Grand Rounds Recap 8.9.23
/R1 CK: Pericarditis & myocarditis - r3 taming the sru - r4 case follow-up - ent emergencies - Ortho in a Resource-limited setting - pharmacy updates - pediatric seizures
R1 Clinical knowledge: Pericarditis and Myocarditis WITH Dr. Knudsen-Robbins
Overall, maintain a high index of suspicion, much of work-up is non-specific
Pericarditis:
EKG: diffuse ST elevations, Spodick's sign, also can be normal
Dx need 2/4: typical pain, EKG, new/worsening effusion, friction rub
If arrhythmias - consider concomitant/alternate pathology
If trop elevated - consider concomitant myocarditis
Mostly viral but also consider TB, neoplastic, systemic or autoimmune disease
Likely acute viral can go home on NSAID’s and colchicine if no high-risk features
Myocarditis
Exam: tachycardia out of proportion to fever
EKG: sinus tach, global findings, block, fragmented QRS
Echo: normal, global findings, regional wall motion abnormalities, enlarged wall/septum
Admit
Taming the SRU WITH Dr. Harward
Resource mobilization and team preparation are essential components of any complex resuscitation
Basic tenets of resuscitation are universal: airway, breathing, circulation (the air goes in & out, the blood goes round & round...)
Left ventricular assist devices (LVAD’s) mechanically augment left ventricular function
some patients retain enough native function to have a palpable pulse -- conventionally measured BP is reliable in these patients
hemodynamic stability is best assessed by MAP in patients without a palpable pulse
clinical indicators of perfusion (mental status, capillary refill, cyanosis) are the best way to rapidly assess hemodynamic stability if quantitative measures are not available
Chest compressions can be safely performed in patients with implanted LVAD’s
there is a theoretical risk of displacing the LVAD with chest compressions, but (limited) available evidence suggests this is not common
clinically significant aortic regurgitation develops or progresses in 10% of LVAD patients -- a minority of these patients will have their aortic valves partially or completely oversewn with coaptation sutures
withholding cardiopulmonary resuscitation will always result in the death of your patient
LVAD-specific complications include suction events & VAD thrombosis
suction events occur with loss of left ventricular preload and may result in ventricular arrythmias; these correct with GENTLE fluid resuscitation (straight leg raise, 250mL bolus)
LVAD thrombosis may affect the inflow/outflow cannulae or the LVAD pump itself and are highly lethal; patients should be anticoagulated at all times
r4 Case FOllow-up WITH Dr. Gillespie
Communication strategies in taking a history are just as important as understanding the way laboratory tests work in interpreting “data” in patient care. Approach your word choice and angle in obtaining a history and learning a patient story as you would in choosing a diagnostic test (ex. CT head versus CTA); different questions beget different stories.
Patients may come from different perspectives, backgrounds, communication styles, environment interpretations, cognitive biases. A patient perspective may be presented differently or at times, be difficult to tease out, however often contains key data that may be disguised. Recognize there is often “signal” in the noise.
We all carry cognitive biases and heuristics that modify the interpretation of our surroundings and the information we obtain and analyze. Recognizing the personal factors you carry into interpreting information can equip you to become a more informed analyst.
Community corner: ENT Emergencies WITH dr. Lafollette
Quincke’s Edema
Isolated uvular angioedema
rare presentation of angioedema
likely a histamine-mediated allergic angioedema (aka type I hypersensitivity reaction)
Management
antihistamine/H2 blocker/steroid administration
stop offending ACE-I/ARB
period of observation
discharge w/ allergist follow-up
Complex Facial Lacerations
Consider anesthesia
including need for nerve blocks
Extensive irrigation
Examine need for muscle layer repair
such as inability to wrinkle forehead
Layered repair is usually best
Update tetanus vaccine
Discharge on antibiotics and plans for outpatient follow-up
Lemierre’s Disease
Form of thrombophlebitis involving the internal jugular vein thrombosis
typically caused by Fusobacterium necrophorum
Seen in younger, healthy patients with history of recent oropharyngeal infection
typically recent bout of Strep pharyngitis
Presentation typically involves prolonged sore throat and fevers, usually for 1-2 weeks after initial symptom onset
expect lymphadenopathy and painful neck on exam
Diagnosis involves CT of the neck with IV contrast
Management
antibiotics with anaerobic coverage
such as unasyn or zosyn for several weeks
Acute Dental Fractures
Management based on Ellis classification
Class I (enamel only)
dental referral
Class II (enamel + dentin)
expect to see yellow dentin on exam
coverage with calcium hydroxide paste
consider antibiotics
urgent dental referral
Class III (enamel + dentin + pulp)
expect to see pink pulp/bleeding on exam
coverage with calcium hydroxide paste
add antibiotics
emergent dental/oral surgery referral (need to be seen within 24h of leaving the ED)
Acute Necrotizing Ulcerative Gingivitis (ANUG)
Associated with immunosuppression, poor oral hygiene, malnutrition, EtOH/tobacco-use
Commonly seen in younger patients and involves severe gingival disease
Present with dental/mouth pain, fevers
On exam expect halitosis, gingival bleeding, tooth mobility, lymphadenopathy
look for blunting of papillae between the teeth
also expect an ulcerated gingiva
Diagnosis is clinical
yet consider HIV testing
Management
Chlorhexidine mouthwash
Consider oral antibiotics if systemic symptoms are present
Acute HIV Infection
Symptoms typically develop 2-4 weeks after initial exposure
pharyngitis
fever
fatigue
also headache, rash
Yet 10-60% of patient may be asymptomatic
65% will also not have LFT abnormalities
Subcutaneous Emphysema
Could occur in the setting of recent dental work
as 2nd & 3rd molars directly communicate with the submandibular space
especially if they perform a Valsalva maneuver following recent molar work
Typically need a period of observation
Followed by discharge on oral antibiotics
such as amox/clav
T-tube
This is a flexible, usually silicone, tracheal stent
Usually placed in the setting of tracheal stenosis
If patient presents in respiratory distress with T-tube in place:
first troubleshoot in place, including suction
if unsuccessful, can remove the T-tube using the external limb and proceed with intubation if needed
caution as T-tubes are commonly placed in the setting of tracheal stenosis
therefore beware of the indication prior to removing the T-tube and intubating from above
Orthopedic Trauma in a resource-limited setting WITH Dr. Bryant
Principles of Immobilization
Splint in a functional position
Splint like you mean it
always pad bony prominences
anticipate your splint staying on for a prolonged time, so avoid excess padding as it can make the splint loose and useless
Case #1
8yo with closed forearm fracture with inability to follow-up due to cost and length of travel
Avoid fiberglass as family will not be able to self-remove it
Write a fracture passport on the splint
note the type of fracture, date of injury, date cast was placed, date to remove
Teach family how to self-remove the cast
typically with vinegar soak for >25mins followed by unrolling maneuver
can use strip of a rubber tire to protect the skin underneath
Case #2
32yo F with open medial malleolus fracture s/p reduction who is unable to afford post-reduction x-ray
Antibiotics choice based on Gustilo-Anderson grading
Grade 1 or 2: cefazolin, clindamycin, fluoroquinolone (24 hours is typically enough)
Grade 3 or higher: antibiotics above, plus addition of gentamicin
Antibiotic choice also based on contamination
soil? PCN
freshwater? gentamicin
Saltwater? doxycycline
Consider a splint/cast window to allow direct monitoring
mainly used for fracture blisters and/or open wounds
yet takes away from the strength of the splint/cast
Case #3
43yo with FOOSH injury and closed wrist deformity, yet no x-ray machine is available to you
Least likely injuries to need an x-ray in a resource-limiting setting?
wrist in extension
clavicle
tibial
pediatric forearm
Most likely injuries to need an x-ray?
hip
penetrating skull
ankle
elbow
possible proximal dislocation
foot with inability to angulate
Can rely on other tools, such as ultrasound instead
Case #4
16yo on day 4 following a tibial fracture, who is walking on cast and leg now appears angulated again while still inside the cast and patient is unable to afford additional plaster/medications
Can open a wedge in the cast, near the fracture site, to correct the displacement manually again
Case #5
25yo M with a closed mid-shaft femur fracture after being hit by a truck
Can use various sites for skeletal traction including
distal femur, proximal tibia
As well as calcaneus, distal tibia
Caution that pin site infections are relatively common
need to extensively clean area, start antibiotics
may need to remove pin and place another one elsewhere
Pharmacy Updates WITH Lesley Pahs & Nicole Harger Dykes
Euglycemic DKA
Definition
normal glucose (<250mg/dL)
metabolic acidosis (pH <7.3, bicarb <18mEq/L)
ketosis (preferably serum beta-hydroxybutyrate >3mmol/L)
Risk factors
SGLT2 inhibitor use
fasting state
ketogenic diet
intra-abdominal pathology (AGE, pancreatitis, etc.)
glycogen storage disease
infection, sepsis
intoxication/Ingestion (alcohol, cocaine)
chronic Liver disease
kidney disease
pregnancy
surgery
SGLT2 inhibitor pathophysiology
Na+/glucose co-transporter is inhibited
overall leading to an increase in ketogenesis and renal loss of bicarbonate
Clinical Presentation
Nausea, vomiting
Malaise, fatigue
In the setting of known EDKA risk factors such as SGLT2 inhibitor use
Treatment
Same as DKA
IVF, potassium, insulin/glucose
treat underlying cause including cessation of SGLT2 inhibitor
Other adverse reactions of SGLT-2 inhibitors
AKI, hyperkalemia, hypovolemia, bone fractures, infections (including UTI’s), hypersensitivity
Xa Inhibitor Reversal
Reversal options
Andexanet Alfa: aka Andexxa
only FDA-approved agent
acts as a decoy molecule and sequesters Xa inhibitors
administered as a bolus, plus 2-hour infusion (complex dosing based on which anti-Xa is being reversed and timing of last dose)
very expensive
exclusion considerations: GCS <7, patient expected to go for surgery for higher mortality hemorrhages, estimated mortality <1 month from any cause, ICH volume >60cc
adverse effects include a 10-18% risk of thrombosis (including DVT, stroke, acute MI, and PE)
4-factor PCC
acts to replete clotting factors
includes factors II, VII, IX, X
competes with Xa inhibitor
compared to andexanet alfa
less risk of thrombosis
less expensive
no clear dosing regimen
typically given as 50 units/kg
yet more recent given as 25 units/kg
can also give as a flat dose of 2,000 units
Controversy remains over the best choice for Xa inhibitor reversal
prospective RCT study is currently in process comparing andexanet alfa to usual care
When to reverse?
patient on AC and remains pharmacologically active
rivaroxaban/edoxaban: last dose within 18 hours (or 24 hours if CrCl <50ml/min)
apixaban: last dose within 18 hours (or 24 hours if Scr >1.5mg/dL)
lab assessment with PT> 16s, anti-Xa level greater of equal to 0.5
use clinical judgement to assess bleeding risk and presence of significant blood loss, while also consider site of bleeding
discuss with pharmacist about appropriate reversal agent
Dexmedetomidine: aka Precedex
Selective alpha-2 agonist at the presynaptic membrane
prevents NE reuptake
leads to sedation, anxiolysis, and analgesia
Pharmacokinetics
onset in 5-10 minutes
lasts 1-2 hours
metabolized in the liver
Indications for use
agitation: schizophrenia or bipolar disorder
general anesthesia
sedation in mechanically-ventilated patients
no loading dose
continuous infusion: 0.2 to 1 mcg/kg/hour
procedural sedation
loading dose: 0.5-1 mcg/kg over 10 minutes
followed by continuous infusion: 0.2 to 1 mcg/kg/hour
can titrate to desired level of sedation
UC Health-specific policies
Do not use in patients receiving continuous neuromuscular blockade
Restricted to:
prevention in shivering in hypothermia protocol patients
to avoid intubation in patients requiring continuous sedation
facilitate planned extubation
failed sedation despite intermittent benzodiazepine or continuous propofol infusion
alongside benzodiazepines for treatment of alcohol-use disorder
this requires attending physician approval
sublingual film form can be used for agitation in the ED
Adverse effects
bradycardia, tachycardia
hypotension, hypertension
bradypnea, hypoxia, and respiratory depression
No absolute contraindications exist
Yet there are disease-related considerations
cardiovascular disease: may exacerbate underlying myocardial dysfunction
liver dysfunction: drug is metabolized through the liver
older patients: higher incidence of cardiovascular effects
Antibiogram update
Klebsiella aerogenes is becoming more resistant to ceftriaxone and pip/tazo
Escherichia coli is less sensitive to levofloxacin and ciprofloxacin, compared to cefazolin and ceftriaxone
Pediatric seizures WITH dr. sahai
Newborn seizures (0-28 days old)
Newborns are unique due to lack of myelination, presence of an overactive brainstem, and have a hyper-excitatory nervous system
therefore less likely to have classic generalized seizures
expect more subtle exam findings such as bicycling, sucking, lip smacking, roving eyes, staring, blinking, swimming movement
Mimics of newborn seizures include:
Sandifer- back arching, typically associated with a feed/laying flat/spit-up, and tends to resolve as GERD resolves
Benign Sleep Myoclonus- jerking movement only when sleeping that last 3-5 seconds
Jitteriness- normal gaze, no autonomic changes, worse with stimulus
Breath Holding- typically after a crying episode, become briefly tonic with associated color change
Opsoclonus- typically still need a neurology consult due to association with a primary neurological pathology, such as neuroblastoma, yet can also be benign
Common etiology of newborn seizures
meningitis/TORCH infections
electrolyte issues
hypoxic ischemic encephalopathy
ICH
cerebral dysgenesis/genetic
Treatment of newborn seizures
phenobarbital
1st line
20mg/kg load, followed by 10-20mg/kg second load
phenytoin
levetiracetam
midazolam
Treatment of concomitant newborn electrolyte issues
hypoglycemia: D10 2cc/kg bolus, followed by a drip in 1/2NS
hypocalcemia: Calcium gluconate 10% 2cc/kg over 10 minutes
hypomagnesemia: Magnesium 50mg/kg IV
Head US is 1st line imaging in neonates to assess for ICH
no definitive data on the role for CT
will need an MRI to assess for structural changes
Pediatrics Seizures (>29 days old)
Infantile Spasms
usually before 1st year of life
brief, symmetric sudden contractions of flexor and extensor groups
yet can be subtle with only neck flexion and upward eye movements
early treatment can help improve neuro-developmental outcomes
unique treatment w/ ACTH
Febrile Seizures (6 months to 5 years old + fever + no history of afebrile seizures)
Simple: <15m, non-focal, one episode in 24h
no role for EEG or head imaging
otherwise, routine fever work-up based on age, presentation, vaccination status
consider LP if AMS, meningeal signs, 6-12 months old with partial immunizations, or pretreatment with antibiotics prior to seizure
counseling parents
slight increase in future risk for a seizure compared to the general population, yet no difference in neurological outcomes
antipyretics do NOT increase risk of recurrence
vaccines are still safe to administer after a seizure
MMR has highest risk of seizure associated with it
usually within 1-2 weeks after the vaccine
Complex: >15m, may be focal, two or more episodes in 24h
no need for emergent EEG
most literature points to no need for emergent imaging unless focal neurological signs are noted
consider glucose level, metabolic panel, EKG, urine toxicology
for fever work-up consider CBC, BCx, UA, UCx, viral panel
LP should be considered if <12 months, febrile status epilepticus, mental status change, or meningeal signs
admission is not always need and work-up can be performed as an outpatient including EEG
Status Epilepticus (defined as persistent seizure activity or intermittent activity without return to baseline between episodes that last for more than 5 minutes)
Provoking factors
fever
recent illness
risk of malnutrition, feeding abnormalities
trauma
ingestion
recent vaccines
Management
1st Line
Yes IV/IO access? Lorazepam IV
0.1mg/kg IV over 2 mins (max of 4mg)
No IV/IO access? Midazolam IM
0.2mg/kg for <13kg, 5mg for 13-40kg, 10mg for >40kg
2nd Line if still seizing after 5 minutes
Levetiracetam
60mg/kg over 5 mins (max 4.5g)
Other options: fosphenytoin, valproate
3rd Line if still seizing after 10 minutes
Midazolam
0.2mg/kg IV bolus
followed by 0.2mg/kg/hour infusion
Unprovoked/Afebrile Seizures
Various etiologies
genetic
metabolic
structural
autoimmune
idiopathic
Classified as
Generalized
Partial
Absence Seizures
“staring spells”
no post-ictal period
most spontaneously remit
Benign Rolandic Epilepsy
most frequently during sleep transitions
focal seizures with tonic or clonic activity often involving the face with paresthesia of 1 side of the lower face or tongue, drooling, and dysarthria
Juvenile Myoclonic Epilepsy (JME)
occurs most frequently during sleep-wake transitions
triggered by sleep deprivation
Myoclonic jerking
Work-up
while labs (glucose, electrolytes, etc.) are frequently obtained for first afebrile seizure, there is no evidence to support this
EEG can be arranged as an outpatient
consider emergent imaging post-ictal paralysis is not quickly resolving or there is a presence of AMS
those with focal onset seizures will need an elective MRI looking for structural issues
otherwise, no need for MRI for those with generalized seizures, normal development, and reassuring exam
counseling parents
roll the child onto his or her side, place nothing in the mouth, and time the seizure
showers recommended over baths
children can swim but under direct adult supervision
avoiding any heights or climbing
okay for vaccinations
driving:
Ohio: no specific length of time. Applicant must disclose condition
Kentucky: seizure free > 90 days and taking prescribed medication. Must present a physician’s statement.
AED’s can interfere with OCPs
