Grand Rounds Recap 06.16.21
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GLOBAL HEALTH GRAND ROUNDS WITH DR. FADLALLA
Dr. Fadlalla’s Journey towards a career in MSF
Born in Sudan and influenced by stories of family and friends with limited access to care.
Medical School: Completed a mission trip providing primary care in Juarez, Mexico
Introduction to fundraising, supply acquisition, setting up a clinic
Recognized the potential for harm as an incoming practitioner and the importance of understanding the specific needs of the population and challenges of the area.
Unsustainable model without medical record keeping
Residency: Focus on training with an eye toward his ultimate goal
Attending: NGO medical mission to Lesbos, Greece during the Syrian refugee crisis
Team consisted of 3 physicians, 1 nurse, 1 volunteer, 1, translator, 1 local logistician. Dozens of NGOs present with hundreds of volunteers comprising medical response at the shore, temporary refugee camps, permanent refugee camps
Big lesson: organizing a humanitarian response is complex
Large organizations like MSF are better equipped to provide resources and organized efforts
Volunteers have varying levels of training, practice patterns, and there is no system to verify credentials
Finding a care niche increases impact for smaller organizations
Loose communication and redundancy lead to chaos and inefficiency
NGO medical mission to Thessaloniki, Greece during Syrian refugee crisis
Later in the crisis with formal refugee camps that people lived in for months
Formal medical care had been set up, but trauma and mental stress take a staggering toll on people and psychological care is important
Big lesson: Evaluation of context would help target response to changing needs
Masters of Public Health
Prior experience had revealed gaps in knowledge and created a hunger to fill these
Big lesson: MPH provides context and tools to increase efficacy overseas
Working with MSF in Nukus, Uzbekistan
Neutral and impartial. Maintain independence from political, economic, or religious powers. Majority of funding from private sources. Missions ongoing in 70+ countries.
After application and interview you join the physician pool and enter a discussion of where you would be most helpful
Worked on drug resistant TB project: patient care, mental health, pharmaceuticals, laboratory, advocacy and education
Charged with oversight of local medical teams
Completed practicum and capstone for MPH while on mission
PERIANAL AND PERIRECTAL ABSCESSES WITH DR. RAFFERTY
Three and only three causes of anal pain
External thrombosis
Anal fissure
Anal abscess
Hemorrhoid anatomy:
Internal hemorrhoids are above the dentate line and cannot hurt
External hemorrhoids are below the dentate line and do hurt
Case: 45 y/o female spent the day raking leaves presents with anal pain. She tried Preparation-H at home without relief. Exam demonstrates an external hemorrhoid with a small area of clot erosion.
Management:
Duration of symptoms irrelevant, if eroding or painful should treat
Expectant management: 7-10 days to resolution
Excision: pain for 7-10 days, but mass resolved
Firm indications: erosion or intolerable pain
Ellipsoid excision technique:
Local anesthesia
Ellipsoid excision of the central ⅔ of the hemorrhoid
Bleeding can be stopped with chromic or silver nitrate
Home treatment:
Ibuprofen and tylenol
Soak in hot water 3x per day
Can alternate with ice to the anus
Metamucil powder and miralax powder only (capsules can cause constipation)
Avoid Sitz bath and donut pillow as they stress the area and cause bleeding
Circumferential hemorrhoid:
Involves all three portions of the venous plexus
Should not excise in ED
Valium an help with anal spasm
Refer to Colorectal surgery
Home management as above
Mixed Hemorrhoid
Both external and internal prolapsed present
Don’t treat in ED
If incarcerated do not incise
Consult in ED if necrosis present
Hemorrhoidal crisis
Circumferential thrombosis with necrosis
Consult in ED. Will likely need OR
Rectal prolapse:
Folds are circumferential vs. radial fold with hemorrhoids
Often associated pelvic floor abnormality and associated with other urogynecological symptoms
If not incarcerated or necrotic can reduce with sugar and pressure
Incarceration is reason for surgical consult
Anal Fissue:
Symptoms: pain with bowel movement that lasts hours, blood on tissue, hard stool, sensation that bowel movements are blocked
Physical exam: sentinel tag on the midline (most commonly posterior) hides the tear. Better visualized with eversion of the anal canal
Caused by split in mucosa with exposed muscle fibers
Management:
Powdered fiber supplement: metamucil or citrucel
Laxatives if constipated
Warm tub soaks 3x per day
Topical nifedipine (requires a compounding pharmacy)
Topical NTG (can cause headaches)
Tylenol, ibuprofen, valium (for anal spasm)
Avoid narcotics to prevent constipation
Anorectal abscess
Cryptoglandular in origin at the transition zone
Symptoms: several days of increasing pain, swelling, fever, urinary retention, pain initiating BM
More common in males during the spring or summer
Diagnosis: with circumanal palpation, do not need DRE.
Perianal abscess: drainage in the ED
Perirectal abscess: draining internally. Okay to drain in ED with lateral incision
More common in males
Be concerned if there is pain without external physical findings
Should get CT to eval for infection in post-anal space
Intersphincteric and supralevator abscesses need colorectal surgery consult and drainage
Rarely need Abx, but if concerned can start cipro and flagyl
Drainage technique:
local anesthesia
finder needle can be used for better localization, be careful not to drain entire abscess as this can make incision difficult
Incision as close to anus as possible
11 blade for radial skin incision
Blunt dissection with kelly
Do not need to break up loculations
Can use Pezzer catheter (10-12 fr) or wick of iodoform gauze to stent abscess
Can remove gauze in 1-2 days
Need f/u in 10-14 days
Pilonidal disease
Infection of pilosebaceous unit in the natal cleft (will be in midline)
Congenital pits that become infected
Typically about 5 cm from anus
Pilonidal abscess management:
best to drain off the midline to allow wound to stay open
Place packing for 48 hours and refer
Antibiotics recommended: Keflex
Hidradenitis Suppurativa:
Multiple external tract that have been present fo months
Typical wound care if no large abscess
Drainage if large abscess present
Antibiotics if complicated or other signs of infection
When to call a surgeon:
Urinary retention, signs of sepsis, immunocompromised/ immunosuppressed, concern for deep infection, necrotizing fasciitis, Crohn's disease (fissure off midline)
Things to be aware of:
Anal cancer:
Increased concern with long standing symptoms
Symptoms: mass, pain, bleeding, itching, discharge
Examples include anal melanoma and condyloma
Need referral w/in 3 days
Herpes
Kaposi sarcoma
Anal cancer from condyloma
Prolapsed anal polyp
Pagets disease: adenocarcinoma in situ of the perianal skin
R1 CLINICAL TREATMENT: Dyspepsia WITH DRS. MILLIGAN AND HALL
A more in-depth post by Dr. Milligan can be found here.
Definition of Dyspepsia: epigastric pain, early satiety, nausea, vomiting, +/- heartburn
Organic causes account for 20-25%
GERD
Due to decreased LES pressure
Chocolate, peppermint, and caffeine decrease LES tone
Pregnancy decreases LES tone
Increased abdominal pressure (pregnancy)
Delayed gastric emptying
PUD and gastritis
Due to imbalance of acid and protective factors
Malignancy
Functional causes account for 75-80%
Endoscopy negative
Visceral hypersensitivity to acid, distention, or peristalsis
Dysregulated motility
Helicobacter pylori infection
Psychological factors
Approach to diagnosis and treatment:
Rule out serious causes such as ACS
Are they high risk for malignancy: EtOH, smoking, or smoked meat consumption
Alarm symptoms: new onset 55+, unintended weight loss, gastrointestinal bleeding, iron deficiency anemia, progressive dysphagia, and persistent vomiting
Empiric treatment for 4-8 weeks with antacid
Treatments in the ED:
Antacids: magnesium or aluminum salts, calcium carbonate
Neutralize acid and reduce pepsin activity
Duration of 60 minutes
Better control at 60 minutes than famotidine
Cochrane review found no benefit if no heartburn sxs
GI cocktail: antacids +/- lidocaine +/- antispasmodic
Study comparing against mylanta alone showed no difference with addition of lidocaine or donnatal
Lidocaine decreases palatability, questionable increase in aspiration risk
H2 Receptor Antagonists
Antagonize H2 receptor to decrease acid secretion via cAMP pathway
Renally cleared: dose reduce for renal disease
Incomplete acid suppression: best for infrequent symptoms
Delayed healing of ulcer or esophagitis compared to PPI
Tolerance with repeat dosing, so best for infrequent symptoms
Famotidine (Pepcid)
Dose: 10-20 mg oral or IV
Onset of action within 1 hour (oral), 30 minutes (IV)
Duration of action: 10-12 hours
Cimetidine (Tagamet)
Dose: 200-400 mg oral
Onset of action within 1 hour
Duration of action: 4-5 hours
Cimetidine is the oldest H2RA and has the most side effects. Additional adverse effects include gynecomastia and galactorrhea in a dose-dependent fashion, rare if used <8 weeks. Potent CYP450 inhibitor, avoid giving with warfarin
Ranitidine (Zantac)
FDA recommended pulling from market in 2020 due to carcinogen contaminant (NDMA) concerns
Proton Pump Inhibitors
Act on the final common pathway: proton pump
Exist as pro-drug and take 2-3 hours to take effect via activation in stomach
For immediate relief: IV form is faster
Most effective when you have maximal proton pump activity (1 hour before breakfast)
First line therapy for patient with uninvestigated dyspepsia
Increased effectiveness with time
Better for recurrent symptoms (1-2 per week or greater)
Caveats: longer time of onset, more effective with repeat dosing, rebound acid secretion
Increased risk of pneumonia and C diff from micro aspiration as not sterile
Increased fractures in observational studies
Interaction with clopidogrel: inhibits CYP enzyme that is responsible for clopidogrel prodrug activation. No significant difference in RCT in cardiovascular outcomes, but there is decreased risk of upper GI bleed when PPI used
Pantoprazole (Protonix)
Dose: 20-40 mg oral or IV
Onset: 2.5 hours (oral), 30 minutes – 1 hour (IV)
Duration: 24 hours (oral, IV)
Omeprazole (Prilosec)
Dose: 20-40 mg oral once or twice daily
Onset: ~1 hour (oral)
Duration: Up to 72 hours
Esomeprazole (Nexium)
Dose: 20-40 mg oral once daily
Lansoprazole (Prevacid)
Dose: 15-30 mg oral once or twice daily
Onset: 1-3 hours
Duration: 24+ hours
Lifestyle modifications:
avoid alcohol
do not eat before bed
food journal for triggers
Consume smaller meals more frequently
reduce smoking
reduce caffeine, spicy food, fatty food, chocolate
Discontinue NSAIDs
Quick hits:
Sucralfate: complex polymer that binds to damaged mucosa to promote healing. No significant difference compared to placebo. Obscures visualization on EGD.
Bismuth: Coats and protects damaged mucosa. Can turn stool black. Has salicylate component and can contribute to salicylate toxicity. Bismuth toxicity can cause encephalopathy and parkinsonism. No evidence for improvement in symptoms
H. Pylori eradication: best done in outpatient setting. No evidence that there is a significant difference in symptoms resolution.
Pregnancy: H2RA and PPI are accepted.. Bismuth should be avoided as salicylate component can cause premature PDA closure in 2nd and 3rd trimester
R2 CPC WITH DRS. WINSLOW AND CONTINENZA
Male in his late teens with PMHx of developmental delay and autism presents to the hospital due to altered mental status. Patient was found this morning on the floor next to his bed by his caregiver in his group home. He had a period of possible witnessed seizure activity with left gaze deviation and jerking of the left upper extremity lasting approximately 30 seconds. The patient is nonverbal at baseline, but is lethargic per caregivers. He has had one episode of emesis since being found this morning. Over the last several days he has had 3-5 episodes of diarrhea daily and poor oral intake. He was diagnosed with viral gastroenteritis 7 days prior and noted to have a fever of 40.3 C at the time. No other fevers reported since then.
Medications: haldol, escitalopram, valproate, olanzapine, Clonidine, mirtazapine, topiramate
Vitals: HR 104, RR 20, BP 138/76, Sat 97% RA, Temp 95.6 F
Exam: Non-verbal. Awakens to verbal stimulus and tracks examiner. Tachycardia with regular rhythm and no murmur. Tachypneic with clear lungs. Abdomen is soft and nondistended with bruising over the RLQ. Slight peripheral edema present. Cool mottled appearance with delated capillary refill. Bruising and abrasions to the left side of the face and dried blood present about the mouth.
Labs:
VBG: 7.1/40/69/-16.5
Lacate 0.8
WBC 72.8, Hgb 10.1, Plt 30.4
Na 127, K 3.9, Cl 93, HCO3 17, BUN 64, Cr 5.44, Glu 102
ALP 90, AST 47, ALT 54, Bili 0.3
INR 2.0
Ammonia 116
UA: Large protein, no ketones, no bilirubin, moderate blood w/ 30 RBCs, WBCs > 100, nitrite positive
Flu A/B negative
CT head, cervical spine, chest, abdomen, pelvis w/out contrast: severe pancolitis and left sided perinephric stranding
...and then a test was ordered…
[interlude]
For complex cases: choose a system such as the VINDICATE pneumonic.
Don’t be afraid to ask for help.
Be wary of vital signs that do not match (i.e. tachycardia with hypothermia).
Stool enteric pathogen panel: Toxigenic E. coli causing HUS
Hemolytic Uremic Syndrome caused by Shiga Toxin
Triad of acute renal failure, thrombocytopenia, and anemia
If prodromal diarrheal illness present: “D+ HUS”
Epidemiology:
1-2 cases / 100k children per year
most common in patients < 5
mortality 3-5%
Most common cause of acute renal failure in childhood
Most common serotype: O157:H7
Transmission:
natural reservoir is gut of cows
Direct transmission in agricultural industry
undercooked meat
contamination of water or produce
person to person
Pathophysiology:
Produces Stx1 or Stx2
Toxin binds intestinal epithelium
Enters into gut and causes destruction of epithelial cells
Binds to renal epithelium and causes renal failure
Initiates inflammatory cascade causing the microangiopathic hemolytic anemia
Management:
Cr >2 was 91% sensitive and 87% specific for eventual need for dialysis
Antimotility agents slow gut transit and increase toxin exposure
Antibiotics are not recommended by CDC, but there is clinical equipoise.
Destruction of native bacteria and allowing overgrowth of STEC if resistant.
Lysis of bacterial cell walls causes release of preformed shiga toxin.
R3 SMALL GROUPS: Genitourinary Disease WITH DRS. HASSANI, GAWRON, LAURENCE, AND WALSH
GU Admit Discharge Transfer with Dr. Laurence
High Flow Priapism
Results from increased arterial flow, often secondary to trauma, resulting in swelling. Nonischemic.
Often painless
Blood gas from the area will be normal
Less common (only about 2% of priapism cases) and can be seen in spinal trauma.
Low Flow Priapism
Results from venous outflow obstruction, resulting in increased congestion and ultimately ischemia
Typically painful
Blood gas from the area will be acidotic
Much more common than high flow priapism
Often medication induced (Trazadone, systemic anticoagulation, PDE5 inhibitors) or a sequela of sickle cell disease
Priapism treatment explained below by Dr. Gawron
Patients with sickle cell disease may require exchange transfusion.
Pelvic Inflammatory Disease
Clinical diagnosis. 75% of cases occur in females 15-25 years of age.
Complications notable for infertility, chronic pelvic pain, complications of pregnancy. Patients who have had PID are 12-15% more likely to have an ectopic pregnancy. Untreated PID can progress to TOA which has a 5-10% mortality rate.
Treatment is Ceftriaxone 500 mg IM, Doxycycline 100 mg BID.
Patient counseling is extremely important given high risks of complications if untreated. Don’t be hesitant to admit to ED Obs or inpatient for initiation of antibiotics if barriers to antibiotic access are present (eg, limited finances, housing, safety at home).
Tubo-Ovarian Abscess
Tubo-ovarian abscess is a walled-off infection of adnexal structures, typically the fallopian tubes or ovary, and occasionally adjacent intra-abdominal structures. It is an unfortunate sequelae of untreated PID and can be life-threatening in the event of rupture.
Test of choice: Transvaginal US to assess for ovarian torsion or alternative pathology.
Treatment: Up to 70-80% of appropriately selected TOA cases resolve with appropriate antibiotics alone (Cefoxitin 2g IV q6H + Doxycycline 100 mg IV/PO q12h or Cefotetan 2 g IV q12h + Doxycycline 100 mg IV/PO q12h). Gynecology consult and surgery if concern for rupture.
Testicular torsion
Torsion occurs as a result of abnormal fixation of the testis within the tunica vaginalis which allows the testis to twist.
Presence of cremasteric reflex DOES NOT rule out torsion, and prehn’s sign does not distinguish between torsion and epididymitis.
Rapid diagnosis necessary to prevent necrosis. 96% when perfusion restored < 4 hrs after episode onset. Clinical diagnosis, scrotal US helpful, but should not delay care needed.
Attempt detorsion with lateral rotation up to 540 degrees (as most torsions are medial) if expected delay in ultimate care and if plan for transfer.
Ovarian Hyperstimulation Syndrome (OHSS)
OHSS characterized by bilateral ovarian cysts that can occur days to weeks following gonadotropin administration; it can also lead to capillary leakage and third spacing of fluid. Occurs in approximately 1/10 women undergoing IVF, but with variable severity.
Characterized as mild, moderate, severe, critical depending on clinical features (eg, presences of ascites, intractable nausea, emesis, dyspnea, oliguria, etc) and lab findings
No bimanual exam given concern for ovarian fragility, further stimulation.
Have a high index of suspicion for OHSS in any women undergoing ART. Consult OB/Gyn early to arrange for quick follow up on discharge if mild case and controlled symptoms. Some moderate cases may be okay for discharge as well. Symptom management, stabilization, and arrange for transfer, appropriate care if critical.
Rapid Fire Visual Diagnosis with Dr. Hassani
Cervicitis treatment: azithromycin or doxycycline + ceftriaxone
Paraphimosis is treated by compression and manual reduction, if this fails a dorsal slit can be placed to assist reduction.
Most common cause of urinary retention is BPH
The finding of clue cells should only be treated if the patient is symptomatic
Phimosis is treated with topical steroid lotion and reduction or circumcision
A strawberry Cervix is seen with trichomoniasis cervicitis and is treated with flagyl
In trauma patients with blood at the meatus, you must get a RUG or CT Urogram to further evaluate for urological injuries.
Transillumination of the testes suggests hydrocele as the etiology of testicular swelling
Antibiotic treatment of Fournier’s must include gram positive, gram negative and anaerobic coverage.
Primary and secondary syphilis are treated with IM Penicillin. Tertiary syphilis is treated with IV penicillin.
Low flow Priapism Procedures with Dr. Gawron
Oral terbutaline is no longer recommended
Priapism Treatment:
Dorsal nerve block:
Lidocaine without epinephrine preferred
Inject at the base of the penis at the 10 and 2 o’clock positions on the dorsal surface
Needle depth of 3-5 mm with “pop” as Buck’s fascia is crossed
Corporal aspiration
Large bore needle inserted at 10 or 2 o’clock position near the base of the penis
Butterfly needle preferred as this allows easy aspiration
20-30 cc syringe used for aspiration until detumescence
Small aliquots of saline irrigation can be used if blood is coagulated
Post detumescence:
apply a plastic bandage
Consider starting patient on pseudoephedrine
Follow-up with urology within 3 days
If attempted detumescence fails, transfer to a facility where urology is available.
Suprapubic Catheter Placement with Dr. Walsh
Decompressed bladder is a contraindication to ED physician placed suprapubic bladder catheter as there is a high risk for injury to adjacent structures
Equipment: Scalpel, trocar, and suprapublic catheter. Alternatively can use a CVC catheter as long as all of the ports are within the bladder however the CVC catheter will not have a balloon to prevent the catheter from dislodging.
Step 1: Anesthetize with local injection of lidocaine
Step 2: Make a skin nic over the area of insertion
Step 3: Insert trocar with sheath in place. Use one swift motion. Urine should flow through the sheath.
Step 4: Remove the trocar leaving the sheath in place in communication with the bladder
Step 5: Insert the cath through the sheath and inflate the balloon
Step 6: Remove the sheath and attach the catheter to the foley collection bag.
