Grand Rounds Recap 07.22.20
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TEAMWORK WITH DR. ROCHE
Teamwork barriers
Professional silos (i.e. RN, techs, RT, pharmacists)
Specialty tribes
Hierarchy/seniority
Physical space (i.e. welcoming consultants to the ED, our ‘house’)
Set the tone
You set the direction of the team, such as frustration at the waiting room versus excitement to see patients
Establish and protect personal capital, with trust being a key tenant
Effective communication & shared mental model
There is a common perception that we communicate more than we do. Communicate early and often, restating goals and establishing timelines with patients, consultants and nursing team.
Communicating intent can ensure everyone’s on the same page while also allowing for reflective feedback to understand the barriers your team is facing.
Split the model into a task model (specific actions) and a team model (roles and goals).
Graded assertiveness allows for an escalation of communication style.
Small recurrent actions, such as turning down the lights for patients, can lead to the culture you’re trying to create
Core Principles
Team leadership - Converting threats to challenges, often dictated by perceived ratio of resources to need. “Fly ahead of the plane” i.e. anticipate one to multiple steps ahead of the team. Prevent groupthink.
Mutual performed monitoring - Knowing your physical space in order to know when it’s not going right (i.e. how to use the defibrillator even though you may not be the one pushing the button)
Backup behavior - Knowing everyone’s job to some degree and everyone’s capabilities
Adaptability - Flexibility in bringing other members of the team on
Team orientation - Team before self, patient before team
Implicit bias - White males standing in the back of a resuscitation room are often perceived as the team leader; being cognizant of implicit bias is the first step to combating
R4 CASE FOLLOW-UP WITH DR. LANE
Incidental findings
Tell the patient about the finding in person and in written discharge instructions (encourage development of a standard means of communication like our .edradincidentaloma)
Follow up is not magic. To help facilitate, you can send a message via EHR to the patient’s PCP if one is listed. For patients who are uninsured or have Medicaid, use the community health workers to help find PCPs.
Ovarian torsion
Don’t forget about intermittent torsion as an etiology of recurrent unilateral lower quadrant pain, especially with multiple ED visits with unexplained etiology.
Per ACOG, there are no clinical or imaging criteria sufficient to confirm the preoperative diagnosis of adnexal torsion. Doppler flow alone should not guide clinical decision making.
CT: Shown to have 100% sensitivity with enlarged ovarian volume, cyst at least 2.5 cm, adnexal masses (Moore et al 2009) or adnexal enlargement greater than or equal to 4 cm (Hiller et al 2007), but the sample sizes in both studies are small.
US: Completely normal ultrasound is reassuring but not conclusive.
CT vs. US: CT is non-inferior to ultrasound with strict parameters and neither is perfect
INTEREST GROUP SERIES: SPORTS MED joint examinations WITH DRS. BETZ, GAWRON, & IPARRAGUIRRE
General
The ED orthopedic exam is focused, problem based, and meant to rule out; whereas, an extended examination is meant to rule in. Both require inspection (i.e. exposure of the joint on both sides for comparison), palpation, ROM, and neurovascular assessments.
Can’t miss pathology for all joints includes: open/closed fracture, dislocation, and septic joint.
Shoulder
Specific can’t miss pathology: posterior sternoclavicular dislocation (may be associated with life threatening injuries to the mediastinum and warrants operative reduction), full thickness rotator cuff tear, and mimics (i.e. MI, PE, pneumonia)
For palpation, start at the SC joint, walk down the clavicle, then AC, acromion, proximal humerus, and spine.
For diagnosing shoulder dislocations, XR requires AP, lateral Y, and axillary views. Ultrasound is quick, sensitive, and specific, also helping with intra-articular joint injection.
Reduction techniques include: Stimson, Davos, FARES, traction-countertraction
Knee
Specific can’t miss pathology:
Quad/patella tendon rupture: Extensor mechanism injuries are easy to miss. Test via straight leg test (patient lifts leg from hanging position, ideally, or off the bed if supine) and assess patellar location (should be one finger breadth above the joint line).
Knee dislocation with spontaneous reduction before ED presentation, occurring 20-50% of the time, is concerning for popliteal artery injury or peroneal nerve injury leading to foot drop. Perform a good neurovascular exam and ABIs, proceeding to CTA if abnormal.
Tibial plateau fracture can be missed on plain films. Pay attention to the lateral joint line and have a low threshold for CT, as these are high risk for compartment syndrome.
Hip injury with referred pain
For palpation, test for bony tenderness, soft tissue involvement (i.e. tendon rupture), and effusion (“milk the joint”)
Knee immobilizers are indicated for patella dislocation, tendon rupture, and tibial plateau fractures and not indicated with ligamentous or meniscus injuries.
Ankle
Specific can’t miss pathology: ankle sprain mimics including Maisonneuve fracture/syndesmotic rupture, deltoid ligament sprain, talar fractures, navicular fracture, proximal 5th metatarsal fracture, peroneal tendon rupture, LisFranc fracture/rupture, calcaneus fracture, Achilles tendon rupture
Ottawa Ankle Rules help with decision making but have significant limitations including: no palpation of medial ligaments/deltoid complex, no proximal fibular tenderness, no palpations of anterior tibiotalar joint, no palpation of 1st/2nd metatarsal base
R2 CPC WITH DRS. ZALESKY & ADAN
Case Presentation
Middle aged female with DM2 presenting from an outside hospital with 3 weeks of R wrist and L foot pain. MRI was performed concerning for osteomyelitis, so transferred for orthopedic evaluation. On ED presentation, she also endorsed vaginal discharge on ROS. VS normal. Exam showed swelling, redness, warmth, and pain with range of motion of both joints, along with findings suggestive of a fungal GU infection. Labs significant for a WBC 16K, bicarb 6, anion gap 23, BS 111. Joints were tapped and concerning for a septic process. Then a test was ordered…
Beta-hydroxybuterate = Elevated to 5.75
Euglycemic DKA
Patients on Sodium Glucose Co-Transporter-2 (SGLT-2) inhibitors are at risk for euglycemic DKA, a side effect of the medication with cases reported by the FDA in May 2015 but never further evaluated.
SGLT-2 inhibitors work on the proximal nephron, where 90% of glucose is reabsorbed. Blocking this causes glucose wasting through the urine, resulting in decreased insulin levels and increased ketosis. Patients on these medications are always in a small amount of ketosis, making them easy to tip over into DKA and high risk for GU infections.
LIT BLITZ WITH DR. BENOIT
Risk Scores
Bima Academic EM 2020: Aortic Dissection Detection Risk Score plus a normal D-dimer has a sensitivity of 99.9% in ruling out aortic dissection without a CT scan
Thiruganasambandamoorthy JAMA IM 2020: Canadian Syncope Risk Score -2 to 0 rules out 30 day adverse events in patients with syncope that had no serious condition identified
Kearon NEJM 2019: In patients with sx suggestive of PE, low Well’s score (0-4) plus D-dimer < 1 ug/mL (double traditional cutoff) rules out PE without a CT scan
COVID Related
Beigel NEJM 2020: Remdesivir is superior to placebo to improve time to recovery in COVID19
Hwang American J of EM 2020: 73% failure rate of N95 masks after 6 minutes of CPR as measured by a quantitative fit test
Mehra Lancet 2020: No difference between hydroxychloroquine with or without macrolide versus standard of care in terms of mortality in COVID19, but data was not correct and thus the abstract was retracted
Intubation
Brown Academic EM 2020: Video laryngoscopy (VL) performs better than direct laryngoscopy (DL) plus a bougie in improving first attempt intubation success
Guihard JAMA 2019: Compared to rocuronium, succinylcholine improved first attempt intubation success in a physician-staffed EMS agency
Kreutziger Critical Care Medicine 2019: No difference in McGrath Mac VL versus DL for first attempt success in physician-staffed EMS agency
Sepsis
Fujii JAMA 2020: In patients with septic shock, vitamin C IV + thiamine + hydrocortisone is no different than hydrocortisone alone in terms of time alive without vasopressors in the ICU
Delaney EM Australasia 2019: No difference in 90-day mortality between peripheral and central lines for initiation of vasopressors in septic shock
Cardiac Arrest
Ramirez American J of EM 2020: Rate of survival of cardiac arrest events in TV medical dramas was 62% versus 11% in real life
Adan Annals 2019: Open-chest cardiac massage and peripartum c-section were performed by one of our attendings (Dr. Andrew Adan) in the setting of peripartum cardiomyopathy and out-of-hospital cardiac arrest, resulting in both mother and baby surviving
Grunau Annals of EM 2019: In patients with out-of-hospital cardiac arrest, less than 3 minute dosing of epinephrine performed better than longer intervals in improving neurologic status at discharge
Lascarrou NEJM 2019: Therapeutic hypothermia (33C) versus targeted normothermia (37C) in patients with non-shockable rhythms does improve neurologic status at 90 days
Mody Resuscitation 2019: IV > IO access in rates of ROSC for out of hospital cardiac arrests
Rundgren Critical Care 2019: No difference in incidence of AKI for early versus delayed versus no coronary angiography in patients with out-of-hospital cardiac arrest
Other
Brown NEJM 2020: No difference in observation versus chest tube for moderate to large unilateral primary spontaneous pneumothorax
Ceylan J of EM 2019: Modified valsalva improves sustained cardioversion of SVT compared to standard valsalva and carotid massage
Deyle NEHM 2020: Physical therapy performs better than intra-articular steroid injections in improving osteoarthritic knee pain and function at 1 year
Jahan JAMA 2019: In patients with acute ischemic strokes from large vessel occlusions, shorter treatment times for endovascular-reperfusion therapy improve neurologic status at discharge
Butler Lancet 2020: Tamiflu (oseltamivir) improves time to recovery in influenza-like illness in the primary care setting, up to 3 days if >65 years old with comorbidities
CRASH-3 Collaborators Lancet 2019: In adults with DBI, TXA given within 3 hours of injury performed better than placebo in improving head injury-related death
Dietze JAMA Open 2019: As compared to intranasal narcan, intramuscular narcan reduces the need for rescue doses of narcan at 10 minutes
Kapur NEJM 2019: No difference in fosphenytoin versus valproate versus levetiracetam for improving seizure cessation and LOC at 60 minutes in status refractory to benzodiazepines
