Grand Rounds Recap 9.25.19
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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
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
