Grand Rounds Recap 5.25.22
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Doom From Down Under WITH VISITING PROFESSOR DR. JENNY BECK-ESMAY
Case 1: An Unusual Presentation of Ectopic Pregnancy
The Case: A teenage female presents with sudden onset LLE pain.
Described as aching in the calf onset while walking to school, extends proximally up posterior leg to hip, walking with a limp.
Physical exam notable for tachycardia but no other abnormal findings, specifically normal MSK exam. Appears uncomfortable, LMP 2 months ago, hx of irregular menses, +vaginal bleeding today, mild abdominal pain although states is chronic.
PMHx GERD, ovarian cyst. Not on OCPs.
Workup: Positive pregnancy test, hemoglobin to 9 from 12, TVUS showed ruptured ectopic and moderate free fluid in pelvis, no abdominal tenderness, negative FAST exam
Ectopic pregnancy:
Occurs in 1.5-2% of all pregnancies
Up to 18% of patients who present to ED in first trimester w/ vaginal bleeding are found to have ectopics
Leading cause of pregnancy-related maternal death in first trimester and accounts for 3-6% of all pregnancy-related maternal deaths
Don’t be reassured by normal/low-normal heart rates as stimulation of vagal response by hemoperitoneum can lead to bradycardia when otherwise would expect tachycardia from hemorrhagic shock
Obstetric/pelvic etiology of sciatica is common – be sure to consider the pelvic mass in new onset of symptoms if remainder of clinical picture is unclear
Management of ectopic pregnancy
Medical
Methotrexate
Contraindications: fetal cardiac activity, serum hCG >5000-10000 depending on local practice, signs of impending tubal rupture or concern for large size of ectopic mass, heterotopic with viable IUP, breastfeeding, immunodeficiency, PUD, active pulmonary disease
Counseling for methotrexate: must be trended to bHCG of zero, ectopics can rupture at any time in the resolution phase of ectopic
Up to ⅔ women can have separation pain ~1wk after MTX treatment →no treatment needed, is thought to be due to tubal distension
Expectant management - measurement of serum hCG levels every 2-3d until undetectable, assuming levels are decreasing as expected and pt remains asymptomatic.
Can take up to 10weeks for hCG to be completely negative
Surgical
Case 2: Toxic Shock Syndrome
The Case: A healthy teenage female presents with 2-3 days fever, vomiting, malaise, diarrhea, maculopapular rash. LMP started 5 days ago but has now stopped, never been sexually active, denies vaginal bleeding or discharge.
Vitals grossly abnormal on presentation with hypotension, febrile, tachycardia.
Labs show WBC 24, plt 92, creatinine 6, lactate 3.8
Physical exam notable for diffuse rash and lower abdominal pain. Pelvic exam performed with purulent vaginal discharge and a tampon in place (pt reports she thought she had taken out several days ago)
Hospital course notable for ICU admission with pressor requirements but ultimately grew staph aureus from vaginal swab. Patient ultimately made complete recovery.
Toxic Shock Syndrome (TSS)
Typical causative organisms is staph aureus or strep species
Clinical constellation includes fever, septic shock, desquamation of palms and soles, diarrhea, diffuse erythematous rash
Often has prodromal period with more flu-like symptoms prior to significant clinical decline and development of shock
Significant rise in incidence after patent filing of tampax in 1936, high as 10/10000, now dropped to ~1-3/10000 by 1980s and remained stable.
Higher association of TSS with super absorbent tampons or in patients who used tampons continuously for non menstrual bleeding → decreased incidence coincides with removal of highest absorbency tampons from the commercial market
Treatment includes early antibiotics and source control aka removal of infectious nidus if present
empiric therapy = vancomycin + clindamycin + piperacillin-tazobactam OR cefepime OR meropenem
Can require surgical debridement in advanced cases or if abscess present
IVIG can be considered in cases refractory to vasopressors
In cases of undifferentiated sepsis, do not forget to consider GU/Gyn source
Case 3: Pelvic Inflammatory Disease and Tuboovarian Abscesses
The Case: A middle aged female with PMHx of obesity initially presented to OB/Gyn with urinary frequency and RLQ pain. Diagnosed with UTI and started on nitrofurantoin. Presented to the ED 6 days later with reports on no clinical improvement despite taking the antibiotics and now is having worsening pain which is radiating to her back. In the ED, was febrile, tachycardic. UA repeated which was normal but providers think may be secondary to her already being on antibiotic therapy and diagnose her with pyelonephritis. No blood work obtained. She is discharged on sulfamethoxazole-trimethoprim. 3 days after her ED visit, has sudden onset of shortness of breath at home with syncope. EMS brings her to the ED where she suffers a cardiac arrest and expires.
Autopsy reveals cause of death was sepsis from pelvic inflammatory disease with right tubo ovarian abscess and peritonitis
Became a medical malpractice case due to lack of performing (or documentation of offering to patient) labs, pelvic exam with a $1.2 million dollar settlement.
Consider anchoring bias,
PID/TOAs
1 million cases annually in the US
Complications after PID:
PEACH Study - evaluated risk of reproductive sequelae in 800 American women who were treated for clinically diagnosed mild-to-moderate PID within 3 years→ 18% infertility, 0.6% ectopic pregnancy, 29% chronic pelvic pain, 15% recurrent PID
Delayed treatment leads to worse complications
Diagnosis of TOA → CT better than US in terms of both sensitivity and specificity
Also helps with drainage/surgical planning
Use as first line imaging in non-pregnant patients
Treatment and disposition:
Admit patients who are pregnant, are unable to reliably complete therapy as an outpatient (access to medications, ability to take appropriately, etc), those who present with severe disease manifestations including sepsis or TOA
Outpatient treatment = 500mg ceftriaxone IM once + doxycycline 100mg BID x10d + metronidazole 500mg BID x14d
History of the pelvic exam and pelvic speculum
Vaginal visualization devices have been found as far back as in the ruins of Pompeii
Given the sensitive nature of this exam and disturbing attitudes throughout history regarding the importance of consent for the performing of it, some states are increasingly passing stricter laws about the ability to perform these exams.
Bottom line, get consent if not critical to the life-saving management of an unstable patient (like the patient in TSS in Case 2)
2011 WEJM study evaluated predictability of pelvic exam findings in ~180 women → pelvic exam findings are predictable or don’t change management 94% of the time.
That 6% miss rate is still not acceptable per EM standards of care → just do the pelvic exam if you’re even remotely thinking about it (or at least discuss with patient and document)
Case 4: Ovarian Torsion
The Case: A young female with PMHx of PCOS presents with LLQ pain starting today without vaginal bleeding or cramping. Physical exam with LLQ pain on palpation and L adnexal tenderness without masses. Pelvic ultrasound shows a left adnexal cyst with no sonographic evidence of torsion. Patient still in exquisite pain, poorly managed with opiate analgesia. After being consulted, gynecology takes her to the OR and finds a torsed left ovary.
Ovarian Torsion
Presentation
Most common presenting symptom is pain
90% report pelvic pain but can also have back or flank pain
Vast majority describe pain as sudden onset
Wide variety in description of quality of pain
Up to 20% will have low grade fever
Diagnosis
Must maintain high clinical suspicion (beware the bad exam!)
Pelvic exams are overall largely unreliable for detection of pelvic masses or adnexal abnormalities (even by gyns on exams performed under anesthesia)
ED interrelated reliability is especially poor for detection of adnexal tenderness or pelvic masses
US has high specificity but poor sensitivity
Most sensitive marker of torsion is unilateral ovarian enlargement (~80% sensitivity)
String-of-pearls sign is very specific
Dopplers aren’t great (60% of torsion cases have normal blood flow) due to the dual arterial blood supply of the adnexa
Also are less adept at detecting venous abnormality which can precede arterial occlusion and also is detrimental to ovarian viability by itself
Effective Lifelong Learning WITH VISITING PROFESSOR DR. JENNY BECK-ESMAY
There is simply too much information available in modern medicine for physicians to be expected to have all appropriate knowledge at all times
Amplified by the development of increasingly more medical subspecialties
Limited data that participating in CME improves job satisfaction
Barriers:
Lack of motivation
Inadequate time for dedicated CME
Limited resources, both in terms of educational content and financial
Lack of awareness → “you don’t know what you don’t know”
Ambivalence or reluctance to change
Group think → don’t want to be the odd man out if no
Majority of education currently is in a passive learning format and is not conducive to building skills necessary for effective lifelong learning → people may just not know where to start or how to do this after graduation from a structured learning/training environment
Is CME effective?
2015 Study in the Journal of Continuing Education in Health Professions showed that CME has a high positive impact on physician performance. There was a positive trend in patient outcomes but not significant.
CME was more effective if it was interactive, used a variety of methods, incorporated longer sessions and spaced repetition and if it was on topics that were identified as important by the physicians themselves rather than mandated from outside body
Meaningful features in lifelong learning in physicians
Recognition of need by the individual themselves
Self initiation
Personal motivation
How to Learn Better
Take Charge - be the grown up you know you are
Be organized
Learn at work
Just in time learning, CME (best in groups)
Seek evidence of your own efficacy (follow up patients, get data, etc)
Solicit Feedback
Find ways to use evidence-based medicine at point of care/in real time
Information Management
Focuses on usefulness of information to patient care
Usefulness = (Relevance)(Validity) / Work
Relevance - direct applicability to the patient care
Validity - technical rigor in terms of EMB
Work - time, money, effort, etc needed to get your answer/information
Foraging tools - alert people to new, relevant, valid information. This is how you learn information exists
Hunting tools - allow you to find information again, quickly, exactly when you need it
Recommended Resources
News aggregator
Feedly, flipboard, nuzzle, etc
Acts as a “foraging tool” manager
“Read by QXMD” app - articles/journal subscription
Also allows you to follow collections curated by other people
Twitter
@foamstarter is a good place to start
Allows for engagement and discussion, rather than just passive reading
Be careful, the role of influencers and viral conversations can sway EMB and data-supported practices drastically
Googlefoam.com
Run by the people who run LITFL
Is a “hunting tool”
Preferentially searches all FOAM sites and medical literature rather than general google
Eliminates the WebMD, etc.
Critical thinking re: secondary resources (UpToDate, etc)
Questions you can ask/consider for every FOAM resources
What if something is published with incorrect information?
What if the early studies don’t match more recent data?
What if something fails replication or validation?
What if I misinterpret as I’m reading?
Has the standard of care changed since this was published?
Teresa Chan FOAMEd Appraisal Questions
Is this at the right level for me?
Is it just an opinion?
Has it been peer reviewed?
Is this author credible? What are their credentials?
Are they using their own words?
Are the authors or aggregators transparent?
Any conflicts of interest?
Ranking and Critical Evaluation
AIR (approved instructional resources) Score by ALIEM - developed for EM FOAMEd specifically
METRIQ score (medical education translational resources impact and quality score)
Social media index - impact assessment of FOAM sites
Building a Foundation:
Canadiem podcast - each episode goes through a chapter of Rosen’s
Don’t diss the textbook
Morbidity and Mortality Conference WITH DR. COLLEEN LAURENCE
Aortic Dissection and Pericardial Tamponade
Aortic dissections are classified into Stanford A or B, or less commonly Debakey Types I-III
⅔ of dissections are Stanford Type A
Pericardial effusions in Stanford Type A dissections
Develop either by transudative fluid movement across the thin-walled dissection flap tissue (more common) or through direct rupture of adventia by dissection flap
⅓ of patients w/ have hemodynamically insignificant effusions
8-31% develop tamponade
Tamponade is the most common cause of prehospital death in patients
Presence of tamponade physiology doubles perioperative and in-hospital mortality
Should we drain these effusions?
Used to be more controversial -> rapid drainage previously thought to lead to increase in BP which subsequently worsened dissection and created a vicious cycle of clinical decline
Based on very small retrospective study from 1994 where average volume drained by pericardiocentesis was 100-300mL and SBP increased by 40-80mmHg
More recent data suggests that controlled drainage shown to be relatively more successful in terms of sustained survival
2010 AHA and 2015 ESC guidelines changed to recommend controlled drainage to achieve SBP not greater than 90mmHg and to not exceed 50mL drainage at one time
Procedural Quick Hit: Pericardiocentesis
Can be done blind although better to do US-guided if available, even in an arrest situation
Complication rate much lower with US-guided (0.5-3.7%) compared to blind/ECG-guided (15-20%)
Three possible locations for needle insertion:
Subxiphoid (1-2 finger breadths to left of xiphoid, inserting needle at 45º-angle towards left shoulder)
Site of choice for ATLS
Most common blind-approach
Parasternal (4th intercostal space along left sternal border, needle perpendicular to skin)
Site of choice for ACLS
Apical (must be US-guided, needle inserted in plane with phased array probe from location with best AP4 view)
Complications of a pericardiocentesis include:
Puncture of right ventricle, stomach, or liver
Pneumothorax
Infection
Life-threatening Hemorrhage
Considerations for site choice
Mean skin to pericardial fluid distance is largest in subxiphoid (5.6cm) vs parasternal and apical which are ~2.5cm)
Highest predicted complication rate subxiphoid > apical > parasternal
Matches actual data
Patient factors including habitus or active compressions
Tip and Tricks
Have someone else hold the probe for you
Confirm location w/ injection of 1-2mL agitated saline
Decrease depth to improve resolution of needle (just need to see fluid and most anterior cardiac tissue)
Consider placement of an indwelling pigtail or CVL for maintaining access and allowing for ongoing drainage if needed
Posterior Stroke
Posterior circulation (PC) strokes account for ~20% of all strokes with 2x the rate of misdiagnosis as anterior circulation
Variable presentation including but not limited to: dizziness, vertigo, dysarthria, atypical motor deficit distribution, nausea and vomiting, altered mental status
Treatment
tPA has long been considered only option as PC strokes were not included in many seminal thrombectomy efficacy trials (eg. HERMES)
Recent metaanalysis of 12000+ patients over 18 studies evaluating mechanical thrombectomy (2022) in these patients found
Comparable rates of successful mechanical thrombectomy (TICI>2) in posterior strokes compared to anterior
Patients with PC LVOs s/p thrombectomy had
decreased odds of functional 90d outcome as defined as modified Rankin Score 0-2 (OR1.26, CI 1-1.59)
increased odds of 90d mortality (OR 0.58 favoring anterior circulation LVOs)
Theorized to be in part due to delay in diagnosis for PC strokes
Consenting for tPA
ACEP guidelines recommend shared decision making and obtaining consent prior to tPA administration
No standardized approach is provided
tPA is FDA approved for 0-3 hour window and technically does not require consent in that time frame
Surveys of national practice patterns show ED docs are overall not consistent with their shared decision making and obtaining consent for tPA
Being an emergency physician (as compared to neurology, for example) and practicing in a non-academic institution associated with increased tendency to always obtain consent for tPA
Increased consent obtained in 3-4.5hr window compared 0-3h
Statistics you can use for your own tPA shared decision making script:
One of every three patients treated showed some functional improvement after tPA administration
Odds of little to no long term disability increase from ~38% → 50% after tPA
Only 1/100 will have severely disabling or fatal outcome from ICH after tPA administration
Find your favorite infographic to use with patients for improved communication
Infective Endocarditis
Hard to diagnose
Nonspecific signs and symptoms, most often similar to flu-like illness
Malaise (80%), fever (90%), headache, weakness, arthralgias
Most “classic” physical exam findings are rare, poorly sensitive and often more subacute
Murmurs are present in ~85% of cases!
Right-sided endocarditis usually presents with more acute illness, shock
Left-sided endocarditis often more indolent, flu-like and nonspecific
High risk patients:
Known valvular disease, prior endocarditis (HR 65), or structural heart abnormalities (congenital or acquired)
Nosocomial-Associated
Prosthetic valve (HR 19)
Endovascular hardware (pacemaker, PICC, etc)
IDVU/PWID
High risk for multiple episodes with up to ⅓ having at least 2
Hemodialysis patients
Immunosuppression (including diabetes)
Diagnosis
Modified Duke Criteria → not really in the scope of practice for ED
Blood Cultures
Get 3 or 4, with at least 1 hour between first and last
90% speciate with ≥2 cultures
98% speciate with ≥3 cultures
Are negative in 5-20% of cases even with appropriate technique
More blood is more better (increased sample volume improves sensitivity) → aim for 20cc/bottle
Collect from straight stick or new IV placement
TTE vs TEE
Even though we are not credentialed to evaluate valves on ED bedside echo, can place a comment if abnormality noted on scan
Cannot be directly used for diagnostic or management purposes, more to influence next steps (call cardiology, get comprehensive study, etc.)
Comprehensive TTE carries pooled sensitivity of 71%, pooled specificity of 80%, pooled +LR 3.5, -LR 3.7.
Has better sensitivity for right sided endocarditis
Prosthetic valves difficult to evaluate with TTE
If vegetations seen, increased size improves sensitivity
Other labs including leukocytosis, inflammatory markers are poorly sensitive
Hemoptysis
Hemoptysis is blood expectorated from tracheobronchial tree or lung parenchyma vs. pseudohemoptysis is blood expectorated from nasopharynx, larynx, or GI tract
Classically, massive is defined as 100mL to 1L in a 24hr period
Very hard to quantify, both by providers and patients
More relevant to determine how the patient is handling the bleeding vs. sheer volume alone
Taking into account gas exchange, hemodynamics
Most common cause is infection (TB #1 worldwide)
Can be caused by end-stage primary pulmonary pathologies, malignancy, trauma, iatrogenic injury, fistula development
90% of massive hemoptysis bleeding originates from bronchial arterial system which is under systemic pressure
5% each from pulmonary arteries and “other”
Diagnostics
Labs, CXR (can identify source of bleeding in most cases), CTA +/- bronchoscopy
CT has very high sensitivities for identifying both site and cause of bleeding and is helpful for IR/interventional planning but requires stabilization
CT often more helpful in identification of bleeding source than bronchoscopy due to the difficulty with direct visualization in the setting of large volume active bleeding
Airway management
Warning signs = ineffective cough, anticipated course, worsening respiratory
Anticipate all the difficulty - HOB up, biggest ETT you can (at least 7.5), have a DL option with surgical airway setup, SUCTION, address coagulopathy in advance
Do not use double lumen tubes in ED - often misplaced in ED and do not standard accommodate bronch wands
Bleeding Management
Reverse pts on anticoagulant therapy or who are coagulopathic for other reasons
Product resuscitation but consider permissive hypotension
Nebulized TXA has some evidence in non-massive hemoptysis but unlikely to reach site of bleeding in event of massive hemoptysis so less effective
Almost no data on systemic TXA
Disposition and prognosis
Very high mortality rate and high risk of recurrence if severe enough to require embolization
Hickam’s Dictum and Other Quick Hit Case Lessons
Gout predisposes patients to VTE, most commonly in the 1 year preceding initial diagnosis
most commonly manifests as PE
Postpericardiotomy pain syndrome is a febrile illness secondary to autoimmune reaction after incision to pericardium
Typically occurs as a single episode 3-6 months after inciting event although can occur at any time post-operatively
10-40% incidence, can lead to tamponade or constrictive pericarditis
Differential diagnosis for persistent (>48h) or intractable (>1mo) hiccups includes stroke, intracranial lesion, encephalitis, acute myocardial infarction, pericarditis, pneumonia, GERD, bowel obstruction, medication adverse effect, hyponatremia or post-procedural complication
GERD most common cause
Occam’s razor (“entities should not be multiplied beyond necessity”) is useful but not infallible
The simplest explanation is often the correct one
Hickam’s Dictum (patients can have as many diseases as they darn well please) comes into play often in patients with significant comorbidities
Do not force a round peg into a square hole–if things aren’t adding up, check your assumptions, go back to the patient and get more information, consider more diagnostics, ask for second opinions.
