Grand Rounds Recap 4.12.2017

R4 Clinical Soapbox with Dr. Philip Mudd

A Case: A middle aged male shows up at 8 AM with sore throat, subjective fevers, and URI symptoms. He had a strep swap performed which was negative and was treated symptomatically for URI. He returns 5 days later with persistent symptoms, body aches. Again, he has a relatively benign exam with mild oropharyngeal erythema without tonsillar edema, exudate, unchanged from before.

On the second visit the patient was tested for HIV and found to be positive. He was likely in the acute viral phase during both presentations.

Can we diagnose acute HIV in the ED? Yes, most patients have some symptoms during their acute infection even if they are nonspecific. 

How prevalent is acute unrecognized HIV? Even when the absolute prevalence is low, a considerable proportion of undetected HIV cases in an ED population are acute.

Who is most at risk for HIV transmission in our population? Sharing needles during IV drug use and receptive and penetrative anal intercourse are higher risk that penetrative or receptive vaginal intercourse.

Can we prevent HIV-1 transmission in at-risk individuals? Yes! And highly effectively.

CLINICOPATHOLOGIC Case Conference with Dr. Harrison vs Dr. Roche

The case: middle aged male with PMH of alcoholic cirrhosis with esophageal varices s/p banding and TIPS procedure who presents for left upper abdominal pain which is worse with coughing. He also complains of distention, nausea. On exam he demonstrates jaundice, mild wheezing, abdomen is non-tender to palpation with distention but no obvious fluid wave. Additional pertinent findings include: spider angiomata, no asterixis.

Labs show INR 1.4, Ammonia 125, otherwise unremarkable. Paracentesis reveals 605 nucleated cells with 25% neutrophils and ~1000 RBCs.

Dr. Roche's differential for abdominal pain in patient's with cirrhosis:

  • SBP
  • Pancreatitis
  • Gastritis/UGI ulcer disease
  • Surgical causes (appendicitis, cholecystitis, SBO, perforation)
  • HCC/Hepatoma
  • Portal vein thrombosis
  • ACS
  • AAA

Dyspnea in cirrhosis:

  • PE: Coagulation balance in liver failure - inability to produce some clotting factors increases bleeding risk but decreased protein C and S increases DVT/PE risk as well.
  • Pleural effusion

Nonsurgical TIPS complications to consider in the acute period just after the procedure:

  • Hepatic encephalopathy
  • Rapid progression of right heart failure
  • Worsening hepatic failure

SBP is a dangerous diagnosis so even if the tap is not a slam dunk for SBP, if your clinical suspicion is high it is not unreasonable to admit for observation and serial examinations while awaiting results of the culture.

Dr. Roche's Test of Choice: CTPA
Diagnosis: PE

The actual test of choice: CTA Biphasic Liver
The actual diagnosis: acute occlusion of the TIPS

Transjugular Intrahepatic Portosystemic Shunt (TIPS)

Shunts blood from the portal vein to the hepatic vein to relieve venous congestion and prevent life threatening esophageal bleeding.

  • Patients have less re-bleeding than with banding but will have more encephalopathy.
  • No difference in mortality between the two.

Complications of TIPS:

  • Dysfunction (occlusion or stenosis)
  • Transcapsular puncture
  • Intraperitoneal bleed
  • Hepatic infarction
  • Fistulae
  • Hemobilia
  • Sepsis

How to assess for TIPS dysfunction:

  • Portal angiography is the goal standard
  • Doppler ultrasound (sensitivity 53-100%, specificity 62-98%)
  • Helical CTA (sensitivity 97%, specificity 89%)

TIPS Thrombosis: 2 year revision rate is 70-90%

Interpreting the Urinalysis with Dr. Jared Ham

Read his primer on the UA.

Case 1: Dilute Urine (low specific gravity)

  • Consider causes for dilute urine: diabetes insipidus, psychogenic polydipsia
  • Ask about headaches, vision changes

Diabetes Insipidus:

  • Central versus Nephrogenic (central is more common)
  • Test of choice: 24 hr urine collection, however you can diagnose with a random urine and serum osmolality

Case 2: Dark urine with bilirubin and normal urobilinogen

  • Direct hyperbilirubinemia due to cholestatic process
  • Urobilinogen is normally present in urine in a small amount, however when elevated this can indicate hemolysis

Case 3: Large blood in urine

  • Hematuria (many causes!)
    • Kidney stone
    • Malignancy
    • Infection
  • Myoglobinuria (particularly if there is large blood on dipstick but RBC count is normal on micro)
    • Rhabdomyolysis - check renal panel, total CK, LFTs, check compartments, give fluids to goal UOP 200-300 cc/hr
    • Myositis
    • Burns

Case 4: Sterile pyuria

  • Pattern: negative nitrites, + leuks on dipstick and WBCs on micro
  • Can come from irritation from nearby infection (appendicitis)
  • Could still be UTI from a non-gram negative organism

CPQE: The discharge of low risk patients with pulmonary embolism
Dr. Alexa Sabedra and Dr. isaac Shaw

 Why should we discharge some patients with PE?

Hospital admissions for PE are expensive.

  • Most admissions are a three day stay
  • Average cost was more than $5000

Some patients are likely safe to discharge with PE.

Early studies of patients with PE that were treated at home:

  • 14 early studies
  • Heterogenous definitions of "low risk" PE
  • Largest prospective study with 152 patients
  • One death related to hemorrhage
  • VTE recurrence: 0-6.2%, f/u in three months
  • No PE related mortality

Risk Stratification Rules

Addition of biomarkers does not necessarily improve prognostication.

The sPESI is a good screening tool for low risk PE when appropriate exclusion criteria (such as those from the HESTIA study) are also applied.

Barriers/Eligibility for Outpatient Medications:

  • Insurance prior authorization; 48-72 hours
  • Free month trial card online
    • Medicaid/Medicare D not eligible
    • Most practical for patients who have private insurance or are internet savvy

Stay tuned for the upcoming CPQE protocol for more details!

Pediatric Ultrasound with Dr. Riham Alwan

Fast Examination in Pediatrics

  • Sensitivity 52%
  • Specificity 96%
  • Negative predictive value 97%

In adults the RUQ is the most frequent location of free fluid however in children free fluid is most often found in the pelvic window.

Using ultrasound to evaluate for appendicitis:

  • Use the linear probe in a systematic fashion scanning the RLQ
    • Look for the psoas muscle and iliac vessels
    • Look for the appendix lying over or medial to the psoas
    • After starting there, if you don't find it use a "mow the lawn" technique to search as you move throughout the RLQ
  • Findings to look for:
    • Fat stranding
    • Diameter (extra-luminal at the maximum diameter: 6mm or less typically normal)
    • Compressibility (should be compressible)
    • Free fluid

Point of care ultrasound in PEM: Summary of the Evidence

Other indications:

  • Hip ultrasound
  • Intussusception

Management of Dental EMergencies for the Emergency Physician
Dr. MCmahon and Dr. Dagher

  • Adult teeth are numbered 1-32 however a description including name, laterality, and maxillary/mandibular is perfectly acceptable
  • Dental trauma: check out
    • Root fractures:
      • evenly distributed between fractures of the cervical, middle, and apical portions of the tooth
      • the closer a fracture is to the root tip, the better the prognosis
      • often require stabilization
    • Crown Fractures
      • Ellis classification
        • Class I: Enamel only
        • Class II: Enamel and dentin (cream colored layer)
        • Class III: Enamel, dentin, and pulp (cream and pink colored layers - painful)
        • Class IV: Cementum, dentin, and pulp
      • Exposed pulp should be covered to prevent infection/pain (our dental carts include calcium hydroxide paste for this purpose) - this temporizing measure should be followed with rapid dental follow up for definitive treatment
  • Dry Socket
    • Classic Symptom Triad (3-5 days post extraction): pain, malodor, bad taste
    • Occurs from loss of blood clot in socket, may show necrotic debris
    • Treatment options
      • Anesthesia (nerve block or local)
      • Irrigate with saline
      • Curettage to induce bleeding and create new clot
      • Dressing, paste, gel foam placed in socket

Taming the SRU with Dr. Walker Plash: Mass Casualty

On a dark and stormy night, Dr. Plash receives pre-notification of a mass shooting with at least 12 injured.

First steps:

  • Notifying and mobilizing the trauma team and OR staff
    • Anesthesia
    • Anyone who can wield a scalpel
  • ED Staff: RNs, medics, PCAs, X-ray technicians
  • Getting the department ready
    • Preparing the SRU
    • Discharging as many patients that are ready as possible

Lessons learned:

  • Have someone available to triage less severe injuries to places other than your most high acuity area
  • Have more stretchers available
  • Remembering that you still need providers to manage sick medical patients - a patient that was actively seizing showed up during this MCI. The ED doesn't shut down to other patients.
  • Adopt the principles of MCI even in mini mass casualties.