Grand Rounds Recap 11.1.23
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Morbidity & Mortality WITH Dr. Yates
Foot Infection
NSTIs are rare but deadly pathology that need to be considered with any soft tissue infection
NSTI is a clinical diagnosis, but there are many imaging and laboratory assessments to help increase clinical suspicion
Expedited disposition to the OR for NSTIs under 12 hours from ED presentation significantly decreases mortality
Emesis
Transaminitis is a common finding in emergency department patients, making a systematic approach to diagnosis important and not anchor early
Biliary tract disease has multiple different presentations with laboratory abnormalities and imaging helping to determine level of obstruction
Biliary tract disease and acute viral hepatitis can have commonalities in presentation, so important to find differentiating factors and consider imaging for rule out of obstructive disease
Hyperthermic Associated Toxidromes
Hyperthermic-associated toxidromes are rare pathologies with overlapping presentations that need to be considered in an altered patient using anti-psychotic (NMS) or serotonergic (SS) medications
Mortality is due to the complications from hyperthermia, altered mental status, and neuromuscular activity
Supportive management is the mainstay of treatment with additional antidotes having limited evidence
Breast Implant Complications
While system 1 thinking helps with efficiency, it can lead to cognitive biases and diagnostic errors
Being aware of our own cognitive biases may benefit our patients with reduced diagnostic errors, and may benefit our interaction with consultants
The most common complications of breast augmentation are seromas and hematomas, yet infection needs to be considered especially if implants are placed in a foreign country due to use of “textured” implants which increase risk of cancers and infection
Rash
Incidence of syphilis has been on the rise over the past 5 years
Syphilis is known as the “great mimicker” for a reason, and the secondary syphilis rash can present in a variety of ways
Anterior uveitis is the most common presentation of ocular syphilis, can present during any stage, and requires IV penicillin for treatment
Family Presence During Cardiac Arrest
Family presence at bedside has shown positive psychological variables for both families and healthcare workers
Family presence has not been shown to increase healthcare worker stress, decrease ROSC or increase mistakes during resuscitations
Continued education on importance of family presence during resuscitations is needed to improve healthcare worker attitudes
Global Health WITH Dr. Bryant
In low resource settings, there are many substitutes for our usual burn care: cool running water to reduce need for graft and ICU, boiled or borax infused water if no clean water, and honey can be considered instead of bacitracin.
Eschars can form quickly and cause limited expansion of the torso and compartment syndrome of the extremities. It is important to understand depth of cut to bleeding fatty tissue, and to clean and splint afterwards to help with deformity.
Using common items to help with splinting to avoid loss of function with adhesions and scar tissue is key for recovery over flexible surfaces.
R1 Clinical Knowledge - MAHA WITH Dr. Gallen
With evidence of hemolytic anemia and thrombocytopenia on labs, “is this TTP or not?” is an essential question because prompt initiation of therapeutic plasma exchange decreases mortality from 90% to about 10-15%
PLASMIC score on MDCalc is a validated algorithm that can help identify TTP and guide decision making regarding initiation of TPE
Acute kidney injury or failure in HUS often presents days after the initial onset of symptoms (abdominal pain and bloody diarrhea) and while bloody diarrhea is present in only 60-90% of cases, hematuria is a relatively consistent finding in patients with HUS
DIC is triggered by tissue factor activation of the coagulation cascade and can be distinguished from other MAHAs by coagulation lab abnormalities such as increased PT, aPTT, D dimer and decreased fibrinogen
There are various types of DIC and management depends on which type of DIC the patient has. The ISTH tool on MDcalc can be used to assess the presence of overt DIC. Despite research assessing interventions at various points along the coagulation cascade/inflammatory pathways, there remains no consensus for best treatment and treating the underlying cause is recommended
Clinical Decision Rules: Head and C spine Imaging WITH Drs. D Thompson and Goel
C-spine Imaging:
NEXUS is a large, well-done study validating criteria for low-risk of cervical injury that are easy to remember and use at the bedside, and is used in our clinical decision guidelines on AgileMD.
Differences with Canadian criteria from NEXUS include elderly, ROM and mechanism.
Head Imaging:
Canadian (CCHR) > New Orleans (more specific, equally as sensitive)
Several validation studies have been performed with consistent results again stating CCHR safe to use without missing any CI TBIs
Application of these criteria can reduce head CT utilization
Consider not automatically scanning traumatic injuries in ages 65-75 in appropriate situations
Taming the SRU - Brash syndrome WITH Dr. Brower
Be wary of prehospital report, avoid anchoring and keep a broad differential, sometimes unresponsive patients have heart block
It takes a team to Tame the SRU. Build strong relationships with consultants as it will pay dividends in the long run
Treatment of BRASH syndrome centers around correcting hyperkalemia and catecholamines to support perfusion. Pacing is a last resort given the reversible etiologies
If pacing, anteroposterior is better than anterolateral, but transvenous pacing reigns supreme as it is more comfortable and eliminates chest wall factors
R4 Capstone WITH Dr. Finney
Keep your patients and yourself human
Wellness looks different for everyone
Take breaks even when you don’t think you need them
Be honest with how you’re feeling
As an R3 in the SRU, you are cut out to take care of anyone, anytime, anywhere
Sometimes, there is nothing good about a situation, but you will get through even the hardest things
