Grand Rounds Recap 7.27.22

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Morbidity and Mortality WITH Dr. Kimmel

  • Acute Heart Failure

    • Proportional Pulse Pressure <25% shown to have a PPV of 87% for Cardiac Index of  <2.3​

    • Bendopnea occurs due to elevated LV filling pressures and is associated with higher morbidity and mortality in patients with HF​

    • Orthopnea >2 pillows had OR of 3.6 for PCWP >30​

    • Many clinical findings of HF have poor sensitivity for HF exacerbation​

    • Lung US has higher sensitivity for pulmonary edema ​

    • BNP is an independent predictor of mortality among HF patients

  • Ectopic Pregnancy 

    • Must visualize yolk sac on BSUS at minimum to rule in IUP​

    • Visualizing myometrial mantle important to ensure adequate implantation

    • Pregnancy of Unknown Location (PUL) requires gynecology consult ​

    • Ectopic pregnancy can be managed medically or surgically​

  • Pneumothorax 

    • Lung ultrasound is significantly more sensitive for the diagnosis of PTX​

    • Lung point sign is extremely specific for PTX​

    • Subcutaneous emphysema can limit the use of ultrasound 

  • Finger Dislocation

    • 5th digit PIP Dislocation

    • Naming

      • P1,P2,P3 segments (phalanx)

    • Reduction 

      • It is crucial to be done correctly as you can cause  injury to the volar plate which can become entrapped in the joint space 

    • Most resoursces from Hand surgery, Sports Medicine and EM procedure text books recommend post reduction films

      • The degree of joint edema can make it difficult to determine successful reduction and may change after discharge

    • Learning Points

      • Assess dislocation for associated fracture​

      • Hastings classification can help determine stability of fracture fragment ​

      • Volar plate injury is common in PIP injury and can complicate reduction​

      • Obtain post-reduction radiographs to ensure adequate reduction​

      • Document range of motion and joint stability post-reduction​

      • Splint dorsal dislocations in 30˚ flexion​

      • Each joint and injury pattern is managed differently​

  • DOAC Overdose 

    • Rivaroxaban Overdose 

      • Inhibits Factor 10a blocking thrombin formation and in turn fibrin formation

      • Not necessarily dose dependent bleeding and DOAC toxicokinetics has a threshold saturation effect as there is only so much factor Xa to bind. 

    • Learning Points

      • Anti-Xa level may be falsely undetectable if measured soon after ingestion. Repeat if high suspicion for DOAC ingestion​

      • PT/INR will be elevated but do not correlate with level​

      • In acute bleeding, reversal with Andexxa is recommended​

      • Dialysis is ineffective, but PLEX may be useful​ per case reports

      • Conservation management and observation is sufficient in the absence of bleeding

R4 Case FOllow up WITH Dr. Goff

  • Gastritis with intractable nausea / vomiting

    • Risk factors: NSAIDs, EtOH, infection (H. pylori)

    • High risk metabolic complications:

      • hypochloremic metabolic alkalosis

      • hypovolemic hyponatremia

      • hypokalemia

    • Treatment

      • treat the cause of the gastritis if possible

      • anti-emetics

      • IVF with normal saline

      • potassium chloride for repletion

    • High risk physiologic complications:

      • Cardiac arrhythmia due to hypokalemia

      • Non obstructive ileus due to hypokalemia

      • AKI / ARF due to dehydration

      • Biliary stasis

      • Pneumothorax in the context of vomiting

      • intrathoracic pressure changes may contribute to spontaneous pneumothorax

      • must consider possibility of esophageal rupture

    • Esophageal rupture (Boerhaave's syndrome)

      • results in mediastinal septicemia

      • NPO, IVF

      • Broad spectrum antibiotics including anti fungal per local practice

      • conservative versus operative repair depending upon severity of condition

Patients and Gun Saftey WITH Dr. Yates

 Firearm Injury Prevention in Emergency Department Patients

  • Firearms

    • Firearm deaths have been increasing and recently overtook mother vehicle related deaths

    • Most Firearm deaths are suicide (54%) followed by homicide (43%)

      • All intentional firearm released injuries 

        • 32% led to ED visits

        • 37% lead to hospitalizations

        • 33% lead to death 

      • Suicide 

        • 1% of suicide attempts

        • Firearm suicide make up 50% of completed suicide attempts

        • Firearm suicides have an 85% lethality rate

    • Firearm related injuries 

      • Death 10.2 per 100,000

      • Hospitalization 11.6 per 100,000

      • ED visits 10.4 per 100,000

      • Annual Cost $229 billion Overall and 8.6 Billion in healthcare

    • Guns in America 

      • 390 million privately owned firearms

      • 44% of households have at least 1 firearm 

    • At risk populations

      • Suicide

      • Dementia

      • Intimate partner violence

      • Recurrent firearm injury

    • The data 

      • 11% of ED patients who are suicidal were seen to have access to firearms 

      • Only 50% have documented lethal means access assessment 

      • Patients are willing to discuss firearms and safety in the ED though firearm owners are less likely to follow advice about safe firearm storage and temporary removal. 

    • Temporary Transfer of Firearms 

      • Where can people temporarily store firearms

        • Family or friends 

        • Gun sellers or stores

        • Shooting ranges

        • Law enforcement 

    • Physiatrist Education 

Sickle Cell Management WITH Dr. Karkoska and Dr. Thant

  • SCD overview 

    • Sickling of RBCs due to misshapen Hgb leading to microvascular occlusion 

    • It affects every organ of the body with culminate effects over time 

  • Acute vs chronic 

    • Try to use acute occlusive event instead of crisis 

    • Acute: pain that results in an unplanned visit though most are treated at home 

    • Chronic: pain present on most days over the past 6mo in at least 1 location 

  • Rates of opioid use disorder are note higher in patients with OUD

  • Chronic pain challenge 

    • Over half of patients with SCD have pain on more than half of their days 

    • Often have higher rates of comorbid depression

    • High healthcare utilization

  • Acute pain 

    • American Society of hematology guidelines on acute pain management 

    • Patients receive first pain med within 1 hour of arriving to the ED with frequent reassessments every 30-60 mins 

    • Patients with acute occlusive event should be triaged to a level 2 

  • Individualized care plans 

    • Improved pain control and fewer hospital admissions

    • Goal is to have all patients at UC to have an Individualized care plan (ICP) 

    • Patients have been made aware of these Individual care plans 

  • Don’t miss serious complications 

    • Acute chest

    • Acute stroke

    • Bacteremia

    • Hyperhemolysis