Grand Rounds Recap 08.12.20
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ULTRASOUND GRAND ROUNDS: NERVE BLOCKS with DR. MINGES
Using ultrasound to assist in regional blocks improves success rates of blocks, minimizes amount of anesthetic required, and minimizes risk of vascular and nerve injuries
Peripheral nerve blockade can be performed two ways: individual nerve block versus plane/plexus block
Fascial plane/plexus block are larger and broader, therefore often easier to target
Require larger volumes of anesthetic
Lower risk of direct nerve injury from injection/laceration
Individual/targeted nerve block are more targeted regions
Lower volume of anesthetic
Often carry higher risk of nerve and vascular damage
When injected into the sheath, will get circumferential bathing of the nerve in anesthetic vs surrounding the sheath and allowing for diffusion across it
Getting prepared:
Needle: whitacre tip/quincke tip spinal needles are effective if nerve block needles are unavailable
Gather chlorhexidine wipes, sterile towels, syringe, sterile gloves, IV extension tubing, ultrasound
Position yourself and patient comfortably
Have an assistant ready for a 2-person technique
Primary proceduralist accesses regional area desired
Second set of hands helps aspirate and inject anesthetic where desired
Ropivacaine and bupivacaine can be used as anesthetic agent
Toxicity signs include numbness of tongue, lightheadedness, visual and auditory disturbances, muscular twitching, unconsciousness, convulsions, coma, respiratory and cardiac arrests
Pre-block checklist:
IV access established
Patient on monitors
Ensure no pre-existing neurologic deficit is present
Consultant physician is aware/on board
Patient weight documented, dose checked
Ensure Intra-lipid available
Indications for intra-lipid: seizure, CV instability, cardiac arrest
1.5ml/kg bolus + infusion at 0.25-0.5ml/kg/min for a max dose of 12ml/kg
Superficial cervical plexus block (for IJ and subclavian CVC placement)
Provides regional block to lateral aspect of neck from clavicular region to post-auricular region
Needle approach is from lateral/posterior to medial from posterior margin of sternocleidomastoid muscle
Use short <1.5’’ needle, 20 gauge and up
10-15ml of anesthetic volume
Forearm block
2-5ml per nerve
Ideal to surround the nerve sheath
Don’t inject in/poke the nerve
Consider intra-articular lidocaine injection to provide anesthesia for shoulder dislocations
Serratus anterior plane block
Attempt to cover lateral cutaneous nerve to provide anesthesia for rib fractures/lateral chest wall procedures
Total volume to inject is 30-40ml - dilute appropriate anesthetic dose with 15ml of NS
Improvement in pain and performance on incentive spirometer per trauma literature
Fascia iliaca block
Targeting lateral femoral cutaneous nerve and femoral nerve; deposit within fascia initially to dissect plan and work your way toward the femoral nerve
Improved pain control, decreases need for procedural sedation, decreases length of stay, improved patient satisfaction
20-40ml of anesthetic typically required
YEAR DIRECTIVES with DRS. CURRY & RYAN
R1/R2 EMTALA with DR. CURRY
There are three main obligations through the EMTALA law
Provide all patients with a medical screening examination
Stabilize any patient with an emergency medical condition
Transfer or accept appropriate patients as needed
The transferring hospital must continue providing care in route
The receiving hospital has the facilities, personnel and equipment to provide necessary treatment and must be contacted and accept the patient prior to transport
It is an anti-discriminatory law
It is not the same as malpractice
R3/R4 CONTRACT NEGOTIATIONS with DR. RYAN
Contract basics:
Compensation (salary)
Base pay (set salary for set/projected hours)
“At Risk” (group metrics, quality metrics, merit badges, committees)
Variable compensation aka Bonus - what is this based on? RVU vs group returns on billing that are affected by…?
Extras (overtime, shift differential)
Benefits
Health/dental insurance
What is covered? What is your cost? PPO v high deductible
Retirement
What does the group contribute?
Vesting period - is there a required time commitment before you have access to the funds contributed?
CME/Tax deferred accounts/HSA
Tuition remission
Life insurance
Disability Insurance
Specialty specific
Premiums
Pre-tax vs post-tax dollars
What percent of salary is covered?
Group vs individual
The earlier you get it - the better!
Malpractice
Claims made (you are covered while working for a given group - does not cover you if you leave the group and then get sued for a case even if it was during your work with that group) v occurrence
Who pays the tail? - Covers you for a given amount of time after claims-made insurance policy has terminated.
Does it vary by when you leave the group?
What is their level of insurance?
What is the group’s history?
Cost of living - home? Transit? Parking? Schools?
Opportunity cost - commute?
Extras
Academic/Community admin: office space, admin support, computer and furniture
Moving allowance/signing bonus: new tax law implications, how long until you “own” this?
The non-compete clause
What is negotiable?
Academic
Salary - rarely
Hours - commonly
Benefits - never
Signing bonus - occasionally
Community
Salary - occasionally
Hours - occasionally
Benefits - never
Signing bonus - commonly
Contract questions
Pay shift differential, moonlighting, when do you get paid
Dispute resolution, maternity/paternity, sick time, sabbatical
Responsibilities: clinical, administrative, education, research
Department v division? Length of contract and current status?
R3 TAMING THE SRU with DR. CONNELLY
CASE 1: A middle-aged man with a history of seizures presents after a witnessed seizure. He received IM versed in the pre-hospital setting, is noted to be unconscious and requires BVM-assisted respirations. On presentation to the SRU, he is noted to have generalized tonic-clonic seizure activity for 10 minutes, and is given versed 10mg IM and narcan 2mg IV. He is not protecting his airway, has notable tachypnea and tachycardia with a depressed mental status, and has a glucose of 259. He is intubated with difficulty, gets loaded with keppra, however there is concern for non-convulsive status epilepticus. CT/CTA demonstrate encephalomalacia and he is admitted to the NSICU for further management.
CASE 2: A male in his 60s presents as a stroke alert. He was noted to have left-sided weakness in the pre-hospital setting with last known normal 30 minutes prior to ED arrival. In the SRU, he is noted to have a left-sided facial droop, slurred speech, left arm and leg drift, and left facial twitching. CT head is notable for a subdural hemorrhage. There is concern for seizure-like activity, and he receives ativan 2mg, keppra 3g, and fosphenytoin 20mg PE/kg before the seizure is aborted. He is admitted to the neurology stepdown service.
Status Epilepticus
International League Against Epilepsy
Semiology, etiology, EEG correlate, age
Generalized tonic-clonic seizures
A patient is likely to have continuous seizure activity if an episode is ongoing for longer than 5 mins
Long term consequences (neuronal injury, neuronal death, alteration of neuronal networks and functional deficits) occur with episodes >30 mins
Focal seizures
A patient is likely to have continuous seizure activity if an episode is ongoing for longer than 10 mins
Long term consequences occur with episodes >60 mins
Management
0-5min: ABCs
5-10min: Benzodiazepines
Lorazepam and diazepam have been shown to be equally efficacious with no difference in complications (Alldredge et.al. NEJM, 2001).
No difference in complication or time to seizure termination between IM versed and IV lorazepam (Silbergleit et.al. NEJM, 2012).
10-30min: AEDs
Phenytoin, valproate, levetiracetam are equally efficacious
No difference in major adverse effects, mortality, or functional outcomes at discharge or 1 month (Mundlamuri et.al. Epilepsy Research, 2015).
30-90min: Anesthetic
Pentobarbital associated with decreased short-term treatment failure and decreased breakthrough seizures. However, it is associated with increased hypotension (Claassen et.al. Epilepsia, 2002).
Ketamine - reported dosing of bolus 1mg/kg - 5mg/kg followed by an infusion 1mg/kg/hr - 10mg/kg/hr. Retrospective studies report success in ~74% of adults.
Take home points
Seizure presentation can be highly variable
Manage generalized convulsive status epilepticus emergently
Benzos x2 -> AED -> Anesthetic
R1 CLINICAL TREATMENTS: ANGIOEDEMA with DRS. WOSISKI-kuhn & IPARRAGUIRRE
Pathophysiology
Histamine-mediated
Allergic angioedema: release of histamine via mast cells or Ig-E
Non-histamine:
ACE-inhibitor
Hereditary angioedema
Miscellaneous
Acquired: may be associated with lymphoproliferative disease
Pseudoallergic: medication related - bupropion, vaccinations, SSRIs, COX2 inhibitors, Ang2 antagonists, NSAIDS, statins, PPIs, excessive alcohol, opioids, contrast, tPA
Post-tPA has an incidence of 0.4-7.9% and occurs 5 minutes to 3 hours post-administration. More common in patients on ACE inhibitor therapy
Idiopathic
Important history characteristics: personal and family history, current medications, exposures, timing of episode
Incidence and impact
ACE-inhibitor mediated
0.1-0.8% incidence in all ACE-inhibitor prescriptions
100,000 ER visits annually
Can occur after years of stable therapy, and is most common in women, African Americans that have a preexisting NSAID allergy
Presentation
Starts with focal swelling and evolves over hours
Absence of other skin changes
Won’t respond in the classic way to treatment
Management
Anaphylactic:
Remove the offending agents
Epinephrine
Steroids
H1/H2 blockers
Potential for albuterol or racemic epinephrine in severe cases
Hereditary:
Berinert (plasma-derived C1-INH)
Ecallantide (kallikrein inhibitor)
Multi-center, randomized controlled trial
Mild to moderate angioedema within 12 hours of onset
Assessed for improvement of edema, VS, absence of stridor or dyspnea
Higher rate of achieving disposition criteria in those treated with ecallantide
Icatibant (bradykinin receptor antagonist)
Cinryze (FDA approved as a prophylactic C1-INH therapy)
FFP - advantage: contains C1; disadvantage: contains other enzymes that may exacerbate swelling
TXA - antifibrinolytic and therefore inhibits plasmin production -> decreases bradykinin production
Patient’s on ACE-i with angioedema
Did not standardize dose/timing of TXA administration
Clinical improvement was subjective, did not define criteria
Intubation as deemed necessary
R2 CPC with DRS. CRAWFORD & DOERNING
A male in his 30s with a history of diabetes, hypertension, and ESRD on iHD who presents to the ED with hiccups for three days. He denies abdominal pain, nausea, and vomiting. He has not had dialysis in 4 days and reports shortness of breath and feeling “bloated.” He denies chest pain or diaphoresis. He is noted to be borderline tachycardic and hypertensive. He is otherwise well-appearing with an unremarkable cardiopulmonary and abdominal exam. He has a mild leukocytosis with neutrophil predominance and BNP in the 200s. EKG demonstrates tachycardia without ischemic changes, CXR negative. He received zofran and thorazine for symptoms. And then a test was ordered…
CTPA for pulmonary embolism
Hiccups
Hiccups, or singultus, are spasmotic contractions of the diaphragm and intercostal muscles with abrupt closure of the glottis.
Hiccups lasting greater than 48 hours portend an organic cause
CNS: ischemic/hemorrhagic changes, encephalitis, head trauma
Vagus/phrenic nerve irritation: goiter, pharyngitis
GI disorders: GERD, gastric distension
Thoracic disorders: neoplasm
Cardiovascular disorders
Postoperative state
Toxic-metabolic: alcohol
Psychogenic
Drugs: steroids
Treatment
Physical maneuvers: stimulation of the vagus nerve, effecting CO2
Medications: thorazine, chlorpromazine, PPI, baclofen, gabapentin, metoclopramide
PEM Lecture with DR. STRATTON
Relative infrequency of critical illness in children can lead to a bias towards wellness, anchoring on wellness, and premature closure
Finding the sick kid: SAiMPLE to take a thorough history
Signs/symptoms
Allergies - up to date on immunizations?
Medications - polypharmacy
Past medical history
Asking about pediatric specialists that the patient may see
Asking about hospitalizations during life
If the patient is a neonate - baby’s history is mom’s history
Last PO
Event/exposure
Vital signs: get a good reference sheet (PALS card, etc.)
Tachycardia: compensating for something with increased HR as they do not dilate their hearts to increase cardiac output
Respiratory: tachypnea or hypoxia
Upper vs lower airway, obstruction, cardiac, metabolic, ingestion
