than general population
Myocardial infarction
Acute chest syndrome (ACS)
Pulmonary hypertension, venothrombotic events, avascular necrosis, CKD, sepsis, maternal-fetal complications, retinal artery occlusion and vision loss
Highly morbid
ACS accounts for ~25% of HbSS deaths
3% risk of death per incidence
Incidence rate 8.78 per 100 pt years
Pathophysiology
Microthrombi (17%) = direct adhesion of sickle cells to pulmonary vasculature
Fat emboli (16%) = marrow and avascular necrosis
Pneumonia (56%) = predominantly from viral and atypical organisms
Presentation
Often develops 1-3 days after onset of vasoocclusive crisis
Chest pain, fever, leukocytosis, pulmonary infiltrate on imaging
Imaging lags so keep high clinical suspicion in the ED
Treatment
Aggressive pain control
Blood Products Transfusions
Try not to exceed 1u PRBCs because leads to hyperviscosity and can worsen occlusive crisis
Indications: hypoxia, Hgb <5%
Goal Hgb >10g/dL to try and dilute out HgbS
Exchange transfusions
Indicated in patients with multilobar disease, multiorgan failure, hypoxia <85% or refractory to simple transfusion
Empiric CAP coverage (3rd gen cephalosporin + macrolide)
If cephalosporin allergy, use moxifloxacin specifically
Add vanc only if septic or very large infiltrates on imaging
Goal O2 sat >95%, remember pulse oximeters lead to underestimation of hypoxia in black patients
PALLIATIVE CARE & HOSPICE IN THE ED WITH VISITING PROFESSOR DR. KAREN JUBANYIK
Palliative Care:
Goal of palliative care is to improve the quality of life of patients and their families, through the prevention and relief of suffering by means of early identification, assessment and treatment of pain and other problems, physical, psychosocial and spiritual.
Rationing in healthcare is both inescapable and desirable. If we do not explicitly ration, implicit rationing will take place which is more prone to bias.
Advanced planning and conversations about end-of-life care are rare, even in patients classically considered high risk (cancer, elderly)
Surveys suggest the vast majority of elderly people want to die at home yet 70% die elsewhere
Why should we care about palliative care in EM?
More than 50% of patients >65yr visit an ED within their last month of life
Supported by 2012 ACEP Choosing Wisely Campaign → “Don’t delay in engaging available palliative and hospice services in the ED for patients likely to benefit”
Emergency providers can provide a relatively unbiased medical opinion as long-term providers tend to overestimate survival time for their patients.
Some states now have palliative care education as part of CME requirements
As of 2016, fewer than 50% of residencies had any palliative care teaching
Palliative Care Resources:
VitalTalk
EM Talk
Vitaltips app
PRIM-ER trial
EPEC-EM - 3 day training-the-trainer course
CAPC (www.capc.org/ipal)
Steps to incorporating palliative care into your practice
Identify appropriate patients: Ask yourself “would I be surprised if this patient dies in the next 6 months?” → if the answer is no, consider palliative care.
Symptom Management
Identify new diagnosis in conjunction with parallel goal setting
Arrange future care
Barriers to Palliative Care
Large regional variations in practice patterns and capacity affect care
Provider discomfort and biases
Systemic issues in medicine prevent conversations and default to high intensity care
Growth of hospitalist medicine
High turnover of providers on inpatient services, especially in the ICU
Sub-specialization in Medicine leads to less people considering big picture
Relative lack of payment for conversations
Patient and family information/education on severity, prognosis and effective treatment of illness is often limited and can be unrealistic
Severity and prognosis of illness
(Lack of) effectiveness of treatments
Language and cultural barriers
Hospice:
Hospice is a philosophy not a place, most is provided at home (also at SNFs, respite, free-standing centers, in-hospitals)
Exists to provide support and care for terminally ill persons with the aim of alleviating suffering and augmenting quality of life
Is interdisciplinary
Available to people who are estimated to have 6 months to live if the disease process were to take its natural course
Hospice care leads to decreased ED visits, hospital stays, intensive and invasive treatment
Common misconceptions about hospice:
is not “giving up” on care
patients do not have to give up their PCP
do no have to be DNR/DNI
does not hasten death
is not a permanent commitment
PSYCHEDELIC MEDICINE IN 2022 WITH VISITING PROFESSOR DR. KAREN JUBANYIK
Very much still in the research phase
Being investigated as adjunct treatment for mood disorders, PTSD, anxiety, substance use disorders, OCD, headaches, eating disorders
These conditions are very common in our ED population
In 2017, FDA granted Breakthrough Therapy designation for MDMA-assisted psychotherapy for PTSD
Psilocybin been shown to have significant decrease in clinician- and patient-rated measures of depression and anxiety in life-threatening cancer patients, with effects sustained at 6 months
Barriers to use of psychedelic agents in medicine
Competition with pharmaceutical companies
High cost and relatively low access
Lack of cultural acceptance by patients
Limited data
R1 CLINICAL KNOWLEDGE: HERNIAS WITH DR. CHARLES BROWER
Nearly 10% of people will develop some type of hernia in their lifetime
Broadly classified as reducible, incarcerated or strangulated
All strangulated hernias are incarcerated but not all incarcerated hernias are strangulated
Groin Hernias
Most common type of hernia
Male predilection although is still the most common hernia in females
Inguinal Hernias
Present as groin mass, usually more prominent when standing, coughing or straining. Often have been present for awhile but are newly painful.
Femoral
female > male (10:1)
Prone to complications including strangulation and incarceration
High rate of emergency surgeries (~40%)
Obturator
Rare, mostly occur in elderly women
Almost always present with partial or complete bowel obstruction
Carries nearly 20% mortality rate
Abdominal wall hernias
Ventral hernias
20% are incisional, usual result of excess wound tension or wound infections
Umbilical hernias - often acquired in adults (obesity, cirrhosis) - rarely strangulate but when do are deadly
Often congenital in pediatric patients, most spontaneously close by 2 years of age
Parastomal hernias occur in nearly 50% of ostomies
Spigelian and Richter Hernias - two rare types of hernias of the abdominal wall with very high misdiagnosis rates and associated morbidity
Diagnostic evaluation
Largely relies on physical exam
Leukocytosis is not sensitive nor specific
Electrolyte derangements are common
Lactate is often used by surgical colleagues to assess for strangulation and bowel ischemia.
2020 retrospective study showed lactate ≥1.46 was 84% sensitive and 86% specific for need of bowel resection in the OR when assessed in patients with known incarcerated hernias.
Plain films are not helpful
Bedside ultrasound can be a useful tool to identify hernia sac contents and assess for obstruction
Reduction tips and trick
Apply cold packs to hernia site
Aggressive analgesia
Trendelenberg positioning
Use two hands! Grasp and elongate neck of hernia with outward traction then with other hand slowly push on the proximal aspect of hernia at the site of the defect
Disposition and Referrals
Ok for watchful waiting: hernias with large fascial defects, asymptomatic or minimally symptomatic
Should get urgent referral: femoral, adult umbilical, spigelian and richter types
R4 CAPSTONE: IMPOSTER SYNDROME WITH DR. CHRISTA PULVINO
Imposter syndrome goes beyond feeling insecure and actually transforms into a sensation of dishonesty, feeling like you’ve tricked people into believing something you haven’t earned
It isn’t always about insecurity. Broadly, it is a constant state of imbalance between your perception and reality, which in all likelihood is just you experiencing the normal range of human emotion.
Buying into the imposter role limits your options to either reaching the unattainable ideal, or pretending you did
This is what makes you an impostor – it’s not the part where you’re failing, it’s the part where you are spending your energy on hiding rather than self improvement
“When you believe that everything is a weakness, you cannot make steps to improve your actual deficits” -Ajibike Lapite
Dr. Pulvino’s tenants to minimize imposter syndrome:
Be the adult
Remember, nobody was ever going to think you’re perfect
Be brave enough to be honest
Encourage a culture of safety amongst your colleagues
Work towards self awareness
Remember that your best is the best for that patient in that moment
Don’t isolate yourself
