Grand Rounds Recap 8.23.17

Airway Grand Rounds with Dr. Carleton

Case 1
20 yo with PMH of depression presenting 30 minutes after ingesting 60 amitriptyline pills. Arrives semi-upright as sats fall when she lies flat
BP 106/68 HR 132 RR 8 O2 91% on 6L BMI 42

  • Decision is made to enter difficult airway algorithm
  • Forced to act? No
  • Failing to maintain oxygenation? No
  • Can we bag or rescue with an EGD? Possibly not

Decision is made to attempt awake look. Start with topical lidocaine and titrate anxiolysis to effect
What modality do you want to use?

  • DL: "Specious nonsense"
  • VL: Comfortable modality however difficult to lie this patient back and potentially a large amount of secretions
  • Fiberoptic: Preferred modality as the patient can remain seated with improved oxygenation. Also, secretions will drain away from the scope versus towards the laryngoscope
    • Nasal: look with otoscope and this patient has minuscule nasal passages so move to oral
      • Also always consider anticoagulation status, 20% of people will bleed even without being on blood thinners
    • Oral: do you go through a Williams airway or a supraglottic device
      • This patient has an intact gag so putting down an iGel may be less than ideal (keep in mind you can intubate through an iGel with an ETT that is three sizes larger, ie if there is a size 3 iGel in place you can use a 6.0 ETT)

Preoxygenation: You can use a NRB with flow rate cranked as high as it will go however in this patient consider tidal breathing through a BVM with a tight mask seal and a PEEP valve

Oral Fiberoptic Intubation Tips and Tricks
Multiple studies show effectiveness when you subtotally intubate to 15cm, then pass scope as opposed to hubbing the ETT on the scope. This also may prevents people from biting on the wand
Make sure you take your finger off the scope trigger prior to passing the tube so that the scope does not have a curve at the end making the tube hard to pass
Diameters of the Williams airways are are 9 and 10mm, can pass any ETT through these

Case 2
53 y/o with history of glossary squamous cell cancer with prior partial glossectomy, trach and radical neck dissection comes in with difficulty breathing after his trach tube is pulled out. Wears a 6.0 Shiley (ID 6, OD 10)
Stoma is small and the margins are small and he is making stridorous sound during inspiration. When he expires bubbles and blood come pouring out of his trach stoma
He is hypertensive, hypoxic and tachycardic

Ask yourself is he moving any air from above?

  • If not it may have been prior laryngectomy in which case there is no way to intubate from above

How to preoxygenate?

  • Bag through stoma either using a pediatric mask or an extra-glottic devices

Trach Recanalization Steps
Identify landmarks, prep, field block using 1% lidocaine, place mucosal atomizing device and use 4% lido, lubricate and then start with a small ETT, insert tube and blow up balloon, pull out the tube with balloon inflated to then dilate the stoma, repeat using increasing ETT sizes then lastly use the Seldinger technique to place the trach over a bougie or suction catheter.

EM-Neuro Combined conference: Headaches That Can Ruin Your Life with Dr. Neel

Pathophysiology: Brain itself cannot feel pain, pain is often caused by disruption of the meninges, cerebral arteries, the sinuses or cranial nerves
Primary Headaches: Migraines, cluster, autonomic cephalgias, tension and trigeminal neuralgia

  • Migraine: Recurrent (at least 5 attacks), unilateral, 4-72 hours, pulsing, moderate or severe, nausea/vomiting, photophobia/photophobia, aggravated by or causing avoidance of routine physical activity
  • Tension: at least 10 episodes occurring on <1 day per month average, 30 minutes to 7 days, bilateral, pressing/tightening, mild or moderate, not aggravated by routine physical activity

Secondary headaches: traumatic, vascular disorder (ischemic stroke, SAH,  vascular malformation, arthritis, dissection, and thrombosis), substance abuse, infection, facial pain/skull and cranium, homeostasis (arterial hypertension, cardiac cephalalgia, hypothyroidism, hypercapnea/hypoxemia, dialysis and fasting)

Headaches that Kill: Meningitis, SAH, PRES, ICH, dural sinus venous thrombosis, vasculitis, pituitary apoplexy, and tumors
Headaches that Maim: CO poisoning, stroke, temporal arthritis, intracranial hyper/hypotension, and glaucoma
Headaches that Annoy: Primary headaches

Case 1
44 y/o F morbidly obese with acute onset and then LOC, transferred from OSH for neurosurgey consultation, now comatose and intubated
BP 194/105
HCT showing cortical bleeding, key point in this case is that this IS NOT a classic place for a hypertensive bleed
CT-V read as negative however in retrospect the contrast bolus was poorly timed
Ultimate dx: dural sinus venous thrombosis

  • Headache is the most frequent symptom, thunderclap in 10%
  • Treat with anticoagulation despite the fact that there is intracranial hemorrhage!

Case 2
34 y/o F with new headache starting about a month ago, gradually worsening, CT with mild sinusitis, completed two rounds of antibiotics with presumed sinusitis, now hospitalized for IV antibiotics with presumed sinusitis and starts having blurry vision and trouble focusing, now found to be pregnant
On LP found to have pressure of 50
Diagnosis: Idiopathic Intracranial Hypertension

  • Syndrome of elevated ICP due to over secretion or under absorption
  • Typically obese females of child bearing age
  • Symptoms: headache, vision loss (starts with peripheral fields way before visual acuity)
  • One way to clarify central versus peripheral vision is to ask "Are you having problems driving or are you having problems reading?"
  • Findings: papilledema and elevated pressures on LP
  • Treatment: serial lumbar punctures, diamox, corticosteroids, topiramate (some carbonic anhydride inhibitor activity), consider ophthalmologist surveillance for optic nerve sheath fenestration

Case 3:
27 y/o 3 days postpartum now with new double vision and low back pain, positional component after epidural
DDx: post LP headache, pre-eclampsia, pituitary apoplexy
On MRI the dura enhance throughout
Dx: Intracranial Hypotension

  • Symptoms: Classic orthostatic headache, worsened by sitting upright, laugh/cough/valsalva worsens
  • Causes: lumbar puncture, spinal anesthesia, VP shunt, spinal trauma, surgery, DKA, uremia, cough
  • Treatment: fluids, bed rest, steroids?, blood patch?
  • Complications: subdural hematoma from tearning of the bridging veins, cranial nerve palsy

Other Diagnoses to Consider
RCVS: reversible cerebral vasoconstriction syndrome, usually presents 1 week post partum
PRES: posterior reversible encephalopathy syndrome

When to Obtain Imaging?

  • Decreased alertness, onset of pain with exertion, coitus, coughing, or sneezing, worsening under observation, focal headache age >50, worse headache ever, headache not fitting a defined pattern, headache worsened by valsalva

Treatment: Consider a multi-modal approach with NSAIDS, anti-emetics and IV fluids

  • Consider caffeine, 2g magnesium IV and depakote
  • Avoid narcotics if possible

R3 Taming the SRU with Dr. Thompson

Elderly female with 3 months of dizziness, acutely worsened today, worse with backwards head tilt and looking left, no weakness, SOB or chest pain
Neuro Exam: Normal with exception of positive Romberg to the right and disrupted tandem gait, dizziness with Dix Hallpike to left with no nystagmus

  • Head Impulse: abnormal in peripheral causes
  • Nystagmus: Horizontal or unidirectional nystagmus with peripheral causes versus rotary, bidirectional or vertical with central causes
  • Test of Skew

Workup: Normal HCT but WBC of 50 with metamyelocytes and bands
DDx: stroke, dissection, hyperviscosity, intracranial mass/hemorrhage, BPPV
CTA head and neck: grade III carotid dissection with a small psuedoaneurysm

Vertebral artery dissection: younger patients, potentially after trauma (MVC, chiropractor, workouts), complications include vessel occlusion to stroke, thrombus formation to stroke, SAH or pseudoaneurysm
Often present with vague symptoms and ipsilateral neuro deficits
Management: antiplatelet, anticoagulation, endovascular intervention

  • CADISS Study: 250 patient RCT for antiplatelet versus anticoagulation found no difference
    • Recommends antiplatelet for intracranial dissections given high risk of SAH

Bow Hunter Syndrome: rotational vertebral artery compression occurs with mechanical compression of vertebral artery with head rotation

Hyperviscosity Syndrome

  • Can be caused by PV, multiple myeloma and monocytic leukemias
  • Consider with WBC >100,000
  • Can present with oronasal bleeding, vision changes, AMS, heart failure
  • Treatment is plasmapheresis

Wellness Curriculum with Dr. Liebman

Prevalence of burnout is up to 50% across all physicians with a 29% depression rate amongst residents
Most common strategies: mindfulness, stress management and small group discussions
Step by step approach to improving wellness in a physician group
1. Acknowledge and assess the problem
2. Harness the power of leadership
3. Develop and implement targeted interventions
4. Cultivate community at work
5. Use rewards and incentives wisely
6. Align values and strengthen culture
7. Promote flexibility and work-life integration
8. Provide resources to promote resilience and self-care
9. Facilitate and fund organizational science

Discharge, Transfer or Admit Toxicology with Dr. Roche

Case 1
85 y/o M with a fib and CHF, n/v/d for 5 days, syncopal event at home 1 hour ago, lightheaded and confused per family
Vitals: BP 90/60, HR 70
Exam: Pupils midrange, skin is cool and dry
EKG: with deep ST depressions in the anterior leads, and regular with p waves despite history of atrial fibrillation (induced regularity)
Labs: K 3.2, creatinine 2.5
        Get a mag! --> Level is 1.0
        Digoxin level 3
Indications for DigFab: levels of 4-5 in chronic ingestion and 10 in acute ingestion, unstable arrhythmia
Mortality around 15%, consider putting this patient in the ICU

Case 1a:
3 year old possible seed ingestion
Consider Oleander: cardiac glycoside
Can take up to 10 hours to show symptoms
Digoxin assay sensitivities is variable

Case 2
Teenager found down in movie theater bathroom, drowsy, GCS 13, woke up a little after Narcan IN
On arrival breathing regularly
Monitor shows bigeminy to V. Fib and then back to sinus with no intervention
Vitals: 130/100, HR 120, RR 20
Exam: awake by drowsy, diaphoretic, pupils midrange and reactive
1 hour later: vitals normal, AAOx4, totally asymptomatic
Diagnosis: Huffing/Hydrocarbon ingestion --> sensitization of myocardium to catecholamines -->arrhythmia
        Butane: ok for ingestion however in the setting of aspiration can cause devastating pneumonitis
        Nitrous: neurotoxicity from B12 toxicity
        Touelene: metabolic acidosis and renal insufficiency
Do not use charcoal for these patients! Ineffective and high risk of aspiration

Case 3
55 y/o M with CHF (EF 25%), CKD and a toothache
Complains of tinnitus for 1 day, seems confused per daughter
Vitals: 100/70, HR 98, RR 40
Exam: pupils midrange, diaphoretic, mild confusion, "silent tachypnea"
Labs: K 3.6, Cr 3.5 (baseline 1.8), Gap 21, pH 7.4, PCO2 26, HCO3 16 (Mixed respiratory alkalosis with anion gap meabolic acidosis)
Dx: Salicylate poisoning
Mainstay is to alkanalize the blood, will be complicated given CHF history
What do you do with this patient in a community setting with a long transport time?
        Do you transport without an airway? At what point is he going to tire out?
        What if they need dialysis, is that available in your hospital?

Case 4
50 y/o M released from psych facility yesterday, brought for SI, initially denies ingestion but becomes more obtunded and then starts seizing
Labs: Metabolic acidosis with a high anion gap
Dx: ethylene glycol ingesion
Labs: Remember to check a calicium as it is consumed when the ethylene glycol forms oxalate crystals
No fomepizole? Consider EtOH via NGT or IV

  • PO: 4 ml/kg of 20% ABV then drip 0.4 - 0.8 ml/kg/hr
  • IV: 8 ml/kg bolus of 10% EtOH with D5W then drip 0.8 - 1.6ml/kg depending on tolerance
  • Binds alcohol dehydrogenase with higher affinity then the toxic alcohol

Consider antibiotics in anyone this sick as this is still an undifferentiated acidosis
If they get to a point where they are acidotic that they've already metabolized all their ethylene glycol they now they need dialysis

  • If patient no longer has an osmotic gap you have likely gotten to this point

Case 5
My toddler might have swallowed on of these, can I go home in 6 hours?
Buprenorphine: No
Glipizide: No
Amiryiptyline: Probably not?
Lomotil (Atropine/Dihenoxylate): No
Iron: Should be symptomatic in 6 hours, if you can get an iron level and its undetectable then can likely go home
Diltiazem: No
Tylenol: Levelable
Metoprolol: No, more worried about hypoglycemic effects then the cardiac effects

Case 6
Kid ate a laundry detergent pod and is now asymptomatic
Often contain propylene glycol can cause delayed sedation
With no symptoms of esophageal/airway burn after 3 hours no need for empiric endoscopy and likely safe for dischage home

Case 7
Button battery ingestion
Anything in the esophagus needs emergent transfer immediately
If i has passed into stomach or beyond and they are asymptomatic this needs to be followed with imaging but does not need aggressive treatment

Case 8
16 y/o F with developmental delay brought in by mother 3 hours after drinking 8oz bottle of Benadryl because he likes the taste
Vitals: 99, 140/80, HR 140, RR 18
Exam: acting bizarre, dry, flushed, pupils large and reactive
Labs: Normal except for lactate of 3
EKG: narrow complex tachycardia
Dx: Anticholinergic overdose
Keep giving benzos then consider physostigmine before intubation
Avoid physostigmine in the setting of possible TCA overdose!
Need to be admitted for observation as benadryl will likely outlast the antidote