Grand Rounds Recap 10/7

Evidence Based Medicine on Tachydysrhythmias with Drs. Ludmer and Miller

  • SVT is an umbrella term that includes AVNRT, atrial fibrillation and flutter, and polymorphic multifocal atrial tachycardia (MAT)
  • AVNRT (AV Node Re-entrant Tachycardia) is the correct term for what is commonly diagnosed as SVT, 
  • MAT usually occurs in critically ill elderly patients with respiratory failure and is a poor prognostic sign, associated with 60% in hospital mortality. Treatment is to treat the causative pathology.
  • REVERT Trial: Modified valsalva vs standard valsalva performed in 10 EDs with 428 patients in England. Findings included a 17% conversion with standard methods and 43% with the modified valsalva. 
  • Be on the lookout for the complete updated algorithm coming soon to CPQE

R1 Clinical Diagnostics on Arthrocentesis with Dr. Summers

  • In addition to consulting orthopedics for confirmed septic joints, concern for septic arthritis in prosthetics and septic hips should receive formal ortho evals as well. 
  • Differentiating gout and septic joint can be difficult as septic arthritis may be present in joints with synovial fluid positive crystals on the order of 1.5-5%
  • Irreversible cartilage damage may occur within 8 hours of onset of septic joint
  • Synovial gram stain is helpful if the test is positive however negative does not rule out septic joint
  • Synovial fluid analysis
    • WBC: >100k has a positive likelihood ratio of 28 vs >50k has a likelihood ratio of> 7.7
    • Synovial lactate, if greater than 10, has a positive LR>1 
  • Ultimately, if you are concerned about a possible septic arthritis, there is no one test that will make the diagnosis. The H&P should be used in conjunction with arthrocentesis results to make the best possible decision for the patient. 
  • For more information on evaluation of the septic joint, take a look at our CPQE algorithm and Dr. Summers' asynchronous learning module here.

Visual Diagnosis with Dr. Otten

  • A picture says a thousand words... for those of you missed out you can email Dr. Otten sample slides or re-acquaint yourselves with an Atlas of Emergency Medicine

R1 Clinical Knowledge on Tick-Borne Illness with Dr. McKee

  • Lyme disease often (though not always) presents with a classic bulls-eye, target rash called erythema migrans within days of being bit by Ixodes Scapularis
  • Bilateral Bell's Palsy is Lyme Disease until proven otherwise
  • Treatment is doxycycline 100 mg BID for two weeks
  • Erlichiosis and Babesiosis can also be spread by Lyme Disease
  • Rocky Mountain Spotted Fever: Due to bites by Brown Dog ticks carrying Rickettsia Ricketsii classically associated with a progressive petechial rash classically involving palms and soles that can become gangrenous due to thrombocytopenia and associated coagulopathy
  • RMSF: Treat with doxycycline for 5-7 days; these patients can be SICK
  • Tularemia. Comes from infected rabbits (get from ticks). Again, doxycycline is the treatment. 
  • Official CDC recommendation for tick removal: grab tick with forceps, grab as proximal to skin as possible and pull

R4 Capstone with Dr. Doerning: Precipitous Deliveries

  • Observational Hennepin Study of deliveries in the ED from 00:00-08:00: 80 deliveries: 12 without prenatal care, 4 breech (with 2 deaths), 7 nuchal cords (1 death), 2 shoulder dystocia 
  • Shoulder dystocia occurs between 0.2-3% of deliveries and can compromise mother and child; maternal diabetes increases risk by 70%
    • HELPERR: Call for Help, evaluate for Episiotomy, Legs (place pts in McRoberts=push legs up and flatten out back), Pressure (suprapubic region, not fundus), Remove posterior arm, Roll mom onto all fours (Gaskin maneuver)
    • McRoberts maneuver alone alleviates 41% of dystocias 
  • Breech deliveries account for 3-5% of presentations with 65-70% of these frank breech (both legs up in the pelvis and bottom at cervical aperture)
    • Approach to breech? Less is more. Your goal is to allow for spontaneous delivery to level of umbilicus and then rotate baby to back is anterior
    • Pinard Maneuver: Attempt to deliver one of the legs by inserting fingers into vagina
    • Once legs are delivered support passively with gentle traction on hips until scapulas/shoulders are 
    • Mariceau-Smellie-Veit Maneuver--pushing down head with suprapubic maneuver
  • Cord Emergencies
    • Cord Prolapse: Your goal is to relieve pressure on cord which you can do by elevating presenting part mechanically. You can also place foley and fill bladder with 500-700ccs fluid. 
    • Nuchal cord: Reduce as much as possible mechanically and as a last resort cut (deliver as much of baby as possible first)

CPC with Drs. Goel and Srivistava

  • 31 yo relatively well appearing female with sickle cell presents with pain all over her body somewhat similar to prior sickle cell pain crises although with new meningismus and a WBC count of 25k. 
  • Dr. Srivistava: Get the CT head. 
  • Dr. Goel: Got 'em. CT head reveals acute ICH
  • Take-Home: Patients with sickle cell disease are at higher risk for stroke (300% greater risk than average patient population), both for acute thrombotic events due to hypoxia-induced sickling and rouleaux formation but also hemorrhagic stroke due to chronic wear and tear on vessel intima by sickled RBCs
  • Patients with high rates of sickle cell burden, sickle crises, severe anemia are at higher risk
  • Moyamoya: chronic occlusion of circle of Willis vessels causing collateralization of these vessels associated at increased risk of aneurysms and stroke
  • LDH 3 times greater than the upper limit of normal has a high association with pro-thrombotic events in sickle cell patients
  • Remember, sickle cell patients are at much higher risk of ischemic and hemorrhagic stroke and exchange transfusion may be indicated (particularly with ischemic strokes)

R4 Case Follow Up with Dr. Selvam

  • Minimally responsive male presents to the SRU with a core temp of... less than 80 F
  • For the second time this year, please check out this prior grand rounds recap for an in-depth discussion about the management of the hypothermic patient
  • This patient shortly after had a cardiac arrest followed by aggressive resuscitation including bilateral high-low chest tubes and active intra-thoracic rewarming. With a core temp of 82 the patient had ROSC. A central line catheter was placed for infusion of warmed IVF as well. 

CEC Operations with Dr. Miller

  • We have entered the age of data-driven medicine where analytics are playing a huge role in optimizing efficiency
  • As we apply these tools to our own system we can expect systems-level changes that are already under way... stay tuned...
  • As UCMC EPIC is updated there will be a number of changes that will potentially allow EDPs to improve their workflow