Grand Rounds Recap 10.17.18

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QI/KT SICKLE CELL DISEASE WITH DRS. GLEIMER AND KOEHLER

  • PiSCES study showed that sickle cell patients live with pain 55% of days. 29% of patients had some pain >95% of days. Only utilized health care on 3.5% of days, therefore patients frequently have pain that is managed on their own at home. Opioid use was reported on 78% of days therefore, most patients are using combination of opioids at home on most days.

  • Provider bias for these patients is real, in a 2001 study 63% of nurses believed that addiction was more prevalent among sickle cell patients. In a 1997 study 53% of ED providers and 23% of hematologists had this belief. 

  • Assessing pain in these patients should be based on the patients report of pain, this is the gold standard for determining if their pain is improved, as they rarely show the same hemodynamic profile as someone in acute without chronic pain.

  • Paradigm shifting study in 1992 (Brokoff et al) showed that treating sickle cell pain like cancer pain decreases admissions and ED visits.

  • Initial assessment should include vital signs (tachycardia does not equal pain often, fever is another red flag of something more serious as is hypoxia. History should include location of pain, typical or atypical, amount of home medications. Thorough physical exam. 

  • See Dr. Hall’s post for a discussion of requisite laboratory testing for SCD patients in crisis.

  • Protocols are efficacious in decreasing admissions, improving appropriate routes of medication administration, and decreased time to administration of first dose.

    • IM has erratic absorption, increased pain and sterile abscesses compared to SQ.

    • Intranasal has been used in the pediatric literature, too big of volumes for adults.

    • Oral medications may have a role, however most patients have tried and failed these at home.

    • IV is typically difficulty to obtain quickly given longstanding and frequently exacerbated disease, therefore SQ is evolving as the best initial option.

  • Dosing: should be patient specific dosing based on what they are using at home, this was shown to improve pain, have less hospital admission without significant side effects (Tanabe et al 2018)

  • Patient should be reassessed every 20-30 minutes per NHBLI

  • Ketamine may used on inpatient side, most studies use as a bolus and infusion

  • Toradol is often used but is not a good choice for pediatric patients due to increased risk of kidney injury and no opioid sparing effect

  • Fluids may be considered only when hypovolemic, use as maintenance at 1.5, literature supporting hypotonic fluids

  • Benadryl and Phenergan should be given only when necessary for their label indications (itching and nausea) and orally if tolerated

  • Oxygen should only given if patient is hypoxic, no change in discharge or pain scores if not hypoxic

  • Incentive Spirometry is helpful in preventing Acute Chest Syndrome, especially in patients with chest pain that may be predisposed

ANORECTAL PATHOLOGY WITH DR. LAFOLLETTE

ANATOMY

  • Structures proximal to the dentate line (internal hemorrhoids) have an insensate epithelium, whereas structures external to this (fissures, thrombosed external hemorrhoids, abscess) will be tender to palpation

PILONIDAL CYST

  • Fluid-filled sac that has a propensity to get secondarily infected

  • To drain, broadly anesthetize and dissect inferiorly

  • No need for antibiotics unless cellulitis or systemic signs of infection

  • If recurrent symptomatic episodes, appropriate to refer for surgery  

PERIANAL ABSCESS

  • Only if you can visualize the abscess and no significant pain with rectal exam should you consider drainage without imaging

  • 30-70% I&D lead to fistula formation

  • Packing increases pain and increase time to healing, not recommended

  • No role for antibiotics if no signs of cellulitis as the data is mixed

PERIRECTAL ABSCESS

  • Require advanced imaging

  • Managed surgically, may track into pelvis

EXTERNAL HEMORRHOIDS

  • Become symptomatic when acutely thrombosed

  • Excision only indicated for thrombosis and within 2-3 days after clot formation / symptoms

  • Most will spontaneously resolve in 7-10 days

  • Incision is in the longitudinal axis, evacuate the clot

  • Additional symptom control below

INTERNAL HEMORRHOIDS

  • Typically these self-improve, high grade (herniation externally) may require banding in office setting

  • Treat symptomatically

  • Should not be painful, consider external source or underlying infection / mass if painful

  • Anybody over 50 will require sigmoidoscopy or colonoscopy via referral as risk of underlying malignancy as cause is much higher

ANAL FISSURE

  • 90% in posterior line, 10% anterior line, if anywhere else, must be considered pathologic

  • Recommendation is if you can see obvious fissure, DRE is extremely painful so may not be indicated

  • Chronically can be treated with topical nitro or CCB, however symptomatic case usually adequate

SYMPTOMATIC CARE

  • Fiber improves symptom resolution up to 50%

  • Anusol must be given less than a week or it can cause skin irritation and additional problems

  • Sitz baths can help alleviate symptoms, especially with anal fissures

R4 SIM: LV FREE WALL RUPTURE, TRANSVENOUS PACEMAKER PLACEMENT, PEDIATRIC STATUS EPILEPTICUS WITH DRs. SABEDRA, LIEBMAN, RANDOLPH, AND MURPHY

R4 SIM: LV FREE WALL RUPTURE- DR. SABEDRA AND DR. RANDOLPH

55 year-old male with history of recent MI treated with thrombolysis in rural Montana 2 weeks ago who presented with chest pain and syncope.  Initially awake with chest pain, and soft BP.  EKG with diffuse ST elevation and PR depressions.  Small pericardial effusion seen on initial bedside US.  He suddenly has more pain, becomes tachycardic and profoundly hypotensive.  Repeat US shows enlargement of effusion with evidence of tamponade.  Emergent pericardiocentesis aspirates frank blood suggesting LV free wall rupture, prompting call to cardiac surgery.

Post-MI Complications: More than just in-stent thrombosis (although also worth considering)

Mechanical

LV Free Wall Rupture: 3-14 days post MI

  • Acute: most common presentation is DOA

  • Subacute: Can present as syncope with continued chest pain

  • Clinical diagnosis:  History of MI, Unstable evolving effusion

  • EKG can be non-diagnostic

  • Risk factors: Fibrinolytic therapy, Anterior infarct, age>70, female

  • Tx: Open repair, may require pericardiocentesis if crashing with delay to OR and evidence of tamponade

    • If unsure, remember chronic pericardial blood does not clot

    • Fluids, inotropes, vasopressors, IABP all options to stabilize until OR

Interventricular Septum Rupture: 3-14 days post MI

  • Lower incidence with fibrinolytic therapy

  • Hypotension, heart failure, new holosystolic murmur

  • Dx: Echo

  • Tx: Emergent surgical repair if unstable

Papillary muscle rupture: 2-7 days post MI

  • Acute mitral regurgitation

  • Hypotension, pulmonary edema, murmur

  • Conduction: Bradyarrhythmias most common

Peri-infarction pericarditis

  • Transient and self-limited

  • Avoid NSAIDs for 7-10 days after acute MI

Post-cardiac injury syndrome (Dressler’s syndrome)

  • Latency period is typically weeks to months

  • Tx: NSAIDs 

Tamponade pathophysiology - Acute pericardial effusion

  • Beck’s triad as clinical diagnosis (but only found in 33%)

  • Pulses Paradoxus, Narrow pulse pressure

  • Classic ultrasound findings

    • Diastolic collapse of RA and RV

    • Plethoric IVC

    • PSL view in M mode - line through RV appears to collapse

    • Valvular pulsus paradoxus - doppler interrogation of mitral valve

    • Tamponade physiology - RV and RA collapse —> RV failure —>  CO failure

  • Obstructive shock so treat the obstruction

  • Preload dependent so liberal fluids

  • Pericardiocentesis

  • Standard of care is ultrasound-guided approach.  Consider Seldinger technique for catheter placement with stopcock method if anticipated continued need for drainage (i.e. long transport)

Transvenous Pacemaker Placement with Drs Liebman and Murphy 

Indication for pacing in the ED: 

  • Symptomatic or hemodynamically unstable bradycardia

  • No recommendation for use in bradycardia secondary to hypothermia

  • May be ineffective in beta-blocker or calcium channel blocker overdose (but no downside to trying if other treatment modalities fail)

Indication for transvenous pacing: 

  • Patient not tolerating transcutaneous pacing

  • Transcutaneous pacing not achieving mechanical capture

  • Consider if patient is pacer dependent and prolonged transport required 

Contraindications: 

  • No absolute contraindications

Relative contraindications: 

  • Prosthetic triscuspid valve

  • Bleeding diathesis / anticoagulation

  • Digoxin overdose (increased myocardial irritability to mechanical and electrical stimuli)

Complications: 

  • Same as with central venous access, plus: 

  • Ventricular perforation

  • Valvular damage

  • Dysrhythmia

 Procedure: 

Troubleshooting: 

  • Failure to pace: try emergency / asynchronous / DOO mode first; if persistent, check generator, wires, batteries

  • Failure to capture: increase current / reposition wire / reposition patient / rule out severe electrolyte abnormalities / verify polarity

  • Undersensing: this is like being in asynchronous mode - risk of R-on-T phenomenon -- increase the sensitivity by making the sensitivity number smaller

  • Oversensing: the opposite of the above problem - pacemaker doesn't fire because erroneously detects "noise" -- decrease the sensitivity by making the sensitivity number higher 

ACEP Open Forum WITH various residents

5 Oncologic Emergencies with Dr Whitford

  1. Acute Promyelocytic Leukemia/ Blast Crisis

    • Auer Rods present

    • Talk to oncology and start All-trans Retinoic Acid (ATRA)

  2. Disseminated Intravascular Coagulation

    • Low platelets on initial CBC should make you suspect this

    • Fibrinogen low, D-Dimer high

    • Platelets < 20 without bleeding or Platelet < 40 with bleeding - treat

  3. Tumor Lysis Syndrome

    • Uric Acid high, Phos high, Calcium low

    • Treat with allopurinol and in consultation with oncology consider starting rasburicase

  4. Leukostasis

    • WBC >100k, treat with leukopheresis 

  5. Neutropenic fever / Malignancy with SIRS

Opioid Alternatives with Dr. Sabedra

  • Lidocaine comes in other formulations such as cream, ointment, not just patches

  • Physical therapy is underutilized in the ED as a pain adjunct

  • Trigger Point Injections

    • Something to consider in patients with highly localized pain

  • Osteopathic Manipulation Techniques- controversial, but could be a second line pain management therapy

Interesting Legal Cases and Physician Wellness with Dr. Shaw

Physician Financial Wellness

  • 11% of physicians over 70 have less than 500k in wealth

  • Investing early pays off massively in retirement

  • Managing your finances is your second job - learning the basics behind this early can help you avoid costly mistakes

  • REPAYE

    • An income-based repayment plan that has you pay back loans at 10% of your discretionary spending

    • The government pays 50% of unsubsidized loans unpaid interest quarterly to effectively halve your interest rate

    • Residents should consider this plan when refinancing federal loans because of this interest benefit

Two Court Cases Emergency Physicians Should Know About

Kowalski vs. St. Francis Hospital

  • ER physicians discharged a patient who was intoxicated and subsequently got hit by a car 2 hours after discharge

  • He was not slurring his speech, could ambulate, had a friend pick him up

  • Ultimately, the New York Highest Courts found a physician’s duty does not allow, let alone mandate, that physicians detain intoxicated patients, so the case was dismissed

USA vs. AnMed Health

  • AnMed Health held a psychiatric patient for 38 days in their ED for transfer to an outside facility despite having an inpatient floor for voluntary psychiatric admissions and an on-call psychiatrist

  • OIG asserts that Emergency Physicians were not fit to do EMTALA screening, and that they should have had the on-call psychiatrist stabilize and evaluate the patient before transfer 

Difficult Dislocations with Dr. Liebman

Jaw Reduction

  • Most commonly due to atraumatic causes (yawning)

  • Anterior dislocation most common

    • Affected side: push on the coronoid process

    • Unaffected side: pull behind the angle of the mandible simultaneously to rotate the jaw inward

Hip Dislocations

  • Most commonly associated with trauma

  • Posterior dislocation most common

  • Risk of AVN if you don’t reduce

  • Instead of climbing onto the bed, use your knee as a fulcrum with the patients affected leg over own (See the Captain Morgan Technique)

  • Don’t forget about post reduction CT to define acetabular fracture 

T&A Bleed and Atrial Fibrillation with Dr. Randolph

Post T&A Bleed

  • Post-operative bleeds are common but typically do not become significant bleeds

  • If having issues, consider

    • Using nebulized epinephrine

    • Using gauze soaked in TXA or code dose epinephrine and placing over tonsil

    • Consider ketamine if applying direct pressure

Afib Management Update

  • Rate control better for older patients

  • Rhythm control better for younger patients

  • Most studies determine NOAC better than traditional anticoagulants

Bleeding Disorders

  • Atypical ITP may be triggered by quinine ingestion 

Pacemaker Dysfunction with Dr. Murphy

Main Types of Failure

  • Failure to sense

    • Pacemaker does not sense cardiac rhythm

    • Causes include lead dislodgment, electrolyte abnormalities, fibrosis at the tip.

  • Failure to capture

    • Pacemaker generating output but fails to depolarize heart

    • Scar tissue at electrode, lead fracture, lead malfunction common causes

  • Failure to pace

    • Pacemaker not effectively delivering a stimulus

    • Causes include over-sensing (thinks atrial stimulus is a heart beat), battery failure, lead misplacement

Pacemaker mediated tachycardia

  • Reentrant tachycardia from pacemaker (~200 beats per minute) current

  • Apply a magnet to treat this condition

Runaway pacemaker

  • Due to low voltage or battery failure in old pacemaker

  • Fast pacer spikes (200 beats per minute)

Hyperoxia and QI with Dr. Gauger

Hyperoxia

  • Patients with underlying lung pathology should be at 88-92%

  • All other patients should be at 92-96%

  • Literature shows higher O2 saturations are harmful to a variety of organ systems

Quality Improvement

  • ACEP has a grant to fund promising QI projects

  • Only 4 people applied, so consider applying!  

Pediatric EKGs with Dr. Continenza

EKG in Pediatrics

  • RSR’ can be normal in pediatric patients

  • Left Axis Deviation is typically abnormal in children and can suggest structural disease

  • TWI can be normal in children, especially in V1-V2

  • Focal pattern of LVH may be suggestive of HOCUM

R4 CASE FOLLOW-UP WITH DR. CONTINENZA

Young female presents after precipitous delivery of 39 week infant in ambulance en route to hospital. She seems to have had an uncomplicated pregnancy until this point, and placenta delivered upon arrival to the ED, however with subsequent postpartum hemorrhage.

Postpartum hemorrhage:

  • 500 cc blood loss

  • Complicates 1-5% of deliveries

  • risk factors: obesity, uterine over-distention, abnormal placenta, preeclampsia, multiparous, instrumentation, prolonged 3rd stage of labor, precipitous delivery

  • 70% uterine atony, 20% trauma, 10% retained placental tissue/abnormal placentation, 1% coagulopathy (4 T’s: tone, trauma, tissue, thrombin)

Initial management:

  • Step 1:  Bimanual uterine massage, may need internal massage

  • Step 2: Oxytocin: either 10 IU IM or 40 IU in 1 L NS with 500 cc given over 10 min.

  • Step 3. Remember you are experienced in treating hemorrhagic shock:

    • Ensure adequate IV access

    • TXA 1g over 10 min

    • Avoid hypothermia

    • Transfuse product as needed

    • Obtain TEG, replace clotting factors PRN

    • Definitive care (OBGYN, OR)

  • Step 4: determine cause, treat using 4 T’s (Tone, Trauma, Tissue, Thrombin)

    • Uterine atony: (in addition to oxytocin listed above), can give:

      • Methylergonovine 0. 2 mg IM q2-4 hrs

      • Carboprost 250 mcg IM q 15-90 min (max 2 mg)

      • Misoprostol 800 mcg-1mg rectally or 600-800 mcg sublingually/orally

    • Trauma:

      • Manage lacerations and hematomas

    • Reduce uterine inversion (may need procedural sedation, hold oxytocin drip)

    • Retained Tissue:

      • inspect placenta, remove retained placental tissue manually if needed

    • Coagulopathy

      • obtain rapid TEG, coags, CBC

      • replace clotting factors as needed

      • consider DDAVP in VWD

Still Bleeding?

  • May require uterine tamponade with uterine packing or balloon tamponade

  • Can use Condom Catheter tied off, Bakri balloon, or other device inserted in the cervix for balloon tamponade

  • Ensure definitive treatment/OB-Gyn arranged