Grand Rounds Recap 8.26.2020
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morbidity and mortality WITH Dr. li
Reversal of Direct Anti-Xa Inhibitors
Reversal of Direct Xa Inhibitors
Apixaban, Rivaroxaban
PCC (K-centra)=Prothrombin Complex Concentrate
Andexanet alfa (Andexxa) is a recombinant factor Xa protein
2019 NJEM Full Study Report
Included mostly GI and ICH and no control group
Measured outcomes were: change in activity and “hemostasis”
Strict exclusion criteria: <1mo survival, recent thrombosis, GCS<8
82% patients get excellent hemostasis
Defined by CT scans and hemoglobin changes
10% of patients had thrombotic events
CHEST and ESO, ACC recommend reversal
Andexanet alfa recommended if available
UC Criteria for Andexxa:
No previous reversal agent used
Last dose 18-24 hours
PT>16s or anti-Xa >0.5u/ml
Major or life threatening bleed
Important to know last dose of the Anti-Xa and what dose
Dictates high or low dose andexanet alfa
High dose costs $58K
PCC
Can be used if no Andexxa available
2020 Observational study
Excluded many ICH patients
82% had “excellent” hemostasis
4% thrombotic events
Necrotizing fasciitis and waterborne pathogens
Necrotizing Fasciitis
Fast progressing with high morbidity and mortality
Don’t rely on diagnostics or imaging
High suspicion = consult surgery
Broad spectrum ABx in addition to clindamycin
Waterborne Pathogens
Vast majority of waterborne pathogens cause mild respiratory or gastrointestinal symptoms
Edwardsiella tarda
Gram negative bacilli
Bacteremia is rare and often fatal
Catfish often have this bacterium
Vibrio vulnificus
Common waterborne bacteria leading to skin infections
Found in:
Salt or brackish water
Infected oysters, shellfish, seafood
Rapidly progressing cellulitis with bullae
High risk for sepsis
High risk patients:
Liver disease
Diabetes
Renal insufficiency
Doxycycline and 3rd generation cephalosporin
Aeromonas hydrophili
Fresh or brackish water
Cellulitis shows up within 2 days of injury (slower than above pathogens)
Resistant to most Abx
Doxycycline + ciprofloxicin vs ceftriaxone
May progress to bullae, myonecrosis
High risk patients:
Chronic liver disease
Immunosuppressive pt
Nonconvulsive Status Epilepticus (NCSE)
Nonconvulsive Status Epilepticus (NCSE)
Diagnosis
EEG that an EEG trained neurologist reads
Not as rare as initially thought
Diagnosis is often delayed
There is a correlation between mortality and length of time to diagnosis
Presentation
Altered Mental Status or Confusion
Speech disturbances
Altered behavior
Myoclonus
Psychiatric symptoms
Prevalence of NCSE in altered ED patients:
78% of patients had abnormal EEG (not specifically NCSE)
Of these 5% had nonconvulsive seizures
NCSE maybe be seen after the control of convulsive status if no return to baseline
Up to 14%
EEG is indicated in:
Altered patients without obvious source
Especially if they have a structural brain abnormality (mass, stroke, etc)
Long postictal period
Critically ill comatose pt
Convulsive patient that was intubated and paralyzed
Hemorrhagic Ascites
Hemorrhagic Ascites
Pink-tinged is about 10K RBC
Red is about 50K RBC
Causes:
Multiple attempts
Violating a vessel
Intrabdominal cancer
Especially HCC can spontaneously bleed
Intra-abdominal varices
These can rupture just like esophageal
Lupus
Sarcoid
Systemic TB
Endometriosis
Evaluation of hemorrhagic ascites patients in the ED
Spontaneous is the most likely cause, consider CT if hemodynamically compromised / lowering hemoglobin
Higher risk of needing:
Transfusion
ICU
Vasopressor
Elevated Lactate
Lactate is a marker of how sick you may be
Decreased clearance may indicate how poor your outcomes will be
Hypoperfusion
Shock of any kind
Should initially assume this and treat appropriately
Local tissue ischemia
Mesenteric ischemia, limb, burns, trauma, compartment, necrotizing fasciitis
Consider surgical consultation
Drug/toxin
Pharmacologic
Epinephrine
Metformin
Linezolid
Valproate
Albuterol
Propylene glycol is the additive in Ativan drip
Drugs
CO
Cyanide
Cocaine
Toxic alcohols
Thiamine deficiency
Malnutrition (anorexia, alcohol use, hyperemesis gravida)
Significant muscle activity
Seizure
Heavy exercise
Increased use of respiratory muscles
Should clear rapidly after the stopping of heavy activity
Other metabolic
DKA
Mitochondrial disease
Liver dysfunction
Large Vessel Occlusion Strokes
Large Vessel Occlusion
TPA Indications:
Last Known Well <4.5 (<3 with broader criteria)
BP <185/100
No Contraindications
Door To Needle goal is <45 mins
If an LVO is seen
Evaluate for mechanical thrombectomy
If symptoms >6 hours then do a CTP
Evaluates mismatch ratio of ischemic area to penumbra to consider treatment
2019 Stroke Updates:
IV tpa is a Class 1A recommendation if no contraindications
LVO - still gets IV tpa even with thrombectomy
Mortality was improved from 32 to 14% with the combination treatment, although new data suggests less of an effect
Task switching/saturation
50% of crisis events have task saturation
Poor teamwork or communication have increased task saturation
The technical skills do not cause task saturation
Task saturated = adverse outcomes
TEAMWORK is important to prevent task saturation and thus adverse outcomes
Herpes Zoster
Herpes Zoster
Airborne and contact precautions
Antiviral Therapy (Acyclovir)
Age >50
Severe pain
Severe rash
Face, or eye, other complication
All immunocompromised
Works to prevents new lesions and spread and pain
Disseminated
Risk factors:
HIV
Solid organ transplant
Bone marrow transplant
Autoimmune disease
Chemotherapy
Visceral zoster without a rash
Abdominal pain that can progress to pancreatitis, hepatitis, gastritis
Especially consider with the immunocompromised patients
r4 capstone WITH Dr. hall
“Is that really necessary?” - Debunking Dogma
Skeletal Traction for Femur Fractures
Benefits
Improve fracture alignment
Reduce pain/spasm
Improve subsequent reduction
Prevent AVN and Non-union
Meta-Analysis and Cochrane review of 11 studies with 1645 patients
Traction vs no traction
No difference in
Pain reduction
Ease of subsequent reduction
Incidence of fracture healing complications
Impact of prolonged traction with acetabular fractures (2020)
Retrospective of 190 patients in skeletal traction
Incidence of pulmonary complication (PE, ARDS, Pneumonia)
If >72 hours then 13%
If >120 hours is 45%
Repeat Neuroimaging in mild TBI
2014 study: Retrospective with 323 patients with GCS 14 or 15 and had a repeat CT within 24 hours
92 admitted
2 deaths (obvious clinical deterioration soon after arrival)
3 required surgical intervention
25 to ED observation
206 d/c from ED
28 return visits
1 death (had a second fall)
Mean length of stay was 23 hours in this cohort
2019 study
Similar inclusion characteristics as above
935 patients monitored
9 had intervention
6 with decline prior to CT
3 without decline but had >1cm of SDH
Finding: 305 repeat scans performed for 1 neurosurgical intervention that would not have otherwise been detected
Digital Rectal Exam in Trauma
Benefits in detecting
Rectal hemorrhage
Rectal mucosal injury
Spinal cord injury
Post urethral disruption
2007 retrospective study in 1400 patients
Sensitivity for any injury is 22.9%
DRE missed:
63% spinal cord injuries
67% rectal wall injuries
100% pelvic fractures
80% urethral disruptions
2005 prospective study of 512 patients with 30 index injuries (spinal cord, GI, urethral)
Spinal cord
DRE was positive in 36% cases
Other indicators of disease seen in 79%
GI bleed
DRE was positive in 36%
Other indicators of disease seen in 73%
Urethral Injuries
DRE was positive in 50%
Other indicators of disease seen in 100%
8th Edition of ATLS:
Recommends DRE only in select patients now
Qi/Kt: Peritonitis WITH drs. mullen and ramsey
Spontaneous Bacterial Peritonitis
AASLD 2012 Definition:
Ascitic fluid infection without evident intra-abdominal surgically treatable source, mostly in advanced liver disease
Epidemiology:
Common, seen in up to 29% of patients with liver disease
Avg length of stay=1week
Mortality: 25% in hospital
1 year after diagnosis is up to 70%
Pathophysiology
Liver disease leads to portal hypertension
Leading to bowel wall edema and then bacteria translocate into the ascites.
Additionally these patients area on many meds that make them more favorable for bacterial overgrowth
Complement and opsonin proteins are synthesized in the liver
These don’t work well in liver dysfunction leading to immune cells not working well
Acquired immune deficiency
E. coli = 43% Streptococcus = 30%
Clinical presentation:
Fever 69%
Abdominal pain 59%
Altered Mental Status 54%
Abdominal pain 49%
Diarrhea 32%
Ileus 30%
Hypotension 21%
Hypothermia 17%
10-20% may be asymptomatic
Clinical impression by EP’s does not r/o SBP (76% sensitivity)
Paracentesis
Clinical features to indicate a need for paracentesis
Worsening/new ascites
GI Bleeding
Any hospital admission in a patient with ascites
AASLD guidelines due to the high mortality and unexpected infections
Contraindications:
Absolute
Surgical abdomen
Relative:
Coagulopahty
Pregnancy
Distended bladder
Abdominal wall cellulitis
FFP or platelets
Hemorrhage is a complication 0.2%
Not associated with elevated INR or thrombocytopenia
FP or platelets will not help
No severe complications from the procedures despite abnormal labs
Annal of Emergency Medicine in 2008:
No need to wait for coag studies to do the paracentesis
Ultrasound
Curvilinear probe
Superior to traditional based on RCT in 2005
Approaching 100% success rate with ultrasound, 61% traditional
Also helps avoid other structures
Place the sample into the culture bottles immediately as it increases the detection of bacterial (10 cc of fluid after collection)
Delay in paracentesis=increased mortality
2014 retrospective review: early vs delayed para
In-hospital mortality increases with each hour delayed after 6 hours by 3.3%
Ascitic fluid labs: cell count, culture/gram, albumin, protein, glucose, ldh, +/- bilirubin
Cloudy fluid: 2007 retrospective review showed >90% sensitivity of cloudy fluid
2013 study: contradicts this finding
Cell Count: neutrophil % x total nucleated cell count
Subtract 1 PMN / 250 RBC in each sample
PMN>250 cells/mm3 is diagnostic
Gram stain: not sensitive
Culture: not available in the ED
SAAG: >1.1 is consistent with portal hypertension
Total protein <1g/dl is likely SBP
High LDH is likely SBP
Glucose <50 is likely secondary
High amylase is pancreatitis
High bili is gallbladder perforation
Treatment
Ceftriaxone is the empiric treatment 1g q12 hours
Ciprofloxacin is alternative for severe allergy
Albumin
RCT of patients who got antibiotics alone or with albumin
Reduced mortality and renal impairment if given both within the first 6 hours
Cr >1, BUN>3-, bili>4
Dosing: 1.5g/kg IV
Secondary Bacterial Peritonitis
Ascitic fluid infection in the setting of a surgically treatable intra-abdominal source of infection
less common than SBP
Mortality approaches 100% with only antibiotics and no surgical intervention
Runyon’s Criteria: best for perforated causes of secondary bacterial peritonitis
Total protein: >1
Glucose <50
LDH >upper limit of normal serum
Polymicrobial culture also indicative
Consider CT/radiology ultrasound if the patient doesn’t respond to treatment
Peritoneal Dialysis Catheter Associated Peritonitis
Peritoneal Dialysis
Exchanges waste products via a catheter in the peritoneal space
Dialysate is instilled into the space and sits over time while the exchange occurs
The dwell time is between the instillation and when the fluid is pulled off
Continuous: 3-4 exchanges during the day with a dwell at night
Continuous cycler PD: overnight dialysis with multiple exchanges through the night
More common
Exit site infection
Touch contamination
Usually gram positive
Purulence +/- erythema
Prophylactic topical antibiotics: mupirocin or gentamicin
Tunnel infection
Erythema, tenderness, edema, induration along the tunnel path
Can progress to abscess: S. aureus or P. aeruginosa
Higher risk of progression to peritonitis
PD Peritonitis
45-65%: Gram positive
15-35%: Gram negative
3-5%: Fungi
Clinical
Abdominal pain 79-88%
Fever 29-053%
Nausea/Vomiting 31-51%
Hypotension 18%
Cloudy effluent is 84% (more likely in continuous)
Evaluation:
Assess the site
Lab work: basic labs, blood cultures only if you think they are septic
Effluent analysis:cell count and diff, gram stain, culture
If no dialysate dwelling, then instill and have a 2 hour dwell time before pulling off for cell count
Nephrology fellow or a PD nurse can pull this off
Or admit the patient and they will get the fluid pulled off by a trained nurse
Need 2 of 3 for a diagnosis
Clinical features consistent with peritonitis
WBC>100 and or >50% PMNs
Positive dialysis effluent culture
*If there is a cloudy effluent then assume peritonitis without other symptoms
Management: DO NOT WAIT FOR RESULTS
Once pulled off start the antibiotics
No consensus on antibiotics to use: need to cover both gram positive and negative coverage
Gram positive: vancomycin or first gen cephalosporin
Gram negative: 3rd gen cephalosporin or aminoglycoside or cefepime
Vancomycin vs cefazolin: 1 study shows vanc is better, other studies show no difference if using appropriate dosing of cefazolin
Dependent on resistance rates at the hospital locally
GN Coverage: studies are outdated and contradictory
Cefepime vs vanc+Aminogly: cefepime is not inferior
Amino>Cephal: cost effective, synergistic for GP, less likely to induce resistance
Route: literature supports intraperitoneal instead of IV, engage your GI consultants early
Less treatment failure and better penetration
IV only used for septic patients
r3 taming the sru WITH dr. urbanowicz
Myasthenia Gravis
Most common NMJ disorder, similar incidence in men and women
Women present younger with other AI
Men are in the older population
Myasthenic Crisis
4% mortality
60% will require intubation
Clinical diagnosis
Respiratory failure or acute decompensation with known myasthenia
This could be initial presentation
Most common in first 12 months after the diagnosis
30% will have at least one crisis
1 episode predisposes to having another
Precipitation
30% infection
19% drug interactions
Azithromycin, Gentamicin, Flouroquinolones, Prednisone, Magnesium
4% social stressors
Other 33%
Single count breath test
Does correlate with true PFTs
Seated and upright patients
Take big deep breath and count 2 beats per second as you breath out
Normal is 35-45
<25 is abnormal, <20 is concerning
Patients can be trained to do this and trended at home
NIVPP:
Can be effective bridge and can avoid intubation all together
July 2020 Study:
⅓ of patients can be trialed on NIVPP
Of these can prevent intubation between 12-20% of patients
Decreases ICU length of stay and days of mech ventilation
No mortality difference
No decrease in overall hospitalization stay
Similar rates of pulmonary complications
Average length of intubation is 12 days=high risk of VAP
NIVPP patients don’t participate in recruitment or respiratory clearance=high risk of aspiration
Do not use in:
Altered mental status,
Bad baseline disease (greater than ocular involvement)
Obvious sepsis (myasthenia may progress more rapidly than anticipated)
pCO2>45,
will fail NIVPP,
bicarb <30=independent predictor of success
Paralysis
Can last 4x longer in these patients
Succinylcholine
Is unpredictable in these patients
Need to double the dose at least
Rocuronium
Should be used as first choice
Should use half the dose
0.3-0.5mg/kg
May be able to forgo paralytics all together as they are functionally paralyzed at time of crisis
Post-Intubation Problems
Treat the underlying causes
IVIG vs PLEX: institution dependent
Similar outcomes with both of these
Steroids
May provide benefit when they are intubated or when the IVIG or PLEX is already started
