Grand Rounds Recap 7.13.22

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Stroke Update with Dr. Kircher, Dr. Kreitzer, and ED Pharmacists

  • Stroke is a high cause of morbidity and mortality, 5th leading cause of death, 800k affected annually

  • Tenecteplase has higher specificity for fibrin compared to thrombin. It has a longer half-life which allows for bolus dose (5 seconds). No need to redose or drip.

    • Currently FDA approved for STEMI (at dose of 0.5 mg/kg)

  • 2019 Update to 2018 Guidelines for Early Management of Acute Ischemic Stroke (AIS)

    • “It may be reasonable to choose tenecteplase (single IV bolus of 0.25 mg/kg, max 25mg) over IV alteplase in patients without contraindications for IV fibrinolysis who are also eligible to undergo mechanical thrombectomy.”

  • EXTEND-IA TNK: Tenecteplase versus Alteplase before Thrombectomy for Ischemic Stroke, NEJM

    • Tenecteplase (0.25 mg/kg) led to 12% improvement in rate of reperfusion of >50%

    • Number needed to treat of 9

    • EXTEND IA TNK part 2 showed that 0.25 mg/kg dose was non-inferior to 0.4 mg/kg.

  • AcT Trial: PIII pragmatic study of Tenecteplase vs standard of care

    • Tenecteplase is non-inferior to Alteplase (36.9% of Tenecteplase patients achieved mRS 0 – 1 vs 34.8% of Alteplase patients)

    • 1600 patients, baseline NIHSS 9-10, 44% anterior circulation LVO, door to needle time 36 min in both arms

  • No difference in rate of symptomatic intracranial hemorrhage (3% for both tPA and TNK)

  • The Norwegian Tenecteplase Stroke Trial 2 (NOR-TEST 2) showed harm at higher dose of TNK (0.4 mg/kg)

    • Must be vigilant with dosing given a small volume of drug infused. Administration will require wasting of ~50% of vial given packaging of drug at higher dose for STEMI indications.

  • TNK administration workflow

    • Must obtain accurate bed weight  for dosing

    • 0.25 mg/kg bolus over 5 seconds follow with 0.9% NS, do not exceed maximum 25 mg (5cc)

      • Not compatible with dextrose containing solutions

    • Reconstitution Instructions: 

      • Withdraw 10 mL of sterile water for injection (SWFI) and inject into Tenecteplase vial

      • Can GENTLY SWIRL to facilitate reconstitution; DO NOT SHAKE

    • BP goals remain the same for tPA

      • Pre-treatment: If the patient has an elevated systolic BP ≥ 185mmHg or diastolic BP ≥ 110mmHg, then treat per current BP management protocols

      • Post-treatment: Goal blood pressure post-IV thrombolytic is a systolic BP <180mmHg or a diastolic BP <105 mmHg

Ultrasound Grand Rounds: Evaluation of Dyspnea WITH Dr. Minges

  • Ultrasound Evaluation of the Acutely Dyspneic Patient

    • Lung ultrasound can add to efficiency of ED workups (Zanobetti et al 2017)

      • 2700 adult dyspneic patients, randomized to POCUS v. standard workup, compared ultimate diagnosis

      • Time to US diagnosis was 24 minutes vs. Time to ED diagnosis was 186 minutes

      • Overall diagnostic agreement = kappa 0.71

    • Probe selection

      • Curvilinear - higher frequency than phased array, better near field resolution, larger footprint

      • Linear - best for conditions involving pleura

      • Phased array - best to look between small rib spaces

    • Zones of the Lung

      • Anterior Superior, Anterior Inferior, Lateral Superior, Lateral Inferior, PLAPS (Posterolateral alveolar and/or pleural syndrome) point

    • Image Acquisition

      • Longitudinal orientation (indicator to head)

      • 2 rib spaces

      • Probe perpendicular to chest wall

      • Must be in lung preset

  • A-lines

    • Normal lung finding

    • Reverberation artifact between soft tissue and pleural line

      • Harmonics of the distance from probe surface to pleural line

  • B-ines

    • Multiple hyperechoic vertical lines that extend from the pleura and persist at least ~12cm deep

    • Obliterate A-lines

    • Represent fluid within lung parenchyma

  • Z-lines

    • “Comet tail” artifacts that arise from the pleural interface

      • Often seen with the linear probe

    • Do not obliterate A-lines

    • Normal finding

  • Pneumothorax

    • Lung sliding and lung pulse point both rule out PTX

    • Lung point is most specific for pneumothorax

    • A lines can still be present with pneumothorax

      • Represents air-pleural interface and can occur without parietal-visceral pleural interface

    • B lines rule out pneumothorax

    • Color or Power doppler on the pleural interface should demonstrate motion signal beneath the pleural line to signify sliding

  • Other Causes of Absence of Sliding

    • Mainstem intubation

    • Apnea

    • Esophageal intubation

    • Mucous Plugging

    • Adhesions/Pleurodesis

    • Diaphragmatic paralysis

    • Consolidation

  • Pleural Effusions

    • Jellyfish Sign

    • Spine Sign

    • Left sided pleural effusions are visible posterior to descending thoracic aorta on PSLA view, do not confuse with pericardial effusions (which travel anterior to the DTA)

  • Pneumonia

    • Early Mild Disease

      • Pleural thickening

      • Focal B-lines

      • Subpleural consolidations

    • Moderate Disease

      • Lung consolidation

      • Static Air-bronchograms

    • Severe disease

      • Empyema

      • Dynamic Air-bronchograms

      • Fluid bronchograms

    • Subpleural Consolidations

      • Irregularities to the pleural line

      • Nonspecific, can be seen with PE, malignancies, viral syndromes

    • Static Air Bronchograms

      • Hyperechoic spots within the lung tissue that move back and forth with the lungs during breathing

      • Nonspecific, can be seen in atelectasis

    • Dynamic Air Bronchograms

      • Hyperechoic spots within the lung tissue that move independent of breathing

      • Air bubbles trapped within “socked in” lung

      • Specific for pneumonia

    • Fluid Bronchograms

      • Anechoic, fluid filled bronchi

      • Nonspecific, can be seen with malignancies

      • Do not confuse with fluid filling lung fissures

  • Pulmonary Edema

    • B lines do not only represent pulmonary edema

    • Focal B lines can represent consolidated lung, viral pneumonia, ARDS, lung contusion, pulmonary fibrosis

    • 1-2 B lines per lung field can be normal

      • >3 per high power field is pathologic

How to Give Inclusive Lectures WITH Dr. Hughes

Medical texts have historically held long-standing dogma and biases that have existed for many years

  • Racial and biologic differences have been cited as causes for difference in pain control

  • Race has no genetic basis and is a social construct

  • How to Create an Inclusive Lecture

    • Include at least one social determinant of health when presenting a disease process

      • Examples:

        • Economic stability: 1 in 10 live in poverty, steady employment less likely to live in poverty, injuries/disabilities. Noncompliant with meds because can’t afford necessary treatments

        • Healthcare: 1 in 10 are without insurance, less access to preventative health

        • Neighborhood: safety/violence, water/air, secondhand smoke, places to play 

        • Social/community context: bullying, kids with incarcerated parents 

    • Ensure literature presented is applicable to the patient population, or include limitations of applicability

      • Acknowledge limitations of research when applying to different patient populations

    • Exclude patient characteristics when it introduces bias or intentionally include them to increase inclusivity

    • Use people first language and accepted terminology

      • Person-first language: “Person who uses wheelchair” instead of “wheelchair bound”

  • How to Deliver an Inclusive Lecture

    • Use images that reflect diversity and/or breakdown stereotypes

    • Practice pronunciation in advance & be consistent with titling 

    • Design slides with all types of learners in mind

      • Describe your image or point

      • Pay attention to font size and type, color palate for those with color blindness

What I Wish I Knew WITH Dr. Baez

Lifelong learning is part of the job

  • You will encounter things you do not know at all stages of your career

  • Ask for help

    • Rely on your team and other colleagues in the moment during difficulty cases

  • Talk about things that affect you

  • R1

    • Don’t compare yourself to your peers

      • Your skills will change with time in the department; you’ll all be in different stages throughout the year

    • Form good habits now

      • Notes/QPathe

    • Go to the SRU during downtime

      • Watch and observe procedures, leadership styles, team dynamics

    • Don’t forget about the non-medical life stuff

  • R2

    • The autonomy that you have is intentional

    • You will learn more on difficult procedures

    • Let yourself have periods of rest

    • Make the most of your off-service rotations

  • R3

    • Embrace the chaos

    • Assume the best of your consultants

    • Administrative responsiveness is the key to success

  • R4

    • It’s okay to say you don’t know

    • Challenge yourself to be uncomfortable

    • You are never truly alone

  • Career Advice/Job Search

    • Decide your priorities first

    • Start the process early

    • Ask for help

    • Find a good mentor

  • Advice from:

    • Dr. Adeoye

      • Know the language of the business of hospitals

      • The hospital thinks in terms of safety and quality, but also about fiscal responsibility

      • Will grant you the ability to have a larger influence in the hospital

    • Dr. Banning

      • Do everything that makes you uncomfortable, learn it now

      • See your patients more as people or chief complaints/room numbers; interact with them on a personal level to build relationships

  • Baez Residency Blunders

    • Munchies are good

    • Breakfast is important

      • There is more than Echo and HOE

    • WCH has good food

    • Starbucks closes at 3:45   

One Pill Could Kill WITH Dr. Otten

Children are attracted to color or appearance of agents and are willing to taste anything

  • Hazard = inherent toxicity x dose x time of exposure

  • Number one common pharmaceutical leading to death in small children = iron tablets

  • Camphor

    • Aromatic terpene ketone derived from plants

    • Limited to 11% in OTC formulations

      • Vicks vapor rub, Bengay, Absorbine, Tiger balm

    • 700-1000mg fatal

    • Presentation

      • CNS hyperactivity with excitement, restlessness, delirium, seizures

        • Followed by CNS depression

      • Death by respiratory depression and status epilepticus

    • Management

      • No antidote, treat seizures with benzodiazepines, supportive care

  • Methyl Salicylate

    • Concentrated form of salicylate

    • Formulations:

      • Oil of wintergreen, topical lotions (bengay)

    • 150 mg/kg toxic

      • 1 teaspoon of methylsalicylate contains 700 mg salicylate

    • Presentation

      • Nausea/vomiting, tinnitus, agitation, delirium, lethargy, coma, tachypnea, pulmonary edema, fever, renal failure, seizures

      • Hypoglycemia is common in children

    • Treatment

      • Supportive care

      • Activated charcoal

      • Dextrose containing fluids

      • If salicylate level > 50, perform urine/blood alkalinization (goal urine pH 8, serum pH 7.5)

      • If salicylate level > 100, perform hemodialysis

  • Clonidine

    • Alpha 2 adrenergic agonist

    • Formulations

      • 0.1-0.3 mg tablets, transdermal patches

    • Toxicity in 30-90 minutes (average 35 min)

    • Presentation resembles opiate toxidrome

      • Decreased LOC, bradycardia, hypotension, respiratory depression, miosis, hypotonia

      • Risk of respiratory depression and apnea

    • Treatment

      • Supportive

        • Atropine for bradycardia

      • Naloxone

  • Imidazolines

    • Opiate-like presentation

    • OTC ENT preparations (Visine, Afrin, Otivin, Clear Eyes, Tyzine)

  • Tricyclic Antidepressants

    • Toxicity within 6 hours of ingestion

    • Presentation

      • Depressed mental status, seizure, anticholinergic, hypotension, dysrhythmias

      • QRS width predictive of seizure risk

        • 33% with QRS > 100ms

        • 50% with QRS > 160ms

    • Treatment

      • Sodium bicarbonate reverses cardiotoxic effects of sodium channel blockade

        • Maintain pH 7.45 - 7.5

        • 3% HTS (50cc aliquots, watch for QRS narrowing) can be used if sodium bicarbonate is not available

      • Benzodiazepines for seizures

        • Avoid phenytoin (sodium channel blockade)

  • Calcium Channel Blockers

    • Verapamil and diltiazem associated w/ more negative inotropic/chronotropic effects

      • AV nodal blockade occurs more frequently with verapamil

    • Dihydropyridines (amlodipine, nifedipine) exert most effects on peripheral vascular tissue = potent vasodilation

    • Presentation

      • Hypotension, bradycardia

        • May see reflex tachycardia

      • Hyperglycemia

        • Blocks L-type calcium channels within the pancreas = decreased insulin release and hyperglycemia

      • Acidosis

      • CNS effects are rare and should suggest co-ingestion

      • Effects generally within 1-5 hours of ingestion

    • Treatment

      • Charcoal if within 1 hour

      • Whole bowel irrigation for extended release formulations

      • Calcium gluconate 10%

      • Glucose + 1U/kg

      • Intralipid 20% infusion, 1.5 ml/kg bolus

      • Supportive care with vasopressors

    • Toxic Dose

      • Nifedipine - 15 mg/kg (1-2 tabs)

      • Verapamil - 15 mg/kg (1 tab)

      • Diltiazem - 15 mg/kg (1 tab)

  • Sulfonylureas

    • Hypoglycemia may be delayed, 8 hours or longer

      • Must be admitted for observation

    • Treatment

      • Octreotide 50-100 mcg SQ or IV q6-12 hours

      • Supplemental glucose

  • Opiates

    • Codeine and methadone fatal with 1-2 tabs; hydrocodone liquid fatal with < 1 tsp

    • Treatment

      • Naloxone

    • Lomotil = 2.5 mg diphenoxylate (opiate) and 0.025mg atropine

      • Little correlation between ingested dose and outcome

      • Biphasic reaction = atropine effect first and opiate effect later

        • Need prolonged observation

  • Toxic Alcohol

    • Methanol (windshield washer fluid)

    • Ethylene Glycol (antifreeze)

    • Glycol ethers (brake fluid)

  • Pearls

    • Abnormal mental status= hypoglycemia until proven otherwise

    • Narcan is for decrease respirations

    • Wide complex tachycardia + OD= Bicarb

    • Decon at scene if possible (80% of contamination is clothing)

    • Caustic death= airway obstruction

    • 80% of poisoning is supportive care (A,B,C’s)

    • Call DPIC 636-5111 if questions

    • PPE at all times

Efficiency WITH Drs. Hughes and Thompson

Pitfall 1: Task Switching

  • EPIC chat

  • Finish the task at hand before attending to interruption if able

  • Grab ultrasound or other items you know you’ll need before walking into the room

  • Batch calls

  • Pitfall 2: Shotgun Orders

    • Unnecessary tests are the main causes of inefficiency

    • Recognize you may not need labs for every patient

  • Pitfall 3: The Bottleneck

    • Efficiency isn’t for efficiency’s sake; you have to know the goal

    • Have disposition in mind early

  • On Shift Hacks:

    • Documentation

      • Start a note as soon as you sign up for a patient

      • Immediately dictate history, ROS, physical exam

      • Pre-populate discharge instructions

      • Document MDM before disposition or throughout using ‘ED Course’

    • Communication

      • Set up expectations with patients up front

      • Do not delegate communication to the EHR

      • Run the board with nurses

      • Relay intent – not orders

      • Round on patients

    • Quick buttons for starting notes

    • Notifications for pending results that impact disposition

    • Favorites for commonly used follow up options

    • EPIC search functions

      • “LHC”, “echo”, etc

    • Quick lists

      • Code sepsis

      • X-rays

    • Side by side view

      • ED Course

        • “.edcourse” brings it into the note

      • Reports will show all CT scans

    • Dragon mobile integration

      • Available for purchase by residents

  • Time Management

    • Have an awareness of when you are more productive

    • Set time limits on your tasks

    • Build all important tasks into your schedule, including time for yourself and family/friends

  • Inbox Management

    • Set aside time per day to open email, do not open on a rolling basis

    • Unsubscribe or filter unnecessary email

    • File emails even if you have not addressed it

    • Intentionally use draft folder to save as draft

      • Open a reply and save to draft, come back to it after clearing inbox

    • Do not open and ignore emails