Grand Rounds Recap 4.24.19
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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
Stressor: Exercise (GXT) or Pharmacologic (Lexiscan)
Exercise is generally preferred, as exercise capacity is a predictor of mortality
Imaging Modality: EKG, Echo, Nuclear (Sestamibi)
EKG: patients need normal baseline EKGs; 68% sensitivity and 77% specificity
Echo: looks for wall motion abnormalities, valvular pathology. Often it is limited by windows and provider capability; 81-85% sensitivity, 80% specificity
Nuclear: risk of radiation exposure; 90% sensitivity, 80% specificity
Stress testing can help to identify a lower risk cohort: This study showed rates of MI/death 1 year after normal exercise stress < 1%, after normal pharmacologic stress 1.3-2.7%
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
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
Aspiration
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
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
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
Guatemala:
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)
Tanzania:
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:
Be Positive: this is a choice and your attitude is contagious to all around you
Be Fearless: this is not a lack of fear, but being able to manage it
Be Sincere: people notice this and respect it
Be Kind: its the little things you do that truly touch others
Be Flexible: things don’t always happen according to plan, take it as it comes and move on
Be Assertive: when you want things done, don’t be afraid to advocate for it
Be Generous: a physician is a giver, don’t be frugal with this
Be a Leader: strive to be someone who is worth following
Be a Friend: be a friend to others, you never know when you yourself will need a friend
Be the Solution: if there is a problem, figure it out and fix it however you can
Be Inquisitive: noone knows the answer to everything, ask questions to get closer to the answer
Be Tenacious: know who you are and stick to it
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
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%
