Grand Rounds Recap 9.26.18

Morbidity and Mortality Conference WITH DR. Shaw


  • Resuscitative Endovascular Balloon Occlusion of the Aorta

  • The procedure entails placing a 12 french introducer and then balloon through the common femoral artery. The balloon is expanded within the aorta to occlude it proximal to the point of bleeding

  • There are three anatomic zones used when describing where the balloon is inflated

    • Zone I: At the level of the xiphoid, above the renal arteries

    • Zone II: At the level of the renal arteries (avoid balloon inflation here)

    • Zone III: At the level of the umbilicus, below the renal arteries

  • Indications for REBOA

    • Subdiaphragmatic hemorrhage of a noncompressible site

      • PEA Arrest < 10 min

      • Severe hemorrhagic shock

      • AAA

  • Contraindications for REBOA

    • Non-identifiable femoral vessels

    • Proximal aortic dissection/injury

  • Literature review suggests that there may be a mortality benefit for REBOA in comparison to resuscitative thoracotomy; however, more research still needs to be done to clearly answer this question

  • When transporting a patient with a REBOA in place take care to identify the location of the catheter before transport to ensure it has not moved when you deliver the patient and also perform a complete neurovascular examination of bilateral lower extremities

Medical vs. Surgical treatment of spontaneous miscarriages

  • Medical management options include:

    • Mifepristone

      • Progesterone Antagonist

      • Decidual degeneration

      • Preferred over methotrexate

    • Misoprostol

      • Prostaglandin agonist

      • Leads to uterine contractions

  • Surgical management options include:

    • Dilation and Curettage

      • Sharp curettage

      • Suction curettage

  • Medical vs. Surgical management is a decision that includes both clinical presentation, duration of pregnancy, and patient preference

    • Both medical and surgical management are safe before 13 weeks. After 13 weeks most are managed surgically.

    • If a patient is unstable then surgical management is indicated

    • If the patient is stable then patient preference is taken into account

    • Medical management has the benefit of being cheaper and avoids a surgical procedure but has higher rates of retained products of conception and need for subsequent procedure

    • Surgical management has the benefit of being less uncomfortable for most patients, leading to complete evacuation more often, and results in less unexpected admissions

Electronic Medical Records

  • Principles of usability violated by electronic medical records

    • Naturalness: Presenting information in the same manner as your work flow.

      • You can improve this by completing documentation and accessing information in the order of your workflow for each patient.

    • Cognitive Overload: Minimizing screens that have shared information

      • You can improve this by finding an order that is efficient for you to evaluate the chart and doing it the same way every time

    • Efficient Interaction: Minimizing the steps necessary to access the information you need

      • You can improve this by using smart-phrases, templates, order-sets, and the order screen rather than clicking everything individually

    • Customizability: The ability to customize an interface to your preference

      • Make macros, smart-phrases, templates to meet your needs

CXR vs CT scan in Community Acquired Pneumonia

  • Hageman et al in 2009 found a 21% false negative rate for the initial admission CXR in patients subsequently determined to have community acquired pneumonia

  • IDSA guidelines:

    • If you have a high suspicion for CAP, treat with antibiotics and repeat the CXR in 24-48 hours

    • The role of CT in CAP is unclear. It may be used to look for PE, effusion, cancer, abscess etc.

  • Ultimately, CXR lacks sensitivity for pneumonia, especially early in the disease process

    • Early CT may be more accurate, but it is unclear if this will change downstream outcomes

    • Consider the use of CT in patients with absent, ambiguous, or non-specific X-ray findings with whom the diagnosis of CAP remains unclear and you want to also evaluate for other possibilities such as PE, mass, abscess etc.

Coronary CT Imaging

  • Coronary Artery Calcium Score (CACS)

    • A non-contrasted CT study that allows you to calculate an Agatston Score which helps to estimate major adverse cardiac events at 3-5 years.

    • This provides no detailed information on anatomy of the patient

  • Coronary CT Angiography (CCTA)

    • A contrasted CT study used to show luminal irregularities

    • Typically requires the use of Beta Blockers to achieve a heart rate less than 55 to acquire an adequate study

  • CACS has not been proven to be beneficial without a CCTA

  • CCTA can improve ED throughput by limiting the need to hold a patient for chemical/exercise stress testing so long as you have the availability of radiology/cardiology who can interpret the studies

  • CCTA has been shown to have at least equivalent outcomes with cardiac risk stratification as current standard of care.

Chest Tube Persistent Air Leaks

  • Troubleshooting a persistent air leak:

    • First check for a mechanical problem with the chest tube/equipment

      • Clamp the tube closest to the patient. Persistence of an air leak suggests a faulty connection in the equipment

      • If this does not work then reinforce the dressing to ensure no airleak from the skin incision site

      • If no mechanical issue is found you should further investigate the possibility of an alveolar-pleural fistula or a broncho-plueral fistula

  • Alveolar-Pleural Fistula and Broncho-Pleural Fistula

    • Most commonly seen after thoracic surgery (Lobectomy - 0.5%, Pneumonectomy - up to 20%)

    • Can also be seen with radiation, malignancy, necrotizing pneumonia, or trauma

    • Cerfolio classification of air leaks:

      • Grade 1: During any forced exhalation (i.e. cough). This is typically of low concern.

      • Grade 2: Expiratory phase only

      • Grade 3: Inspiratory phase only

      • Grade 4: Continuous bubbling during both inspiration and exhalation. This is most concerning for an alveolar or broncho-pleural fistula

    • Application of positive pressure (i.e. during intubation/BiPAP) can worsen the fistula and lead to tension physiology or hemodynamic collapse. Ideally, you want to identify this process before the need arises to intubate; however, this is not always possible and should be considered as the underlying etiology of a patient who rapidly decompensates after intubation with a known prior pneumothorax.

Global health grand rounds: refugee healthcare  WITH DR. alwan

  • The term refugee is considered a legal term.

    • Taken from Article 1(A)(2) of the 1951 United Nations Convention relating to the status of refugees: A refugee is an individual who is outside his or her country of nationality or habitual residence who is unable or unwilling to return due to a well-founded fear of persecution based on his or her race, religion, nationality, political opinion, or membership in a particular social group.

    • This is important to note because refugee does not legally encompass individuals fleeing general violence, natural disasters, or those not facing persecution. Such individuals may ultimately be granted refugee status; however, to do so would need to meet the legal definition above.

  • Refugees who are fleeing to another country typically do so in stages. It is very common for a refugee family to initially travel to neighboring geographic locations before ultimately making it to their final destination location.

    • This travel can be incredibly logistically and financially crippling for these individuals. This leads to compromises having to be made in terms of lodging accommodations, hygiene, treatment of chronic medical conditions, and management of acute injuries.

    • Refugees are also at a higher risk for physical and sexual assault.

  • The process to become a refugee is rife with challenges

    • There is a variety of required paperwork and something as simple as providing a birth certificate can be near impossible depending on the circumstances surrounding them fleeing their home country.

    • All refugees are required to undergo an initial medical screening examination.

      • Based on this exam they are classically assigned either Status A or Status B.

        • Status A indicates they are otherwise healthy

        • Status B indicates that they have a medical condition. Status B does not distinguish between a mild condition such as asthma and a debilitating condition such as cystic fibrosis.

    • Upon arrival at their destination country they typically have 30 days to undergo another medical examination

      • During this exam they must be compliant with all vaccinations, TB/infectious disease testing, and a general health exam.

  • It is extremely common for refugees to not speak the language of their destination country. This often results in challenges with acquiring work, access to healthcare, use of infrastructure such as transportation.

  • Refugees commonly present to medical settings with oral health concerns (dental hygiene is often the first go when traveling in sub-optimal conditions), chronic pain (often manifestation of emotional distress), and PTSD/anxiety/depression.

R4 Case Followup: management of the decompensating pe patient prior to thrombolysis WITH DR. randolph


  • Middle aged patient presents with shortness of breath and increased oxygen requirement.

  • History of signifiant for quadriplegia with COPD on 2L O2 at home and right sided CHF.

  • Vitals: T 100.5, HR 135, RR 25, BP 81/21, SpO2 91% on 10L optiflow

  • Exam notable for an obese female in respiratory distress with diffuse coarse breath sounds and distant heart sounds.

  • EKG showed sinus tachycardia.

  • CXR showed cardiomegaly with obscuration of the left hemidiaphragm due to heart border vs. effusion.

  • Patient quickly started on broad spectrum antibiotics with IVF resuscitation. Pressors started, placed on flush rate O2 and ultimately determined to need emergent intubation which was performed successfully.

  • CTPA showed bilateral PEs. Started on heparin, discussed with Interventional Radiology for intervention, and admitted to the MICU with IR on board.

  • Patient received catheter directed therapy by IR and ultimately had a good outcome

Management of Decompensating PE patient prior to Thrombolysis

  • These patients can rapidly develop obstructive shock

    • Pulmonary Embolism leads to RV dilation > leads to RV ischemia > worsening mechanics of the RV > even worse RV outflow > subsequent impaired LV outflow > system wide failure > worse preload.

  • Consider the use of IV fluids; however, do so judiciously. RV failure with dilation can be made worse if too much IV fluids is administered.

  • Consider the use of early IV pressors. Studies suggest the use of norepinephrine as first line.

    • Goal to keep systolic pressures high to perfuse the RV

    • Consider dobutamine as second pressor to add-on to enhance cardiac contractility.

  • Consider inhaled nitric oxide.

    • Limited studies and considered a safe addition.

    • Can help by decreasing pulmonary vascular resistance which is compromised secondary to clot burden.

  • Be mindful when deciding to intubate.

    • Consider half-dose induction and have generous use of push-dose pressors.

    • Take care with vent settings especially focus on maintaining low tidal volumes and low PEEP.

    • Peri-intubation cardiac arrest is common in this setting so be prepared for this outcome.

      • If the patient codes be prepared to administer tPA to attempt to lyse the clot

      • If you administer tPA CPR should be continued for at minimum an additional 15-30 min to allow the medication to take effect

  • Remember, the ultimate intervention is some form of clot degrading intervention.

    • Heparin is only preventing more clot from forming but not lysing active clot

    • Early engagement of Interventional Radiology can be used for catheter directed therapy but in critically ill patients in the ED consider the use of systemic tPA if no contraindications exist.

CPC: acute aortic dissection WITH DR. Gottula and dr. hinckley

Acute Aortic Dissection    

  • Acute aortic dissections are rare and difficult to diagnosis; however, timely diagnosis is important as missing the diagnosis leads to higher mortality.

  • Clinical presentation is classically described as acute onset of tearing chest pain with radiation to the back; however, no single symptom is sensitive. Patients can present atypically and therefore you should consider aortic dissection is any patient with chest pain, back pain, or new/evolving neurological deficits.

  • Stanford Classification for Aortic Dissection is the most commonly used classification system

    • Type A:

      • Involves the ascending aorta and/or aortic arch

      • Accounts for 60% of aortic dissections

      • Can result in coronary artery occlusion, aortic incompetence, carotid artery dissection, rupture into pericardial sac leading to tamponade

      • Requires surgical management

    • Type B:

      • begins beyond the brachiocephalic vessels

      • Accounts for ~40% of aortic dissections

      • Typically managed medically with blood pressure control

  • EKGS and CXRs are less helpful in the early diagnosis. CT of the aorta is the gold standard for definitive diagnosis

  • Type A mortality is falling as surgeons and medical centers accept surgical intervention for more elderly and complicated patients

  • Type B mortality remains stable and are occasionally now managed with endovascular aortic repair for complicated patients

R1 clinical diagnostics: Kocher Criteria WITH dr. Leech

See the Intro Post Here

  • The Kocher Criteria is a tool developed for evaluation of the atraumatic, painful hip in children specifically trying to distinguish between septic arthritis and transient synovitis

  • The differential of the acutely painful hip in children is broad including: septic arthritis, transient synovitis, osteomyelitis, slipped capital femoral epiphysis, Legg-Calve-Perthes disease, juvenile idiopathic arthritis, acute rheumatic fever, post streptococcal reactive arthritis, gonococcal arthritis, Henoch-Schoenlein purpura, sickle cell crisis, lyme arthritis etc

  • There are four components that comprise the Kocher Criteria:

    • Non-weight bearing status

    • Temp > 38.5C/101.3F

    • ESR > 40mm/hr

    • WBC > 12,000 cells/mm3

  • One point is given for each of the above and a total is calculated for the patient to generate a likelihood of septic arthritis

    • 0 points: 0.20%

    • 1 point: 3%

    • 2 points: 40%

    • 3 points: 93%

    • 4 points: 99%

Literature Review

  • The Kocher Criteria were subsequently validated by the same group from the original paper and since has not had excellent external validation.

  • Many other studies have not been able to replicate the predictive results of 99% for septic arthritis as seen in the original Kocher study.

    • In fact many studies have found values closer to 50-60%

  • As the prevalence of septic arthritis increases within a study population the positive predictive value of the Kocher Criteria also goes up. This suggests that tertiary referral centers may find greater use of these criteria than smaller centers; however, this has not been extensively studied.

  • Since the inception of the Kocher Criteria, CRP has become more widely available and many emergency department physicians now obtain this value as part of their evaluation of the acutely painful hip.

    • Some studies have found that CRP elevation is actually a better independent predictor of septic arthritis than any of the individual criteria evaluated by Kocher.

  • The use of the Kocher Criteria varies between institutions and individual providers. It is most helpful to confirm an already low suspicion by physician gestalt and should not be used independent of gestalt.

Use of Imaging in the Evaluation of the Acutely Painful Hip

  • X-ray can help identify bony abnormalities and joint effusions but they are less helpful in the assessment of concern for septic arthritis and certainly cannot rule out the disease.

  • Ultrasound is sensitive for effusion but cannot effectively differentiate between effusion caused by septic arthritis vs. that caused by transient synovitis

  • MRI is becoming more popular with orthopedic surgeons as it can help identify underlying osteomyelitis and help with surgical planning.