Grand Rounds 10.25.17


Case 1: Clostridium difficile infection presenting as chronic abdominal pain

The Chronic Pain Drain
Physicians de-individualize, de-personalize the patients and the patient's start to sees insensitive, uncaring and ignorant
This creates a cycle of physician rationalization and patient exaggeration
In one study

  • 67% of patients diagnoses with chronic back pain found have an alternate diagnosis in follow up
  • 4% of all ED visits diagnosed as "chronic" pain found to have other underlying pathology

Common causes of error: incomplete history taking, lack of testing, ignoring abnormal labs

Epidemiology of C. Diff
450,000 cases annually
Has passed MRSA as the most common hospital acquired infection since 2010
Increasing in frequency as more virulent strains emerge
1/5 cases will recur, recurrence defined as second diagnosis 8-10 weeks after appropriate treatment
Impact: Leading cause of diarrhea death with overall mortality of 5%, 2-8% progress to fulminant colitis which has mortality up to 80%

Symptoms: non-specific, osmotic diarrhea, classically foul odor, non-bloody
Time Course: Persistent as opposed to self-limited, use of antibiotics in the past 8 weeks and persistent diarrhea despite cessation of antibiotics
Risk Factors: age, antibiotic use in the last 8 weeks, antibiotic use >10 days, previous infection, acid suppression and chemotherapy

  • PCR DNA amplification on stool is most sensitive and specific
  • Only 50% have leukocytosis and this is usually indicative of advanced infection
  • Albumin <3, Cr >1.5 (more for risk stratification if we're concerned

Mild-to-moderate disease: risk diarrhea plus additional signs or symptoms
Severe disease: albumin <3 plus WBC >15000 or abdominal tenderness
Severe disease with complications: admission to ICU, hypotension, fever, ileus, AMS, WBC >35000 or <2000, lactate >2.2, end organ failure

Mild: Test and wait for results prior to treatment
Moderate: Start flagyl and test, can consider d/c home
Severe: Start PO vanc, admit and test
Complicated: Admit, IV + oral therapy, imaging and surgical consult

Case 2: Spinal cord compression in the setting of metastatic disease
Back Pain: present in 83-90% of cases
Lhermitte's Sign: electrical sensation that runs down the back into the limbs, associated with MS, specific (97%) for any posterior column pathology however sensitivity is low (3-7%)
Weakness: present in 53% of cauda equina however 80% of spinal cord compression which most commonly presents as difficulty with gait
Sensory deficits: more common in cauda equina (79%) than spinal cord compression (50%)
Bladder and bowel dysfunction: Present in 74% in cauda equina cases but less common in cord compression

70% of patients with metastases will have mets to bone, 70% of bony mets wil go to the spine, 70% of those will be in the thoracic spine
Motor symptoms: 
Urinary Retention/Bowel Dysfunction: 65% sensitive and 73% specific
Miss Rate: 23-29%

Take home points
Spinal cord compression is not uncommon in metastatic disease
Use history and risk factors to adjust pre-test probability
Augment exam with ultrasound (urinary retention) and pain control in order to get your best possible exam

Case 3: Lumbar Puncture in the setting of AMS and anticoagulation use
1/35,000 patients on any anticoagluation will experience bleeding complication during LP (RR of 22)
Thrombocytopenia: Consensus is platelet count >20,000 is generally safe
NSAIDS/ASA: Likely ok
Clopidogrel: No good data, in emergency settings likely low risk
Heparin+Lovenox: can check with aPTT, ideally wait 6 hours after a subcutaneous dose
Coumadin: Goal INR <1.5 however complications still low with INR <2, if above goal then empirically treat and reverse until INR is <1.5
DOACs: most say safe after 12 hours since last dose however be mindful of renal function

  • If last dose was day before -> LP
  • If last dose unknown -> treat empirically and delay LP

Case 4: Cardiac Arrest with LVAD
During a resuscitation take the following steps
Phone a friend, airway, breathing, circulation (one two, three, four approach)

  1. Assess the one drive line and drive line site
  2. Check for two batteries
  3. Ensure you have three wires connected to apparatus
  4. Asses the four parameters (power, flow pulsatility index and speed)
  • High power and fluctuating speeds? = possible thrombus, can give heparin or possibly TPA
  • Low Power and high PI = possible suction event, give 250-500cc bolus
  • High Power and low PI = sepsis or hypovolemia, consider small bolus

Code Situations
Arrhythmias are common, still consider your H's and T's, if the LVAD is working correctly consider other sources of bleeding as cause of death as these patients are anticoagulated (head, GI, etc)
No consensus on CPR, discuss with your local LVAD team however recent studies show it is likely tolerated without dislodging LVAD

Leadership Curriculum: Giving and Receiving Mentorship with Dr. Stettler

When surveyed, academic physicians name mentorship as the second most important thing for career development
Benefits of mentorship: increase knowledge of unknown opportunities, benefit of other experiences/past mistakes, external objective opinions, sounding board, keeping you honest in approach and intentions
Frustrations: time, finding a mentor, not knowing how to do this due to lack of training 

Mentor Pitfalls: failure of follow-through, failure to listen/explore, failure of advocacy, taking credit for the work of mentees
Mentee Pitfalls: Failure to contact, failure to plan, failure to follow through

Consider developing an individual development plan (IDP)/mentorship contract: Identifies the relationship, acts as a formal agreement, identifies targeted areas for development, holds everyone accountable

Tips for Success

  • Mentee: Initiate contact, frame the meeting (both in urgency and purpose), reflect upon your objectives and desired outcomes, be self reflective and be honest
  • Mentor: honestly consider your bandwidth, respond promptly to requests for contact, listen for the objectives of meeting and help flesh out goals, understand mentee's point of view, help create goals and an action plan, be prompt, respectful and grateful

R4 clinical soapbox: conflict resolution with dr. titone

Effects of conflict in the workplace: decreased team effectiveness, decreased job satisfaction, increase in healthcare costs, potentially worse patient outcomes

Source of Conflict

  • Resource-based: I want what you have
  • Psychological: Power, control, self esteem and acceptance, often exists under the surface
  • Values/Beliefs: Core values  (religious, ethical, financial or patient care), leads to differences in work ethics and/or expectations, most difficult to resolve

Responses to Conflict
Avoiding: delay the conflict and walk away, neither parties concerns are met
Accommodating: giving in to the other person's position, useful for issues of little importance, shows reasonableness and good will however in the long term can cause the "accommodator" to grow ill will
Compromising: exchanging concessions to meet in the middle, good for issues of moderate importance or when time is limited however does not lead to the best possible outcomes
Competing: winning at another's expense, can be useful when making difficult decisions as a leader however leads to unpopularity
Collaborating: merging perspectives, can be time consuming but leads to ideal outcomes with preserved relationships

Red Flags in conflict resolution: ignoring your personal feelings about conflict, not listening to what is being said, inflexibility to offering the other party an opportunity to admit their mistakes, not admitting your own mistakes, winning at another person's expense

General Principles for the EM Provider
1. Establish common goals and make them patient centered
2. Communicate effectively (use paraphrasing to illuminate the views and values of the other person)
3. Do not take conflict personally (know the "buzz words" that will immediately cause you to become hostile)
4. Avoid accusations and public confrontations
5. Compromise
6. Establish specific commitments and expectations
7. Accept differences of opinion
8. Use ongoing communication
9. Consider the use of a neutral mediator for unpleasant situations
10. Be pleasant!

Every fight is, on some level, a fight between differing angles of vision illuminating the same truth
Find your opponent’s truth and collaborate to find higher ground

r3 taming the sru: pulmonary arterial hypertension with dr. bernardoni

Case: Elderly male with pulmonary artery hypertension, HIV, CHF and chronic adrenal insufficiency
Presents with SOB and hypoxia in setting of normal CXR, leukocytosis, mildly elevated BNP, negative troponin and AI

Spiral of PAH: V/Q mismatch from hypoxia -> pulmonary vasoconstriction -> worsening PAH ->  RV ischemia -> hypotension -> worsening RV function from hypoperfusion

  • RV ischemia -> AV nodal dysfunction -> "ominous bradycardia"

Objectives in the treatment of PAH:

1. Optimize volume status
Patient are rarely volume responsive and if you do overload the RV you will push them further on the Starling curve and worsen the situation
Sometimes they can you know?
Bedside echo 

  • Parasternal long: global look at RV vs LV
  • Short: paradoxical septal motion/D sign = RV pressure moving septum into LV, LV does not remain circular during systole
  • Apical 4: RV:LV ratio, McConnell's sign = dilated RV with only the tip contracting, can occur in anything that stresses RV (classically PE)
  • TAPSE: movement of tricuspid valve, move movement = better RV function, normal >1.8 cm 

If unsure of volume status you do nothing or try small 250 cc fluid bolus but err on the side of diuresis

2. Support systemic pressure
Norepinephrine is the pressor of choice but be aware it increases PVR at very high doses
Vasopressin should be added anytime you're starting norepi as decreases PVR through a NO based mechanism
Phenylephrine should be avoided as it increased PVR 

3. Increase RV inotropy
Dobutamine is the agent of choice as it increases inotropy while decrease PVR, does drop SVR so have vasopressor close by
Milrinone: decreases PVR and SVR but hasn't done as well as dobutamine in head to head trials

4. Off-load RV
Inhaled NO dilates pulmonary vasculature only in ventilated areas
Patients DO NOT need to be intubated for inhaled nitric, can be started through a high flow NC device (such as Optiflo)
 start with optiflow, does not need an ETT

5. Support oxygenation and ventilation (avoid hypoxia and hypercarbia)
Goal O2 sat of around 90%
During RSI induction there is a large decrease in preload which can lead to further RV ischemia (etomidate is the inducer of choice)
PPV can further decrease RV function
Resuscitate before your intubate: consider early art line and use prophylactic push dose epi or empirically start norepi/dobuatmaine prior to intubation
Consider bagging during the apneic period to avoid hypercarbia and worsening pulmonary resistance
Low TV strategy with low plateau pressure, lowest PEEP possible even at the expense of high FiO2, avoid hypercapnea (goal pH equal to or greater than 7.3)

General Tips and Tricks
Tachydysrhythmias need to be converted, push amio slowly and don't be afraid to cardiovert!
A new O2 requirement is a red flag
Correct anemia! Patient do not tolerate this well anemia, Hb goal of 8.0 or above and if they need a transfusion go slow
Patients shouldn't have have pulmonary edema unless they have biventricular failure
Volume status is even harder to determine than usual so look for document dry-weight and LE edema
V/Q scan are useful to rule out PE if there is a contrast contraindication as these patients usually have a baseline scan to compare them to
Patients are prone to thyroid dysfunction