Grand Rounds Recap 6.14.17

HIV Complications with Dr. Ventura

HIV and headache

  • Primary headache disorders make up the overwhelming majority
    • Migrane type > tension type
  • Secondary headache in HIV
    • Toxoplasmosis
      • Most common cause of focal cerebral lesions in HIV
      • Usually in patients with CD4 < 200
      • Treatment: sulfadiazine and pyrimethamine
      • Mortality up to 60% within one year of diagnosis
    • Progressive Multifocal Leukoencephalopaty (PML)
      • JC virus infection associated
      • CD4 < 200
      • Ataxia, diplopia, etc
      • White matter demyelination
    • Primary CNS lymphoma
      • CD4 < 50
      • 20-30% of CNS lesions in HIV/AIDS
      • Often isolated ring enhancing lesion
      • May present with seizures
      • prognosis of 12-18 months with therapy
  • What about HAART?
    • Marinella et al found that cerebral lesions decreased from 21.8% pre-HAART to 7.6% post HAART
  • What findings are concerning for lesions needing head CT?
    • new seizure
    • decreased or altered orientation
    • headache different quality than usual
      • screening by these in one study found 97% of lesions
      • 58% of patients in this study had no focal neurologic findings on exam, but new finding on CT
  • CSF pleocytosis
    • 30% of patients demonstrated CSF pleocytosis in HIV with headache
  • Isolated headache is typically only a problem for concern when CD4 <200

HIV and fever

  • acute HIV infection
    • symptoms due to immune response to the virus
      • fever (90%)
      • fatigue (90%)
      • rash (80%)
    • can be seen at any point in disease process with interruption of HAART
  • Opportunistic infections
    • 92% of HIV related fevers of unknown origin
      • Most common infections included PCP, esophageal candidiasis and disseminated MAC
  • HAART does note preclude diagnosis of opportunistic infection

HIV and Abdominal Pain

  • CMV
    • herpesvirus that infects >60% of the US population
    • CMV colitis CD4 < 100
      • abdominal pain, fever, and diarrhea
      • can lead to hemorrhage and bowel perforation
  • AIDS cholangitis
    • related to opportunistic infections
    • usual presentation in terms of exam and labs with the exception that jaundice is usually not associated
  • pancreatitis
    • up to 14% of HIV patients
    • etiology
      • HAART therapy
      • AIDS associated neoplasms
      • infection
      • alcohol

Taming the SRU with Dr. Goel

Diagnostic and cognitive errors in the ED - taking Metacognition (aka, thinking about thinking)

Three types of diagnostic errors in the ED

  • no fault errors
    • errors out of control of provider
    • often patient driven
  • system errors
    • faulty testing or data
    • errors in processing, etc
    • often out of individual provider’s control
  • cognitive errors
    • wide range of errors, most due to individual provider
    • most common type of diagnostic error in the ED
    • What comes into play, where can we go wrong?
      • perception/knowledge
      • hypothesis generation/data gathering
      • data interpretation
      • verification
    • Types of cognitive biases
      • Availability error
      • premature closure/anchoring bias
        • “when you make the diagnosis, the thinking stops”
        • frequent fliers are prone to being pegged with this
      • Attribution error
        • attribute negative stereotypes to patient and use it as justification to not seek further diagnostics
      • Gambler’s fallacy
        • belief that chance is self-correcting
        • “already had a patient with a PE today”
      • Triage cueing
        • bias based on patient’s triage level/physical location in department
      • Entrapment
        • Ordering Cervical spine CT scan just because patient has a cervical collar in place
  • Cognitive de-biasing tools
    • learn the cognitive biases
    • routinely consider alternatives
    • cognitively unload
    • cognitive stop points
    • culture of accountability
    • simulation training
    • acknowledge your emotions

Leadership Curriculum: Receiving and Incorporating Feedback

Soliciting Feedback

  • The first question to ask is do you even want feedback?
    • No purpose in asking feedback for things that are not modifiable
    • If you know your performance has been suboptimal or does not reflect your true abilities feedback may not serve its true purpose
    • Know yourself.  Know your group.
  • The how
    • As an individual
      • consider (strongly) setting the table
        • inform and prepare those you plan to solicit feedback from
      • consider the timing from the standpoint of the person from which feedback is requested
      • consider the experience differential
    • As a group
      • what you ask and how you ask it is paramount
      • consider the benefits of anonymous vs non-anonymous (and what influences this)

Receiving Feedback

  • In person
    • First: listen
      • Do nothing
      • Consider your face
      • Consider your body language
    • Summarize what you understand
    • Ask questions to clarify, not to argue
  • Written
    • Do nothing, wait.  If you respond to any written feedback within 24 hours you’re doing the wrong thing

Evaluating Feedback

  • Step 1: do nothing
  • Step 2: do nothing.  Reconsider it.
  • Step 3: decide if feedback is real or genuine
  • Step 4: evaluate the source (this is critical)
  • Step 5: evaluate the frequency of similar feedback
  • Step 6: evaluate the specificity
    • Can it be (or does it need to be) clarified?
    • Can it be set in context?

Incorporating Feedback

  • Goal setting
  • Follow-up

Pediatric Emergency Medicine Simulation

2 year old boy presenting to ED via EMS for alteration in mental status.  Patient was playing in his brother’s room, became progressively more sleepy throughout the day.  Appears sleepy for EMS, awakens to tactile stimuli.  Reported hypertensive and tachycardia en route, fingerstick blood sugar of 80.  On ED arrival BP 71/41, O2 saturation 90%, respiratory rate of 10, temperature 36.8 C.  Small pupils on exam.  Reports brother recently started on “ADHD medication”.

Clonidine overdose 

Think of this in the patient presenting as above

Can try narcan for reversal

Avoid atropine (even during intubation) for atropine overdose if blood pressure is preserved/elevated.  The bradycardia is protective against hypertension and pulmonary edema.

Pediatric Emergency Medicine Cases

Case #1

2 year old girl, presenting with shortness of breath and fussiness.  BP 90/60, HR 125, RR 40, T 37.1C, 90% on room air.  Normal urine output, no nausea, vomiting, or diarrhea, recently playful with no recent illnesses.  Increased work of breathing on exam with retractions, coughing, crying and grunting.  No stridor.  Oxygen not very responsive to nasal cannula or high flow nasal cannula oxygenation.  Foreign body in supraglottic region visualized on NP scope.  

Think of foreign body aspiration with acute onset increase in work of breathing in pediatric population.  

Acute occlusion with decompensation, consider management with back blows/abdominal thrusts vs intubation with distal migration of foreign body to right mainstem bronchus as a last resort.

It’s important to have a high index of suspicion.  Aspirated foreign bodies will often not be radio-opaque and chest X-ray will have no significant findings.  

Classic findings of cough, wheezing and diminished lung sounds only present ~50% of the time.

Absence of stridor does not rule out critical airway stenosis. 

Blind finger sweeps are discouraged, may convert a partial airway obstruction to a complete one.

 Case #2

7 month old boy presenting to ED with decreased feeding and sleepiness.  Up to date on all vaccinations, no recent illnesses, meeting developmental milestones.  Patient’s sibling is in daycare.  No new foods.  Latest bowel movement this morning, normal in consistency and color.  Diminished response on physical exam, tacky mucous membranes, grimace with palpation in RUQ, no noted rashes or external findings.  Pale appearing, but skin is warm and well perfused.  Normal pH and pCO2 on gas, normal renal panel besides mild elevation in creatinine, normal CBC.  Abdominal X-ray shows paucity of small bowel gas, no free air.  Ultrasound confirms intussusception.


Younger children (<6 months) and longer duration of intussusception are more likely to experience bowel perforation with air enema.  Overall risk is ~1%.

Recurrence risk over 24-48 hours after reduction ranges from 2-40%.  Most studies show numbers on the lower end of that range.  Discharge after reduction with good return precautions is not unreasonable.  Consider observation in younger patients or sicker in appearance at onset.

Age range is typically 6 months to 6 years.  Older children more commonly have a lead point in GI tract.  

Younger cases are more likely to present with neurologic symptoms (lethargy).