Grand Rounds Recap 8.16.23
/IN-Flight Emergencies - utility of trauma pan-scans - Sepsis operations - bites and stings - Intro to reliability science
In-Flight Emergencies WITH Dr. Urbanowicz
Approximately 1 in 40 flights are affected by a medical emergency, yet <2% planes get diverted
Most commonly due to syncope, headache, dizziness, and/or nausea/vomiting
As a physician, you are not legally obligated to intervene on an in-flight medical emergencies in the US
This does vary for international flights
Aviation Medical Assistance Act (AMAA) provides coverage for ‘good Samaritans’ involved in a in-flight medical emergency
Only applies to medical emergencies, as it does not cover care rendered or medical advice given for non-emergencies
AMAA protection is lost if you receive any form of compensation for your services
AMAA does not give providers any legal authority over the plane or its crew; thus, they cannot be held liable if a pilot does not follow their recommendations (e.g., to divert the plane).
In-flight physiology
Cabin is pressurized, typically to about 8,000ft or less, so expect some relative hypoxia (typical SpO2 reading is 90-92%) and hypoventilation
There is also risk of third-spacing/capillary leak due to vasodilation and decreased oncotic pressures
Gas expansion can lead to an increase risk of a spontaneous pneumothorax, especially in patients with underlying blebs
Higher risk of sensible fluid losses
FAA minimal in-flight medical equipment requirements include:
AED, BP cuff, stethoscope, oral airway, BVM with mask, IV tubing, tourniquet, gloves, needles, syringe, alcohol wipes, tape roll, scissors
AMAA does not make providers responsible if a patient is harmed because of the failure of the airline to have appropriate medical equipment available.
Typical in-flight medications available:
500mL Normal Saline
Acetaminophen, 4x 325mg PO
Diphenhydramine, 4x 25mg PO
Diphenhydramine, 2x 50mg IV/IM
Albuterol MDI x1
D50 x1
Epinephrine 1mg/mL, 2x 1mL
Epinephrine 0.1mg/mL, 2x 2mL
Lidocaine 20mg/mL, 2x 5mL
Nitroglycerine, 10x 0.4mg PO
Atropine, 2x 0.5mg
Aspirin, 4x 325mg PO
If a cardiac arrest occurs during a flight:
If able, move to the galley
High-quality CPR is main focus
Immediately call for diversion of the plane
Avoid termination in the aircraft
Clinical Controversies: Utility of Trauma Pan-Scans WITH Drs. Lane & Mcdonough
Definition of an immediate whole body CT (iWBCT) scan
Shortly after patient arrival. following the primary survey & initial stabilization
Scanning from the vertex to pubic symphysis
Utilizing contrast-enhanced CT imaging
Argument IN FAVOR of iWBCT in patients presenting with blunt trauma
REACT-2 trial
Immediate Total-Body CT scanning versus conventional imaging and selective CT scanning in patients with severe trauma
Randomized controlled trial
Asks the question: is iWBCT, compared to selective CT imaging, associated with an in-hospital mortality benefit in trauma patients?
These were adult trauma patients with compromised vitals, clinical suspicion for life-threatening injuries, and/or presence of a severe injury
Negative study for this primary outcome, but potentially an under-powered study
Also, study involved mortality of all trauma patients, lumping together patients with polytrauma and those with TBI’s
Secondary outcomes show a trend towards, yet still not statistically significant, quicker disposition from ED if iWBCT is performed instead of selective imaging
Furthermore, degree of radiation exposure seems to be similar for iWBCT compared to selective imaging
Yet iWBCT also has the added benefit of uncovering incidental findings that selective imaging may have otherwise missed
Special considerations for performing iWBCT in the geriatric population
Physical exam is a not accurate predictor of injury in geriatric patients
Instead CT scans can help uncover clinically significant findings (such as multiple rib fractures, long bone fractures, etc.)
Can also extend this logic to those with TBI’s or trauma patients are inebriated
Can attempt try to mitigate the risk and harm associated with iWBCT’s
Future use of low-dose iWBCT
Full-body MR imaging is already being used in pediatric patients
Logistic regression in REACT-2 patient population identified 10 characteristics to warrant iWBCT in patients presenting with blunt trauma
Trauma patient with one of the following:
o SBP <100mmHg
o Estimated exterior blood loss of at least 500cc
o GCS of 13 or less
And/or, patient with a clinical suspicion of:
o Fracture of at least 2 long bones
o Flail chest, open chest, multiple rib fractures
o Severe abdominal injury
o Pelvic fracture
o Unstable vertebral fractures/spinal cord compression
And/or, patient with the following mechanism:
o Fall >13 ft height
o Wedged/trapped chest and/or abdomen
Argument AGAINST immediate whole body CT scans in patients presenting with blunt trauma
Though there is a role for the trauma pan-scan, a patient should NOT patient should be pan-scanned due to mechanism alone or because they were roomed in the trauma bay
We are ultimately attempting to find out, do pan-scans reduce morbidity & mortality in blunt trauma? Yet the issue is that a lot of the data involves retrospective studies & meta-analyses
With retrospective studies, one problem is that you can’t interpret the real-time decision-making that went into patient selection
You can’t really know why some patients received iWBCT, while others did not
Additionally, studies involving registries are often labelled as prospective, when the question they are asking is actually retrospective
With meta-analyses, there is a degree of bias with the studies the authors chose to include
Additionally, it is difficult to correlate outcome measures across different studies with different inclusion/exclusion criterion
Gupta et al., 2011
Selective Use of Computed Tomography Compared With Routine Whole Body Imaging in Patients With Blunt Trauma (Ann Emerg Med 2011)
Prospective observational study
701 patients with blunt trauma presenting as a trauma activation
total of 2804 total scans
992 were deemed unnecessary by ED and/or Trauma
794 were deemed unnecessary by ED (but not Trauma providers)
Only 3 scans undesired scans led to a critical actions (0.3%)
Info provided about these patients suggests they should have likely received a pan-scan regardless (including one patient with lower extremity paralysis)
Further analysis revealed that ED team would have ordered less scans overall, yet still ordered 98% of scans that were ultimately led to a critical action
Potentially because emergency medicine providers are exposed to a broader spectrum of severity (not just severe trauma) and are also more focused on resource utilization and the consequences of over-testing
REACT-2 trial
As discussed above, this is a randomized controlled trial in adults presenting with blunt trauma
Ultimately found no difference in mortality when comparing trauma patients undergoing iWBCT versus selective CT imaging
Pan scans are costly
Approximately a $16,000 charge
Pan scans are deadly
About 2% of cancers are attributed to CT radiation exposure
In a patient over the age of 45 years-old, radiation exposure of 20mSv leads to 1 in 1,000 radiation-induced mortality rate
Radiation exposure from trauma pan scans is about 22-29 mS
Meanwhile, selective scan group in REACT-2 trial had less radiation exposure than lowest mSv associated with pan scans
Pan scans are resource intensive
Pan scans are ordered on less then 5% of our total ED-volume, yet takes significant amount of time to complete
Scan itself takes about 15 minutes
Time to read scan is about additional 45 minutes
This can lead to delay in other time-sensitive patients getting to the CT scanner, such as those with a stroke
Instead of blindly ordering trauma pan scans, can instead rely on decision-making tools to guide selective imaging
NEXUS Chest CT clinical decision rule
If CT chest is ordered for criteria listed below, there is a sensitivity of 95.4% for detecting major injuries
Abnormal CXR
Rapid deceleration mechanism
Presence of a distracting injury
Chest wall tenderness
Sternal/thoracic spine/scapular tenderness
There are limited decision-making rules for thoracic spine imaging
Yet a study (Inaba et al., 2015) reported a sensitivity of 98.9% for clinically significant thoracolumbar injuries in patients >60 years-old or high-risk mechanism with any of the clinical signs listed below:
pain
midline tenderness
deformity
neuro deficit
Personal practice pattern for ordering iWBCT in trauma patients
Sick trauma patient gets a pan-scan
Altered trauma patient with a decent mechanism gets a pan-scan
If normal GCS and vitals, use history and vitals to guide selective imaging and you can expand imaging based on x-ray films and selective CT findings.
Joint conclusions
When to order a trauma pan-scan?
HD unstable patient, the presence of a neurologic deficit, altered patient with an unreliable exam, moderate to high mechanism on blood thinner, elderly patient with a suggestive mechanism, those with significant evidence of chest trauma
When to avoid ordering a trauma pan-scan?
Cooperative patient who can provide history, those with reliable exam to follow, those without SOB/hypoxia/severe chest pain in setting of normal CXR, low suspicion for T-spine injury, based on mechanism alone
sepsis operations WITH Dr. Shewakramani
Sepsis is associated with 20-40% mortality
Screening tools for detecting patient at risk for sepsis in the ED
SIRS Criteria (more sensitive tool)
Temp <36C (96.8F) or >38C (100.4F)
HR >90
RR >20
WBC <4k or >12k (or >10% bands)
qSOFA Score
GCS <15
RR >22
SBP <100mmHg
Overall, SIRS Criteria remains the standard for screening patients at risk for sepsis in the ED, while qSOFA can be added to see which patients are at a higher risk for deterioration and mortality
CMS Definitions
Severe Sepsis
Source of infection (suspected or confirmed)
2 or more SIRS criteria above
Plus, evidence of end-organ damage
elevated lactate, creatinine, INR, and/or bilirubin level
decreased platelets
Septic Shock
Lactate >4
Hypotension despite fluid administration
CMS Initial Sepsis Management Bundle
Severe Sepsis
Goals within the first 3-hours
Time zero is when severe sepsis criteria is first recognized or when “severe sepsis” is documented in a provider’s note
Lactate, blood cultures, start antibiotics
Repeat lactate (if initial level is >3)
Septic Shock
Goals within the first 6 hours
Time zero is when septic shock criteria is first recognized (hypotension with infection) or when “septic shock” is documented in a provider’s note
Lactate, BCx, Abx as mentioned above
Plus, administration of IVF’s, vasopressors, reassessment of volume status after IVF administration
Changes made at WCH to improve CMS sepsis bundle compliance with the ultimate goal of improving patient care
Initiation of ‘Code Sepsis’
Automatic ESI level 2, patient moves quicker from lobby to a room
Gives a sense of urgency similar to any other critical illness in the ED
Sepsis order set in Epic
Automatically assign an ESI 2, Q1h vitals, 2 peripheral IV’s
Automatically selected labs include: BCx x2, LFT’s, lactate x2, INR, trop, UA, VBG, CXR
Built-in prompts for administration of fluids
30cc/kg if patient has evidence of septic shock
Can use ideal body weight if BMI >30
If patient has CHF or ESRD, can document rationale for avoiding the typical 30cc/kg fluid administration
Prompts for administrations of antibiotics, as well as antipyretics
Process for drawing and processing blood cultures is now more streamlined
Individual case feedback provided to providers caring for a patient with sepsis
Still have some specific areas for improvement at our institution
Time to diagnosis
Drawing blood cultures before antibiotics
Repeat lactate levels if initial level is >2
Repeat assessments of volume status
bites and stings WITH Dr. roche
Large animal bites
Majority can just heal by secondary intention
Poor evidence for prophylactic antibiotics for mammalian bites
More evidence of benefit of bites involving hand
Treat when signs of infection are present
Mammal bites need to be reported to Hamilton County Public Health (there is a mammal bite report form available)
Rabies
In the US, mainly from bats, rats, skunks, and mongooses
Yet transmitted by dogs in other parts of the world
Dogs will show symptoms within 10 days (pacing, not eating, seizures, etc.)
If able, can ask patients to watch the dog for developing signs of illness
Immunoglobulin
Inject around the site of the bite
Remainder of injection in the deltoid (SAME side as bite)
Vaccine
Administer opposite side of immunoglobulin administration
Total of 4-doses (0, 3, 7, and 14 days)
If immunocompromised, will need a total of 5 doses
Snakes
Venomous Snakes of Ohio
Timber Rattlesnakes
Massasauga
Eastern Copperhead
In the US, typically involves viper-envenomation
Mostly leads to local tissue damage
Yet there is some overlap with neurotoxin effects as well including fasciculation and cranial nerve abnormalities (rarely paralysis)
ED evaluation
Exam
Look for local tissue damage
Progressively mark the spreading redness, edema
Labs
CBC, BMP, coags, fibrinogen level
CK, UA, Dimer, fibrin splint products, TEG/ROTEM
Call Poison control (800-222-1222)
NO role of tourniquet, as it frequently leads to limb loss
AVOID ice/cool compress, as it will keep toxicity localized
Typically monitor for at least 12 hours and consider repeating labs prior to discharge
Grading of Envenomation
Minimal
Expect swelling to site, no systemic signs, normal coags, and no signs of bleeding
This is because most snake bites are “dry” bites
Monitor for a full 12 hours
Consider holding anti-venom
Moderate
Significant swelling, yet not involving an entire extremity
Systemic signs, yet clinically stable
Abnormal coags, yet no bleeding
Severe
Swelling involving entire extremity or threatening the airway
Systemic signs and appear clinically unstable
Abnormal coags with signs of clinically significant bleeding
Anti-venom
Crofab
From sheep
Re-dose recommended
Anavip
From horses
Larger molecule, therefore not cleared by kidney, generally does not need re-dosing
Not approved for copperheads
Mosquitos
Anopheles
Malaria
Aedes
Dengue, Yellow Fever, Zika, Chikungunya
Repellants
FDA-approved mosquito repellants
DEET
Will dissolve plastics, sealants, synthetics
Use <10% concentration with children – higher concentrations last longer (like sunblock)
Picaridin
Oil of lemon eucalyptus
Permethrin
Used on clothing and netting
this will actually kill the insect, not just a repellant
Ticks
Typically need at least 24 hours to transmit the disease
Lyme disease needs at least 48 hours to transmit disease
American Dog Tick
RMSF
Tick Paralysis
Tularemia
Blackleg Tick
Lyme Disease
Babesiosis
Lonestar Tick
Alpha-Gal meat allergy
Removal of ticks
Grab as close to skin as possible with tweezers and pull with steady pressure
Bees, Hornets, Wasps, & Ants
Around 60 deaths / year in the US from Hymenoptera sting anaphylaxis (50% with no history of previous anaphylactic reaction to stings)
Hymenoptera are attracted to sweet-smelling fragrances, such as certain after-shaves and perfumes
Importance of having access to epi
Spiders
Black widow (Latrodectism)
Bite is painful and quickly becomes red
Muscle cramps and stiffness are common, which may ascend to the abdomen and thorax
Brown recluse (Loxocelism)
Painless bite, then becomes itchy/red
Typically heals within two weeks
Some develop necrosis and require longer time to heal, plus increase risk of infection
Systemic toxicity is very rare
May involve hemolysis, hematuria, fever
Scorpions
Arizona Bark scorpion
Found in Arizona and New Mexico (especially in boots left outside)
Neurotoxin released at the time of the sting is the cause of ensuing neuromuscular activity and autonomic dysfunction.
Symptoms include paralysis, muscle spasms, breathing problems, vision problems, swallowing difficulty, and slurred speech.
Anti-venom does exist and is very expensive (Anascorp)
Marine Envenomation
General principles
Remove tentacles
Soak is sea water & vinegar to avoid osmotic change leading to discharging more nematocysts
Subsequent warm water immersion versus ice pack
Introduction to Reliability Science WITH Dr. Wright
Definition of reliability in healthcare
The capability of a process, procedure, or service to perform its intended function in the required time under existing conditions
There are different levels of reliability
Level 1: 80-90% reliability
Level 2: about 95% reliability
Level 3: about 99% reliability
If a process is experiencing <80% reliability, it is consider to be chaotic
Leaders ultimately determine where to focus reliability efforts
There are opportunities throughout our hospital to improve reliability
This is because human behaviors fail at predictable rates, especially in a high stress and fast-paced environments (such as our emergency department)
Designing for Reliability
Level 1:
Often focuses on changing individual actions
Typically involves standardization including feedback mechanisms, awareness/training, order sets/protocols/check-lists, etc.
Level 2:
Often about changing the process and limiting human behavior
Goal is to change the workflow to make it easy to do the right thing (and hard to do the wrong thing)
Human choices become more limited
Such as making the desired action the default, regular reminders, or intentionally inserting redundancy
For example: patients receiving asthma education regardless of physician placing the order is an example of defaulting to the appropriate action
Level 3:
Mostly about improving the whole system and culture, as well as hardwiring to greatly constrain human choices
Important to remember that improving the system and changing the culture happen together, as they are interdependent on one another
This involves sophisticated behavioral designs
Take advantage of habits/patterns (daily huddles)
Make the system visible (control charts, whiteboards)
Use clear communications (protocols with exact phrasing)
Principles of High Reliability Organizations (HRO) are the foundations for level 3 reliability
Preoccupation with failure
Reluctance to simplify interpretations
Sensitivity to operations
Commitment to resilience
Deference to expertise
Use these HRO principles to redesign the process to mitigate known/potential failures
Often includes “hardwiring” the process and creating a strong safety-minded culture
Real-life example of design to improve reliability, involving a project aiming to reduce CAUTI’s at UC Health
Level 1:
Present appropriate indications for Foley placement to nursing staff
Send emails to providers with data and protocols
Grand Rounds lecture to the department
Posting reminder signs pertaining to CAUTI’s throughout the ED
Level 2:
Begin to stock PureWick’s in the ED
Move condom catheters so they are more easily accessible to staff
Require provider order, with specific indication, prior to Foley placement in the ED
Level 3:
Hard stop on Epic with indications for placement and timing of removal
