Grand Rounds Recap 10/14

Simulation with Dr. Hill

Case 1: 45 yo male comes to the ED after being found down at the mall s/p defib x2 for a V fib arrest per EMS with a King Airway in place and undergoing active CPR. In the ED you achieve ROSC after defib x1 for Vfib and then PEA with multiple arounds of epinephrine. EKG shows inferior STEMI.  

Case 2: EMS calls with advanced noticed for GI bleed presents tachycardic and hypotensive, actively bleeding with melanotic stool and hematemesis. 

  • Neither scenario are uncommon in a busy ED and both require collaboration amongst providers and rapid, decisive, accurate decision making. One of the most effective ways to ensure optimization of these high acuty, high morbidity/mortality cases is the debrief. 
  • Consider the straightforward yet functional plus-delta method of debrief: 1) What did we do well and 2) what can we do better?
  • Why is this important? Ultimately, it leads to better care.
    • AHA (Class IIa LOE C) Recommendation to improve future resuscitation performance
    • Has been shown to improve CPR performance and increased rate of ROSC in-hospital
  • The best opportunity for debriefing is immediately after "the event" and worthwhile incorporating into our practice despite pressures to move on to other activities. The next time you are on shift, particularly in the SRU, give it a shot.  

Oral Boards with Dr. Ronan

24 yo FM arrives via EMS after being called by boyfriend: "I think she overdosed," with multiple empty pill bottles. EMS reports narcan given without response, no IV access. The patient is comatose. The patient has a hx of depression. Doxepin, trazadone, OCPs are all found empty at the scene. 

VS: T 102; 84/palp; HR 130; RR 12; Pulse Ox 100% on NRB; FS 96

PE: Dry mucus membranes, 8mm pupils, abd with decreased bowel sounds, thready pulses, myoclonic jerks with extremities, 

EKG shows a terminal R wave in AvR

  • Although the diagnosis of serotonin syndrome needs to be entertained in this ingesting, altered, febrile patient, this patient's presentation is most concerning for the anticholinergic syndrome. The hallmarks of anticholinergic toxicity are the "red as a beet (flushing), dry as a bone (dry skin), blind as a bat (mydriasis) mad as a hatter (AMS), hot as a hare (febrile) and full as a flask (urinary retention)." Tachycardia, decreased bowel sounds, tremulousness and myoclonus are all common as well. 
  • Anticholinergics have sodium-channel blocking properties which can manifest on EKG via 1) a terminal R wave in aVR and/or 2) QRS widening. #2 can be a big problem ie ventricular arrhythmias, death and what have you. Treatment? Give ampules of sodium bicarbonate titrated to QRS widening. If they are refractory, IV lidocaine may be indicated. Consider giving these patient activated charcoal via NG and, if concerned about a significant anticholinergic toxicity, these patients are likely best intubated early in the process. Patients may require vasopressors if hypotensive. 

Patient 2: 14 yo male presents from basketball game with cc of groin pain that started after acute trauma to lower abdomen during game

PE significant for RLQ pain, absent cremasteric reflex on the right, normal on the left, exquisite tenderness to palpation on the right concerning for traumatic testicular torsion. 

The main point here: if clinical suspicion is high, you don't need an ultrasound to call a urologist. The "open book" method of detorsion is the textbook answer for reduction, although may not be successful. 

Patient 3: 24 yo male presents with waking up with stiff, sore, right shoulder.

Remember for oral boards purposes to be complete: a history includes PMH and meds, which, if asked, would lead you to understand that this patient has epilepsy and has not been taking his AEDs--prompting concern for potential seizure as the underlying causative agent for this patient's otherwise inexplicable physical examination findings consistent with posterior dislocation.  The reduction maneuver is adduction and internal rotation while maintaining downward traction. 

Oral Boards with Dr. Powell

Case 1: 78 yo FM p/w cc increasing confusion and "balance problems." Per son she has had progressive difficulties ambulating and progressive confusion.

VS: Afebrile, 146/97, 88, 14/min satting 98% on RA

Physical exam relevant for shuffling gait and positive rhomberg as well as multiple bruises and skin tears to bilateral UE in multiple stages of healing. 

  • Head CT reveals chronic subdural hematoma. Remember to screen the elderly and, in general, vulnerable populations, for abuse. 
  • 50% of these patients will not have a history of falls
  • 10% of these patients will be anticoagulated

Case 2: 34 yo G2P1001 without prior intrapartum complications p/w n/v @34 wks pregnancy x 1 day. She has a hx of borderline high BP during this pregnancy. 

VS: Afebrile; 142/94; P 88; RR 20; Satting 100% RA

PE reveals epigastric abd tenderness without peritoneal signs and uterine fundus palpable 4 cm above the umbilicus

UA shows 1+ proteinuria, plts 78, AST and ALT mildly elevated, all concerning for HELLP syndrome (hemolysis, elevated LFTs, low platelets)

  • Abdominal pain in pregnancy? Remember, in addition to common causes of abdominal pain such as pancreatitis, cholecystitis, and GERD, pre-eclamptics can also present this way or in its more severe presentation of HELLP. This NEVER happens under 20 weeks. If severely hypertensive prior to 20 weeks remember to have molar pregnancy on the differential. Urgent delivery unless signs of fetal distress->emergent. If <34 weeks, have discussion with OB to give steroids for enhanced fetal maturation. In pre-eclamptic patients it is important to contact OB early and arrange for transport in settings where necessary. 

Combined EM/Peds Lecture on Emesis in the Infant with Dr. Riney

Infant emesis Ddx: GER, pyloric stenosis, obstruction (malro, volvulus, Hirschprungs, intestinal atresia, intusseuscption), protein enteropathy, gastro, inborn errors of metabolism,

Children emesis ddx: Pharyngitis, UTI, gastro, gastroparesis, intussusception, intracranial HTN, cyclic vomiting syndrome, migraine, eosinophilic esophagitis, DKA

Malrotation: Most present under 1 year of age however 25% present up to adolescence

  • Consider in any patient with bilious emesis and acute abdomen
  • Dx is w/ upper GI series
  • Treatment: Fluid resuscitation, NG/OG, and ultimately, surgery

Intussusception: Age 6-36 mo. Sudden onset intermittent severe progressive abdominal pain

  • Vomiting may follow pain and is usually non bilious
  • 70% have gross of occult blood in stool
  • Dx: Abd US
  • Mangament: Barium or air contrast enema

Pyloric stenosis: Typically seen in patients 2-8wks age but can be seen from birth-6 months

  • Presentation: Forceful or projectile emesis up to 30 min after feed
  • More common in males and may be familial predilection
  • Dx: Clinical vs US
  • Management: Volume resuscitation-> Pyloromyotomy