Grand Rounds Recap 4.24.19

Morbidity and Mortality with Dr. Baez

Acute Coronary Syndrome

  • 2% of ACS in the ED is missed, these patients have two-fold increase in risk-adjusted mortality but are part of the accepted safety profile of our risk stratification

  • Stress tests attempt to identify critical stenosis obstructing coronary blood flow

  • However, many MI’s and ACS is caused by non-critical stenosis with unstable plaques that rupture. These cases may be missed by stress testing.

    • This study showed that many patients with a negative stress test had a positive cath

    • This study showed a pooled sensitivity of 80% and specificity of 80% for stress testing

    • This study showed no difference in MI rate at 7 and 190 days in patients who got non-invasive stress testing vs patients who did get non-invasive stress testing

    • This study showed no difference in rates of missed ACS or MACE in patients who got non-invasive testing vs patients who did not

    • This study showed 21% of patients with a normal stress test in the past 3 years (many within 1 year) had CAD (defined by positive troponin, need for PCI, AMI, positive stress)

  • Bottom Line: negative stress testing can help to identify a lower risk cohort, however, if a patient has a concerning story do not be reassured by a recent negative stress.

Norwegian Scabies and Use of Contact Precautions in the ED

  • Norwegian Scabies

    • severe infestation with scarcoptes scabiei typically in immunocompromised or debilitated patients

    • characterized by scaly hyperkeratotic plaques, often non-pruritic

    • treat with oral ivermectin and topical permethrin

  • Precautions

    • Contact: MDRO, C-Diff, Norovirus, Scabies

    • Droplet: influenza, respiratory viruses, meningococcus, group A strep

      • This study showed only 22% of providers wear a mask for URI complaints

    • Airborne: TB, measles, varicella

      • This study of ED residents showed 2% had PPD conversion and 2 had active TB, 50% did not use appropriate precautions

    • Standard: all patients

      • This study showed 38% adhered to standard precautions in the ED

  • We can do better, adhere to precautions

    • Wear gloves

    • Wear mask for procedures and respiratory complaints

    • Wear gown for all diarrheal/wound complaints

    • Wash your hands!

Sudden Sensorineural Hearing Loss

  • Sudden Hearing Loss (within 3 days)

  • Sudden Sensorineural Hearing Loss

    • Presentation

      • Rapid decline of hearing over 72 hours

      • Can be unilateral or bilateral

      • 80% of cases of sudden hearing loss, 90% are idiopathic

      • Often presents upon waking, 40% have vertigo, many have tinnitus

    • Differential:

      • Vascular: microvascular, AICA, basilar, venous thrombosis

      • Infectious: herpes zoster, chronic rhinosinusitis, lyme, syphilis

      • Neoplastic: vestibular schwannoma

      • Medications: aminoglycosides, macrolides, loop diuretics, aspirin

      • Autoimmune: SLE, RA, sarcoid

      • Mechanical: barotrauma

    • Workup/Management:

      • Routine head CT, labs are not indicated

      • Outpatient MRI may be warranted

      • Corticosteroids may be offered

        • This study showed patients with steroids had improved hearing recovery (61% vs 32%)

        • This meta-analysis showed intra-tympanic steroids may be more effective than oral

        • ENT at UCMC recommends prednisone 60mg for 10-14 days, ENT follow up in 1-2 days for possible intratympanic steroids


  • Risk Factors:

    • Impaired Swallowing (mechanical, neurologic)

    • Impaired Consciousness (medications, medical conditions, alcohol)

    • Increased Chance of Gastric Contents Reaching Lungs (reflux, tube feeds)

    • Impaired Cough Reflex (medications, alcohol, neurologic disease)

  • Aspiration Pneumonitis:

    • Aspiration of large volume of acidic content

    • Inflammatory reaction, treatment is generally supportive

    • Symptoms improve in 2-4 days, 25% develop secondary bacterial infection

  • Aspiration Pneumonia:

    • Aspiration of less acidic contents

    • Acute pulmonary infection

      • Community Acquired: S Pneumo, S Aureus, H Flu, Enterobacter

      • Hospital Acquired: P Aeruginosa, gram negative bacilli

      • Anaerobes: less common than originally thought, only 16% in this study

  • Management Algorithm:

    • Question 1: Is is Hospital Acquired or Community Acquired?

    • Question 2: Is there a consolidation on CXR?

      • If abnormal CXR you will be treating regardless of whether it is pneumonitis or pneumonia. Use Unasyn/Azithro in community acquired, Zosyn/Azithro in hospital acquired

      • If normal CXR, favor observation in patients with mild/moderate symptoms, treat with antibiotics if severe symptoms

Pericardial Tamponade

  • Definition: Impairment of cardiac function due to pericardial effusion

    • Clinical: Classically JVD, muffled heart sounds, hypotension

      • This study showed many patient with tamponade are not hypotensive

    • Echocardiographic: diastolic collapse of right atria and ventricle, exaggerated respiratory variation of mitral/tricuspid inflow velocities, plethoric IVC

      • See this post for more information on the diagnosis of tamponade using bedside ultrasound

  • ESC Guidelines:

    • if stable, get urgent (12-24h) pericardiocentesis

    • Guidelines include a scoring system for deciding if patient requires emergent pericardiocentesis, the data for this scoring system is not strong and comes from this study

  • UCMC Guidelines:

    • Concerning Features: hypotension, tachycardia, orthopnea, rapidly worsening symptoms, small effusion with tamponade (likely accumulated rapidly)

    • Reassuring Features: malignancy or TB as cause of effusion, pulmonary HTN, large effusion (likely accumulated over longer period of time)

  • Bottom Line: decision to do bedside pericardiocentesis in the ED is controversial and there is not good data to guide your decision. Utilize your interventional cardiologists and have a discussion. If patient is unstable/hypotensive, they likely need an emergent pericardiocentesis.

R4 Capstone: THe HIgh Risk DIscharge  WITH DR. Randolph

  • Discharge from the ED

    • We discharge 4/5 patients that present to the ED

    • Vulnerable time for the patient and for the provider

    • Lots of barriers

      • Easy to admit

      • We are rushed

      • Language/Cultural/Education barriers

    • This study and this study show that we are not very good at discharge information

      • Average reading level is 6th grade

      • Many people do not understand instructions

      • Even 22% of “educated” people did not understand instructions

    • Written Discharge Instructions

      • Variable by provider

      • Good: It’s detailed, permanent, documents

      • Bad: Its poorly understood (especially the pre-formatted instructions)

      • This study showed no difference between hand-written and pre-formated instructions

    • Verbal Discharge Instructions

      • Helps address specific questions of the patient

      • Clarifies concepts

      • Creates relationship with patient

      • But often poorly remembered by patient

      • If you do this, document in the chart

  • How can we do better?

    • Identify the High Risk Discharge

      • Vulnerable population (elderly, disabled, psychiatric disease, language/cultural barrier)

      • Diagnostic uncertainty

      • Abnormal vitals

      • Dehydration and dyspnea

    • Review Everything Prior to Discharge

      • Give 30 seconds of honest thought

    • Identify Their Barriers and Try to Address Them

    • Follow Up

      • Who and when

      • Make the call/referral

    • Written Instructions

      • Be clear, use simple language

      • Return Precautions: Be vague enough to be comprehensive, but specific enough so that the patient understands what to watch for

    • Verbal/Personal Instructions

      • Reassess patient

      • Express your concerns

      • Engage the family

      • Specifically answer questions

Global Health Grand Rounds WITH Veronica Calhoun and DRs. Mand, McKee, and Harrison


  • Case 1: Depression

    • Many aches and pains can be a manifestation of depression

    • PHQ-2: quick questionnaire

    • Consider screening for depression in patients who have recurrent ED visits for seemingly benign complaints

  • Case 2: Pediatric Diarrhea

    • 1.7 billion cases of pediatric diarrhea per year; 525,000 pediatric deaths per year due to diarrhea

    • Guatemala has 3rd highest rate of chronic malnutrition in the world

    • Bacterial, viral, parasitic are common causes of diarrhea

    • Treat with oral rehydration, consider targeted therapy, education on hygiene/safety (clean water)


  • Case 1: Leprosy

    • Relatively uncommon in Tanzania, 220,000 cases worldwide

    • Mycobacterial infection

    • Transmitted via respiratory route, incubation period of 3-30 years

    • Presentation:

      • Early: paresthesias that progress to skin lesions, peripheral nerve involvement (ulnar nerve)

      • Late: claw hands, facial palsy, saddle nose, “Lion Face”, deformities/ulcerations

    • Diagnosis: clinical, biopsy is gold standard

    • Treatment: dapsone + rifampin for 6-24 months

  • Case 2: B12 Deficiency

    • Water soluble vitamin needed for hematopoiesis and myelin generation/maintenance

    • Presentation:

      • Vague neuro symptoms (posterior column symptoms), megaloblastic anemia

    • Diagnosis:

      • Measure B12 levels

    • Treatment:

      • 1000 mcg/day x 1 week IM, then weekly, then monthly

      • 1000-2000 mcg/day PO (if no problem with absorption of B12)

      • Labs respond based on lifespan of cell line

      • Neurologic symptoms resolve over months/years

R4 Capstone: Peer Learning WITH DR. Sabedra    

Learning from your co-residents has been one of the most formative parts of residency. These are all things Dr. Sabedra has learned from her fellow R4’s:

  1. Be Positive: this is a choice and your attitude is contagious to all around you

  2. Be Fearless: this is not a lack of fear, but being able to manage it

  3. Be Sincere: people notice this and respect it

  4. Be Kind: its the little things you do that truly touch others

  5. Be Flexible: things don’t always happen according to plan, take it as it comes and move on

  6. Be Assertive: when you want things done, don’t be afraid to advocate for it

  7. Be Generous: a physician is a giver, don’t be frugal with this

  8. Be a Leader: strive to be someone who is worth following

  9. Be a Friend: be a friend to others, you never know when you yourself will need a friend

  10. Be the Solution: if there is a problem, figure it out and fix it however you can

  11. Be Inquisitive: noone knows the answer to everything, ask questions to get closer to the answer

  12. Be Tenacious: know who you are and stick to it

  13. Be Bold: to make change you may have to have unpopular opinions

R1 Clinical Diagnostics: Cervical Spine Rules WITH Dr. Gawron

  • Background:

    • 13 million patients evaluated in US ED’s for cervical spine injury after traumas

    • Only 0.3% are found to have significant cervical spine injuries

    • 98% of imaging is negative for cervical spine injury

  • The Rules:

    • Nexus Rule (1992), Validation (2000)

      • 99.6% sensitivity, 12.9% specific, reduced radiography by 12.9%

      • See the rule here

    • Canadian C-Spine Rule (2001)

      • 100% sensitivity, 42.5% specificity, reduced imaging by 15.5%

      • See the rule here

    • This study compared the two rules

      • Canadian Rule was more sensitive, specific, and had lower imaging rates

      • Of note, the study was performed by the providers of the Canadian C-Spine rule which may introduce bias

See Dr. Gawron’s post for more information on the topic.

CPC: Takotsubo Cardiomyopathy WITH DRs. Skrobut and Roche

Takotsubo Cardiomyopathy:

  • Background:

    • 2% of suspected ACS cases

  • Risk Factors:

    • Older age, female, smoking diabetes

    • Stressors:

      • Emotional (39%)

      • Physical (35%)

  • Pathophysiology:

    • Mainly unknown but thought to be due to catecholamine excess

  • Presentation:

    • Chest pain, SOB

    • Many present in cardiogenic shock

  • Diagnosis:

    • Characteristic appearance on echocardiography

    • Known stressor

    • Lack of obstructive cardiac disease

  • Management:

    • Avoid inotropes and sympathomimetic medications if possible as this is thought to be part of pathophysiology

    • Mechanical assistance if needed (Impella, ECMO)

    • ACE I, beta blockers, stress management to prevent recurrence

    • Recurrence rate is 5-22%