Grand Rounds Recap 7.28.21
/
Morbidity and Mortality with Dr. Urbanowicz
Case 1: Peritonsillar Abscess
Most common deep space infection of the head and neck seen in the ED
Typically symptoms: pharyngeal pain, trismus, fever, voice changes, odynophagia, neck pain
Alternative diagnoses to consider: retropharyngeal abscess, Lemierre’s syndrome, epiglottitis, necrotizing fasciitis, mediastinitis, carotid artery erosion
Intra-oral ultrasound can better characterize peritonsillar abscess, determine presence of loculations, and locate adjacent structures (carotid sheath) for procedural guidance. Repeat ultrasound can be used to evaluate for complete drainage.
Does require patient cooperation
US: Sensitivity 89-95%, Specificity 79-100%
CT: Sensitivity 100%, Specificity 75%
Needle aspiration vs. Incision and drainage
Similar recovery time and similar time to tolerate PO intake
Needle aspiration is less painful
Trend toward faster improvement with incision and drainage
Higher recurrence rate with needle aspiration
Antibiotics: Amox-Clav for 14 days or Clindamycin if PCN allergic
Patients should have ENT follow-up within 48 hours of drainage
Culture results do not change management
Case 2: Antibiotics in Cardiac Arrest
38% of OOHCA patients are found to have bacteremia
Bacteremia positive patients had decreased survival rates and increased pressor requirements
Meta-analysis and current guidelines do not recommend antibiotics in routine post-arrest care as it is not associated with a change in survival, ICU length of stay, or pneumonia prevalence
Antibiotics should be considered if: evidence of aspiration, new infiltrate on CXR, signs of infection on UA, positive blood cultures
Leukocytosis and fevers are unreliable post-arrest
Lower respiratory tract is the most common source
Case 3: COPD
The single greatest predictor of a COPD exacerbation is having one in the past year. Approximately half of COPD patients in the US have had an exacerbation in the last year. The 30 day readmission rate approaches 20%. Each exacerbation causes further damage to lung parenchyma and worsening of lung function.
Rescue inhalers are the mainstay of treatment.
Systemic steroids should be strongly considered, but consider side effects: tendonopathy, hyperglycemia, increased risk of bacterial infection.
Discuss possible medication side effects. Patients with diabetes should be counseled on management of hyperglycemia when started on steroids.
There is significant overlap between COPD, metabolic syndrome, and diabetes
Diabetes contributes to COPD exacerbations by increasing lung fibrosis, weakening the immune system, and increasing bacterial colonization
This can lead to cycle of COPD exacerbation -> steroid burst -> transient hyperglycemia -> future COPD exacerbation
Steroid induced hyperglycemia typically lasts approx 3 days after steroid treatment
Consider an increased number of glucose checks when prescribing steroids in DM. Discuss whether they have an action plan to treat their hyperglycemia at home.
Improved glycemic control decreases time to clearance of infection, but does not improve mortality
Antibiotics for 5-7 days should be considered if there is sputum purulence plus increased sputum volume
Ensure that patients have necessary medications and follow-ups at time of discharge. Discharge instructions should specifically cover how and when to use each medication.
Case 4: Geriatric Falls
Geriatric trauma accounts for 2.8 million ED visits per year.
Recurrent falls lead to increased mortality within 1-3 years and this mortality increases with each decade of life after age 60.
One in eight patients discharged after a fall return to the ED within 30 days.
Injury pattern from falls is different in geriatric population:
Increased spine fractures from osteophytic changes and decreased flexibility
Increased rib fractures with poorer respiratory outcomes
Increased pelvic fractures from osteoporotic changes
Goldberg et al. proposed a fall intervention in the ED:
ED evaluation for etiology of fall, traumatic injuries, investigation for underlying infectious process
Pharmacy performed a medication reconciliation, educated patients on their medications, and attempted to clean up their medication list.
Physical therapy performed a gait and balance assessment and arranged for home service as needed.
This intervention decreased subsequent fall-related ED visits (NNT 4) and total ED visits (NNT 6) over the subsequent 6 month period
Other low resource interventions: medication review, local resources for seniors, ensuring patients have necessary equipment, interventions to increase home safety (cord minders, rug removal, better lighting)
Case 5 Occult Bacteremia
Lactate clearance is 75% hepatic and 25% renal
Any lactate that is >4 or persistently elevated without an obvious cause should be cause for pause
Increased age is associated with decreased fever in bacteremia
Blood cultures:
Most bacteremic states are intermittent
Blood cultures have a 3-6% true positive rate
Blood cultures only change management in 5% of cases
IVs carry 4x increased risk of contamination compared to straight stick
Minimum volume of blood for culture is 7cc, but 20cc per bottle is recommended
Cultures that result in 48 hours are more likely to represent true bacteremia
Blood cultures strongly suggested in sepsis, HCAP, NSTI, meningitis, osteomyelitis, suspected endocarditis, septic arthritis, fever of unknown origin
Blood cultures can be withheld in simple cystitis, uncomplicated pyelonephritis, community acquired pneumonia, cellulitis or abscess in immunocompetent patients, intra-abdominal infections in the absence of sepsis
R4 Case Follow-Up with Dr. Hassani
New onset psychosis:
Primary psychiatric disorders are often insidious in onset with auditory hallucinations and presentation is typically prior to 40 years of age.
Organic psychiatric disorders are more common in elderly patients, often with non-auditory hallucinations, and abrupt onset.
Missed diagnosis in non-english speaking patients
Patients acuity and limited english proficiency can decrease accuracy of the history
Overall, we do a poor job of taking an adequate history on patients with limited english proficiency
Tips:
Prepare to spend the time to be thorough, and treat taking a history via a phone or video interpreter as a procedure with few interruptions.
In-person interpretation allows for more accurate communication and flexibility
A more thorough exam can help you find things that are missed in translation
Anemia in the ED:
If patients have evidence of ongoing bleeding, hemodynamic instability, requiring transfusion, are elderly, or have heart or renal failure, you should consider admission. These conditions are associated with worse outcomes and more complications.
Sports Medicine with Drs. Betz, Gawron, and Milligan
Intro to Sideline Medicine
There is an increasing national focus on sideline medicine as cases of cardiac arrest in athletes become more prominent
EM physicians provide expertise in: trauma, cardiac disease, neuro-trauma, and musculoskeletal care
Resources are significantly different on the sideline, and injuries are seen in the acute phase, not delayed by transport times
Thinking about the collapsed athlete: heart, heat, head
Contact injury: brain injury, cervical spine injury, blunt cardiac injury, commotio cordis, pneumothorax
Management: presume traumatic cause, stabilize cervical spine, ABCs, support airway
Exertional injury/non-contact: seizure, stroke, arrhythmia/cardiac arrest, asthma, airway foreign body, acute hypoglycemia, hyponatremia, exertional heat stroke, hypothermia, anaphylaxis
Management: presume cardiac cause, roll onto back (do not delay for stabilization of spine), CABs, Early AED
Sudden cardiac arrest in athletes:
Etiology is often unclear.
Structural causes: HOCM, arrhythmogenic right ventricular cardiomyopathy, congenital coronary artery anomalies, marfan syndrome, mitral valve prolapse, aortic stenosis
Electrical causes: WPW, congenital long QT syndromes, catecholaminergic polymorphic ventricular tachycardia
Acquired causes: myocarditis, trauma, toxicologic causes, environmental causes
Survival rates were generally low at 11%. Survival rates have increased with increased AED availability on the sideline. Survival rates increased to 64-89% in student athletes with cardiac arrest if AED was used.
Myoclonus being confused with seizures, overemphasis on concern for c-spine injuries, and cost of AEDs are barriers to early defibrillation.
Recommendations regarding cardiovascular care in student athletes:
Pre-participation evaluation recommended in all
Standard H&P
Value of EKG is debated
Emergency action plan:
Establish efficient communication system
Train first responders in CPR and AED use
Acquire necessary emergency equipment
Predetermine EMS transportation plan
Practice and review plan at least annually
Exercise associated hyponatremia
Excessive sweat leads to salt loss, often replaced by hypotonic fluid. More common in endurance exercise. Symptoms include muscle cramps, extremity edema, N/V, seizure, AMS.
Treatment includes salty snacks, but can include hypertonic saline in extreme cases
Heat Exhaustion:
Inability to continue excess heat due to dehydration, electrolyte loss, energy depletion
Headache, muscle cramps, N/V, dizziness, syncope
Core (rectal temp) </= 40C with normal mental status
Treatment: rest, cooling, rehydration
Exertional Heat Stroke
Life-threatening increase in core body temp leading to CNS dysfunction
Sustained hyperthermia leads to organ dysfunction and death via rhabdomyolysis, DIC, renal and liver failure, arrhythmias
Core (rectal) temp >40C + altered mental status
Cool first, transport second
Nearly 100% survived if cooled within 30 minutes of symptom onset
Ice water immersion is mainstay of treatment
Transport once core temp <39C for 15 minutes
R2 CPC with Drs. Wosiski-Kuhn and Minges
Case:
Pre-teen female presents with left hip pain and fevers for 5 days. Pain started after a recent camping trip, but they did not note any specific bites, wounds, or trauma. One month prior she had poison ivy on her bilateral lower legs. She has also had mild abdominal pain with one episode of nausea and vomiting. She is actively involved in sports, but has not participated due to inability to bear weight.
Vitals: HR 110, BP 121/66, RR 28, Temp 101.5, SpO2 99% on RA
Exam: Left leg cool to touch. Equal DP and PT pulses bilaterally. Tenderness to the right hip with decreased range of motion. No ecchymosis, deformity, erythema, effusions, or lesions on the lower extremities. Abdominal exam with tenderness to the left lower quadrant and suprapubic area without peritonitis.
Labs:
WBC: 5.8
Differential with 73.4% segs and 13.2% lymphocytes
CRP 6 (normal < 0.4)
ESR 28 (normal 0-10)
UA unremarkable
Imaging:
Hip X-ray: normal radiographic examination of the hips and pelvis
Ultrasound of left hip: no evidence of effusion
...and then a test was ordered…
MRI of the hips: Findings concerning for early left proximal femoral osteomyelitis. No evidence of abscess or effusion.
Pediatric Osteomyelitis:
Referred pain is often present, particularly at the knees
Prodrome of non-specific febrile illness often occurs prior to clear etiology
Repetitive microtrauma from sports can increase risk of transient bacteremia seeding the bone.
Testing:
CRP more likely to be elevated (81%) than WBC (36%)
X-ray abnormalities seen at 10-21 days after onset of symptoms
MRI +/- gadolinium is gold standard test
Treatment:
Staphylococcus aureus is most common in all ages
Empiric treatment is anti-staphylococcal PCN or cephalosporin plus gentamicin
MRSA risk factors: clindamycin is first line, then vancomycin or linezolid
Immunocompromised: Mycobacterium tuberculosis, Bartonella henselae, and fungal infections should be considered
Sickle Cell Disease: Salmonella more common and should be treated with 3rd generation cephalosporin or fluoroquinolone
Surgical intervention if: joint involvement, poor response to antibiotics, underlying structural complications, MRSA
Teamwork with Dr. Roche
Not all approaches to team leadership work in every environment.
Trust the leadership style that works for you, but experiment with other options
You set the tone for your team; come to work with a positive attitude.
Uncertainty is not nihilism. Continue to move forward with workup that decreases uncertainty and collaborate with your team, rather than freezing and not moving forward.
If you project your reaction to a stressful situation as a challenge, rather than a threat, you are often perceived as a stronger leader. Knowing your resources and how to use them decreases your level of threat in any situation.
Sharing a mental model helps your team anticipate where things are going. If in doubt, overshare.
Focus on effectiveness over sheer performance: the goal is for your team to leave the task with the endurance and attitude to continue on to the next task. Monitor your team for signs of stress or need for backup.
