Grand Rounds Recap 9.25.19

morbidity and mortality WITH Dr. Klaszky

Sedation in the Elderly

  • Multiple problems with sedating the elderly

    • Variable metabolism of drugs due to comorbidities: cardiopulmonary, neurocognitive, drug metabolism

    • Increased respiratory depression given comorbidities

    • Lack of evidence

    • Perceived higher risk of complication

  • Anesthesia and Emergency Medicine literature reports on most commonly used conscious sedation techniques in elderly:

    • Propofol: safe, but at lower dose of 0.5 mg/kg; similar rate of complications at this dose compared to younger counterparts

    • Opioids and Benzos: Fentanyl (0.5-1 mcg/kg) and Midazolam (0.5-2mg) studied; safer at lower doses with higher risk of respiratory depression compared to propofol

    • Etomidate: Dose of 0.1 mg/kg; risk of myoclonus and emesis

    • Ketamine: Not well studied in the elderly due to cardiovascular risk factors

  • Pharmacologic Restraint: antipsychotics most effective

    • Haldol: 2-10 mg IM; very familiar with, but has modest effect with side effects

    • Risperidone: 0.5-2 mg PO; extensively studied, fast onset, not studied in acute agitation, oral / sublingual only

    • Olanzapine: 2.5-10 mg PO or IM; fast onset, side effects with higher doses

    • Midazolam: 1-3 mg IM, 0.5-2mg IV; very familiar with, rapid onset, can lead to respiratory depression and paradoxical reaction

Spinal Epidural Hematoma

  • Most commonly a procedural complication involving dural puncture

    • usually in patients that are anticoagulated or thrombocytopenic

  • Rarely occurs spontaneously; presents atypically

  • Timely decompression is essential to avoid permanent loss of neurologic function

Cognitive Biases

  • Location Bias: Tendency to treat complaints as either minor severe based on location of triage

  • Anchoring: Rely to heavily on first piece of information when making decisions

  • Playing the odds: tendency in equivocal or ambiguous presentations to opt for more benign diagnosis (common in minor care areas)

  • Psych out error: serious medical conditions are misdiagnosed as psychiatric conditions

  • Zebra Retreat: when rare diagnosis is likely, but physician does not work up due to self-consciousness or under-confidence about entertaining unusual diagnosis (common in younger physicians)


  • Imitrex (Sumatriptan)

    • Seratonin 5-HT receptor agonist: thought to help relieve headaches by vasoconstriction of cerebral blood vessels

    • Comes in multiple different forms: oral (onset 30 min), IN (onset 15-30 min), SubQ (onset 10 min)

    • Indications: moderate to severe migraine HAs; should be taken as early as possible to onset of symptoms

    • Contraindicated in those with CAD as it can cause coronary artery vasospasm, myocardial infraction and ventricular arrhythmias

POC Glucose in Shock

  • Factors affecting POC glucose measurements:

    • Hematocrit: anemia can cause values to be increased, polycythemia can falsely cause low values

    • PaO2: Hypoxia can increase values

    • Acid/base disturbances: severe acidemia (ph<6.9) can alter values

    • Temperature: Hypothermia can cause inappropriately high or low values

    • Hypotension/shock: Can cause either falsely high or low values

  • If concerned about the accuracy of POC glucose, check a venous or arterial sample

EMTALA (Emergency Medical Treatment and Active Labor Act)

  • Passed in 1986 (as part of COBRA)

    • Created as “anti-dumping” law; participating hospitals may not transfer or discharge patients needing emergency treatment without consent from accepting hospital

    • Penalties for violations: $105,000 to both physician and hospital

    • Emergency Physicians provide the most EMTALA care compared to other physicians

  • Transferring Facility

    • Obligations: medical screening exam, stabilization (deterioration unlikely from or during transfer), ongoing care prior to transfer, active labor (must have delivery of the infant and placenta)

    • Appropriate Transfer: If transfer before stabilization due to limited capabilities, benefit of transfer outweighs the risk (certified by physician in writing), receiving hospital contacted (accepts and has facilities necessary for treatment)

  • Receiving Facility:

    • must accept transfer if has ability to treat

    • Overcrowding or temporary unavailability of personnel is not always a reason to refuse transfer (unless on diversionary status)

tPA in Anticoagulated Patients

  • 1.7 is the cutoff where a patient on warfarin can be treated with tPA

  • POC INR is a reliable tool to rapidly determine if tPA can be administered if the value is <1.7; if higher should be confirmed by lab

    • 1.7-2.4 POC INR has less reliability

  • No current recommendations for patients on DOACs; these patients are still eligible for thrombectomy however

Valproate Toxicity

  • Valproic Acid: Used for epilepsy, bipolar disorder and migraines; can come in immediate or delayed/extended release formulations

  • Toxicity: can cause cerebral edema, valproate-related hyperammonemic encephalopathy (VHE), hepatotoxicity

    • Important note: VPA level dose not correlate with severity of clinical symptoms

    • Have a low threshold to obtain ammonia levels, considered toxic if altered mental status with an ammonia level > 80

  • Treatment of Valproate Toxicity

    • L-carnitine: given if patient is in coma, VPA level>450, VHE, severe hepatoxicity

      • 100 mg/kg load followed by 50 mg/kg q8h

    • Hemodialysis: considered if VPA level > 1300, cerebral edema, hemodynamic instability, intubation

Massive Cocaine Overdose

  • Clinical Effects:

    • At recreational doses, cocaine produces euphoria and sympathomimetic toxidrome

    • 1 mMol serum levels: seizures

      • Treat with benzos

    • 5 mMol serum levels: K+ blockade

    • 10 mMol serum levels: Na+ blockade

      • Treat with bicarb, hypertonic saline

    • 100 mMol serum levels: death

r1 Clinical knowledge: Inflammatory Bowel Disease WITH Dr. goff

  • Inflammatory Bowel Disease (IBD): describes two primary processes 1) Ulcerative Colitis 2) Crohn’s Disease

    • Ulcerative colitis: inflammation of mucosa/submucosa; limited to mostly rectum and extending proximally to colon

    • Crohn’s: full thickness involving all layers and can be anywhere in the GI tract; commonly involves terminal ileum

  • Three main categories of patients with IBD:

    • Undiagnosed but generally well patients: consider in patients with recurrent abdominal pain and diarrhea

      • Average time to diagnosis is 1-2 years

      • Highest incidence 2nd and 3rd decades of life

      • Correlated with family history, Caucasian/Jewish descent, GI infections (c. diff, campylobacter, salmonella), smoking, diet, latitude, hygiene hypothesis

      • ED evaluation usually consists of basic blood work (may expand with CRP, ESR, fecal calprotectin if especially concerned), imaging (if concerned about alternate diagnoses), GI referral and discharge home in the absence of complications (perforation, abscess, sepsis, etc)

    • Diagnosed with IBD presenting with acute flare, but no complications

      • Avoid anchoring as IBD patients are at increased risk of cholelithasis, nephrolithiasis and infectious diarrhea

      • Evaluate for complications but judiciously as IBD patients are at increased risk for higher rates of imaging

      • Treat for dehydration, nausea, fever, and pain using an opioid sparing strategy

      • Consider steroids as first line agent for acute flare

      • Discuss with GI for follow up vs possible admission for endoscopy and aggressive induction of admission, particularly if new onset

    • Diagnosed with IBD with acute flare and complications

      • Crohn’s: High risk for obstruction due to inflammation/stricture, fistula, abscess, perforation

      • Ulcerative Colitis: High risk for toxic megacolon, fulminant colitis with hemorrhage

      • Treat underlying pathology with resuscitation, IVF, vasopressors, steroids, broad spectrum antibiotics, possible gastric decompression

      • Admit to GI, surgery or ICU

R1 Clinical Diagnostics: syncope Rules WITH Dr. Chuko and Dr. Jarrell

  •  Syncope in the ED:

    • 1-3% of ED visits in US and 6% of hospital admissions

    • All comers with syncope admitted ~32% of the time

    • 1/3 of admissions non-diagnostic

    • Guidelines have been ineffective in decreasing low risk admission

    • Leads to high healthcare costs with increased CT/MRI, PE work ups and admissions

  • Approach to Syncope:

    • History taking: preceding events, predisposing factors, onset, associated symptoms (nausea, pain, diaphoresis, blurred vision, chest pain, etc)

    • Any eye witness to corroborate story

    • Any lingering symptoms

    • Beware of syncope mimics: toxic ingestion, stroke, seizure, head trauma

    • Physical Exam: examine for any injuries, hydration status, cardiac exam

      • orthostatics not useful; if positive does not rule out serious cause

    • Uniformly should get EKG

  • Syncope Rules

    • San Francisco Syncope Rule: controversial

      • Original study showed 96% sensitivity, 62% specificity

      • External validation showed 74% sensitivity and 54% specificity

    • Canadian Syncope Rule:

      • Pending external validation, but has been prospectively validated

      • scores <-2 with sensitivity 99% and specificity 62%

      • scores <-1 with sensitivity 98% and specificity 54%

    • Current guidelines are ineffective; trust instincts

See original post for more detail on rules here

CPC: Syphillis WITH Dr. Roblee

  • Epidemiology:

    • 30,644 reported cases of primary and secondary syphilis in the US in 2017

    • Risk factors: HIV infection, MSM, incarceration, sex workers, individuals in geographic areas with high prevalence, certain racial groups (black, Hispanic, Native American), males younger than 29 years

  • Primary Syphilis:

    • Treponema pallidum

    • STI: transmitted through direct contact with infected tissue

    • Chancre or painless lesion noted on genitals

  • Secondary Syphilis:

    • Can present with fever, lymphadenopathy, diffuse rash (maculopapular), mucosal lesions, condyloma lata

      • rash classically thought to be on palms or soles, but can present anywhere

    • Considered the great imitator as it can be linked to many other disease processes such as alopecia, hepatitis, gastrointestinal erosion, synovitis, osteitis, meningitis, cranial nerve deficits, uveitis, nephropathy

  • Tertiary Syphilis:

    • Latent Period: 3-15 years

    • mainfest as gummatous syphillis, neurologic symptoms (neurosphyllis, tabes dorsalis), cardiovascular diseases (aortitis)

  • Treatment:

    • Primary, Secondary, Latent: IM Penicillin

    • Tertiary, Latent (>1 yr) or unknown duration: IM Penicillin x3

    • Neurosyphillis: IV Penicillin