Grand Rounds Recap 7.19.23
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social em WITH drs. jarrel, pulvino and kimmel
“One can view the ED (by law, the most accessible door into our healthcare system) as the social barometer of its community. Within the waiting room the emergency physicians witness the confluence of social determinants of health and their deconstruction into pathology.”
Update 6/27/2023: all providers with active DEA licensure in the state of Ohio can now prescribe buprenorphine as a treatment for opioid use disorder (X-waver no longer needed)
Social EM encompasses multiple facets
Expanded testing initiatives (HIV/HCV)
Linkage to care (ED & community)
Clinical research studies
Community education and engagement
Human trafficking screening
Naloxone and harm reduction materials distribution
Early Intervention Program
Substance use disorder linkage to treatment
alcohol use disorder WITH dr. ryan
Alcohol use disorder treatment:
Behavioral assessment/treatments and/or
Medication (naltrexone oral OR acamprosate for AUD)
Naltrexone: first-line treatment
Long-acting oral opioid blocker, reduces cravings for alcohol
Good for patients who desire abstinence OR just want to reduce drinking
Adverse effects: nausea
Contraindications: decompensated cirrhosis, acute liver injury, patients on opioids or buprenorphine
Acamprosate: second-line treatment for patients not appropriate for naltrexone
Balances excitatory (glutamate) and inhibitory neurotransmitters (GABA)
Good safety profile: low overdose risk, not metabolized in liver, may use in patients on opioids
Need to reduce dose in CKD
the cases that haunt me WITH dr. baez
Lessons learned:
You will make mistakes
Sometimes patients have diseases that can’t be fixed
Some patients will make it difficult for you to help them
You are going to mess up on procedures
Trust your training
Sometimes the best we can give someone is the death they would want
We are all in it together
What we do changes lives
Be respectful
You have no idea what the patient is experiencing
Plenty of cases will haunt you, honor those patients and celebrate your wins
patient evaluations WITH dr. baxter
“For the most part, you should have a standard way of doing things. You don’t have to do it that way every time, but if you don’t, have a reason that you don’t. This helps when things get busy.”
Clinical decision rules:
Guidelines are guidelines only
They do not replace common sense
Most guidelines ask for subjective input / sense of the patient
They are good at making sure you use common sense, especially when you are busy and are prone to not fully using common sense
Syncope: SF syncope rule, ROSE score, Boston syncope, Canadian syncope
Many struggle with validation
Take home message: if it isn’t clear vasovagal syncope and they have anything wrong with them, they are not low risk
Can’t typically use these to try to avoid further work-up
Abdominal pain: how do we reduce our CT imaging in the ED?
Interventions that reduced CT utilization:
Diagnostic pathways, increasing alternate test availability, specialist involvement, provider feedback
Interventions that did not reduce CT utilization:
Clinical decision support tools, passive dissemination, patient or family education
neuroimaging WITH dr. knight
Correlate your imaging with the patient’s physical exam
Some pathologies may develop over time and can be subtle on initial imaging
Example case with evolution of diffuse axonal injury requiring external ventricular drain placement, initial CT without significant findings
On the contrary, if presented with an abnormal imaging finding and it’s not adding up, reevaluate the patient to figure it out
Case of holohemispheric lack of contrast: CTA showed contrast unilaterally intracranially and extracranially, absent on other side
Further investigation showed PICC line was intra-arterial, air embolism occurred and the initial imaging was miss-timed given it was not expected to be given through an arterial port
Look carefully or you might miss it
Case with GSW to the head, CTA showed an intact Circle of Willis and empty delta sign
Patient with an abnormal bleed pattern considering sinus venous thrombosis changing the trajectory of their care
oral boards WITH drs. lane, irankunda, goel and lang
Neuroleptic Malignant Syndrome
Overview:
Life threatening emergency associated with use of neuroleptic agents due to dopamine receptor blockade
Causes seen in the ED: antipsychotics, antiemetics and withdrawal from Parkinson’s therapy
Not a dose-dependent occurrence, can happen at any time though highest likelihood is new exposure to medication
Diagnosis:
Clinical diagnosis: must have exposure to dopamine blocking agent, severe muscle rigidty and fever
Also at least 2 of the following: diaphoresis, dysphagia, tremor, incontinence, altered level of consciousness, mutism, tachycardia, elevated or labile blood pressure, leukocytosis, elevated CPK
Symptoms not due to another substance or other identified disorder
treatment:
Remove causative agent
Supportive care: cooling, hydration, sedation
Typical taught to treat with bromocriptine, amantadine, dantrolene though not well validated
Aspiration pneumonia
Classifications:
Infectious process due to aspiration of oral bacteria
Inflammatory process due to aspiration of gastric contents leading to chemical pneumonitis
Infectious and inflammatory process due secondary bacterial infection on top of chemical pneumonitis
treatment:
Community acquired pneumonia coverage + gram-negative pathogens
Higher risk populations (hospitalized patients, alcoholics, immunocompromised patients) are more likely to have MRSA and other resistant organisms, as well as anaerobes
Well-appearing patients: typical CAP coverage (ceftriaxone + azithromycin or levofloxacin/moxifloxacin)
Sicker patients: broad spectrum coverage (ex. vancomycin + piperacillin-tazobactam)
Not all aspiration needs antibiotic coverage- especially patients suspected to have aspiration pneumonitis
