Grand Rounds Recap 11.3.21
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Morbidity and Mortality with Dr. Urbanowicz
Case 1: Transient Ischemic Attack
Most patients present after maximal symptoms have waned and may have complete resolution at the time of presentation
TIA indicates a significant risk of stroke in the following 3-6 months, with most occurring within the subsequent 7 days
ABCD2 Score: estimates the risk of stroke after a suspected TIA
Low risk (0-3): 1% within 48 hours and 3.1% within 90 days
Medium risk (4-5): 3% within 48 hours and 9.8% within 90 days
High risk (6-7): 8% within 48 hours and 17.8% within 90 days
Primary care setting (where initially derived): sensitivity 86.7%; specificity 35.4% for stroke within 7 days
Emergency department (using a cut-off of 2): Sensitivity 92.7%; specificity 12.5% for stroke within 7 days
Overall this score does not reliably discriminate those who are high risk for subsequent stroke when applied
Symptoms that are atypical of TIA, and reassuring:
Gradual onset (>5 minutes)
Marching of symptoms throughout the body
Change in symptom type (isolated motor or isolated sensory)
Isolated sensory changes with a small area of distribution
Symptoms lasting < 30 seconds
10% of patients with these symptoms will ultimately go on to have stroke
Role of MRI DWI imaging
DWI is the most sensitive modality for detection of ischemia
Changes suggest tissue ischemia and infarction
Approximately 30% of “classic” TIA patients have DWI-positive imaging
Ischemic changes on MRI evolve over time
MRI performed within 24 hours dramatically increases diagnostic yield of the subtle ischemia
Thalamic circulatory supply:
Supplied by the posterior circulation, therefore NIH is not particularly sensitive for the true deficit
There are 4 thalamic infarct syndromes:
Hemisensory loss +/- motor and neurocognitive deficits
Isolated change in behavior or level of arousal
Frontal-like symptoms: inattention, memory changes
Visual field deficits
Case 2: Altered mental status as presentation of stroke
Agitation is present in 2.6% of ED presentations
6% of post-ictal patients have agitation on presentation
Agitation can cloud the presentation, but care should be taken to evaluate for underlying pathology
Aphasia in particular can confused with agitation or altered mental status as the patient has difficulty communicating
Neuropsychiatric disturbances can be present in stroke:
1-3% of strokes present with delirium, delusions, dementia, or mania
Most culprit lesions that present this way occur in the right hemisphere or thalamus
These symptoms are often accompanied by mild or absent focal neurologic findings
Many of these patients are younger than 50 years of age
Case 3: Methamphetamine intoxication
The half-life of methamphetamine is 9-10 hours and this period of time can be used to gauge metabolism from presumed intoxication
Median vital signs in methamphetamine intoxication:
HR 102 - significantly elevated HR should trigger further investigation
BP 135/85 - significant hypertension is not necessarily expected
No associated pyrexia, tachypnea, or hypoxemia
Care should be taken to evaluate intoxicated patients for a secondary medical issue
1% of patients presenting to the emergency department with intoxication will have requirement of critical care resources (hemodynamic support, respiratory support, resuscitation, ICU admission)
The largest predictor of critical illness in intoxicated patients is presence of abnormal vital signs
Shock index > 1.3 at time of presentation predicts admission (+LR 6.64) and inpatient mortality (+LR 5.67)
Cardiovascular effects of methamphetamine
The vast majority of non-traumatic medical encounters among patients who use methamphetamine are related to cardiovascular complications
Direct myocardial toxicity can result in ischemia, non-ischemic (dilated), and takotsubo cardiomyopathies
15.2% of patients with heart failure have a history of substance use
Hypertension and tachycardia associated with methamphetamine use can lead to: coronary vasospasm, pulmonary hypertension, aortic dissection, non-occlusive myocardial infarction, and hypertensive emergency
Case 4: Interstitial lung disease
Interstitial lung disease can occur due to a variety of insults: infectious sequelae, environmental exposures, hereditary diseases, sarcoidosis, rheumatologic diseases, smoking, radiation, or post-traumatic
ILD carries a high mortality with medial survival from time of diagnosis in patients > 65 years old is 3.8 years
COVID-19 is likely increasing the prevalence of ILD
Acute exacerbation of ILD is defined as
A known diagnosis of ILD
CT evidence of worsening opacities
Acute worsening of dyspnea (hypoxemia or increased O2 requirement is not necessary)
Acute exacerbation of ILD is associated with significant increase in mortality
46% of deaths in ILD occur in acute exacerbation
Median survival of patient with ILD who experience an exacerbation is 4-5 months
Exacerbations are significantly more likely to be caused by viral infections, rather than bacterial
In the emergency department these patients should be started on CAP coverage with consideration of:
Broad spectrum antibiotics depending on prior cultures
Azithromycin for both atypical coverage and improvement in inflammation
CT without contrast is the test of choice as CXR is less sensitive, given significant opacities present at baseline
Unless the etiology of ILD is rheumatologic, steroids can be deferred in the emergency department
Case 5: Foot and Ankle Soft Tissue infections
Soft tissue infections of the foot can be difficult to diagnose and are often hard to treat due to poor vasculature and inability to rest the area.
Diabetes, neuropathy, and immunosuppression increase risk of infection
IVDU increases risk of SSTI, and 21% of IVDU related medical encounters are due to infections. Additionally these infections tend to be polymicrobial.
Common organisms include: staphylococcus, streptococcus, and pseudomonas
Compartment syndrome can occur as there are multiple small compartments (lateral, interosseous, central, and medial) that are intolerant of swelling.
Taming the SRU: Aortic Dissection with Dr. Ijaz
Aortic Dissection
Due to a tear of the intimal layer, leading to a false lumen
Classified as two types:
Stanford A: involvement of the ascending aorta
Generally requires surgical management
Stanford B: Involvement of the descending aorta
Often treated with medical optimization
Epidemiology and presentation:
Median age of 63 years
66% occur in males
Risk factors: HTN (76%), atherosclerosis (27%), aortic aneurysm (16%)
Only 30-40% present with “tearing” or “ripping” chest pain
Blood pressure at initial presentation
49% hypertensive
35% normotensive
16% hypotensive or in shock
Diagnosis:
CT angiogram is the test of choice
TEE is alternative gold-standard test
MRA is a viable test, but will delay care
TTE is helpful, but cannot rule the diagnosis out
Immediate causes of mortality:
Cardiac tamponade
Aortic insufficiency
Aortic free wall rupture
Myocardial infarction
Treatment:
Goal HR 60
Esmolol is rapidly titratable for HR control
500 mcg bolus followed by infusion starting at 50 mcg/kg
Goal SBP < 120 mmHg
Nicardipine 5 mg/hr titratable to max of 15 mg/hr
Nitroprusside 0.3 mcg/kg/min titratable to max of 10 mcg/kg/min
Aortic Dissection Detection Score (one point for any of the following categories):
Predisposing conditions: Marfan syndrome, Family history of aortic disease, known aortic valve disease, recent aortic manipulation, known thoracic aortic aneurysm
Pain features abrupt onset of pain, severe pain, ripping or tearing pain
Physical exam findings: Pulse deficit of SBP differential, focal neurological deficit + pain, new aortic insufficiency murmur + pain, hypotension/shock state
Risk score </= 1 and negative D dimer rules out all but 1 in 300 dissections (sensitivity 98.8%, specificity 57.3%)
R4 Case Follow-up: Shortness of Breath with Dr. Walsh
Thoracentesis tips and tricks:
Kits for bedside thoracentesis include Y-tubing that has two one-way valves that allow push/pull of the thoracentesis into the collection bag without need to use the stop-cock
Ultrasound can be used to define a safe location to perform thoracentesis
Inferior border is the location of the diaphragm at end-expiration
Superior border is the location of the inferior pole of the lung at end-inspiration
Depth of the parietal pleural line can be used to judge the depth at which fluid should be encountered
Depth to the lung can be used to prevent direct injury
Direct guidance of the procedure is helpful for smaller fluid collections
Volume of thoracentesis:
Theoretical risk of reexpansion pulmonary edema is well documented, but there are two proposed mechanisms of this outcome:
Total volume of the pleural effusion predicts elevation of intrathoracic pressure and subsequent severity of pulmonary edema
Volume of fluid removed predicts volume of lung expansion and may correlate with subsequent rate of pulmonary edema
Conventionally, volumes < 1500 mL were thought to be safe
A large case series of 799 patient with > 1500 mL removed demonstrated a risk of reexpansion pulmonary edema of 0.75%
BiPap is firstline treatment for reexpansion pulmonary edema
Systemic Thrombolytics in Pulmonary Embolism
Systemic Thrombolytics in PE
Agent of choice is tPA
Tenecteplase is being studied but generally has higher bleeding risk and is not currently routinely used nor recommended.
Which patients deserve consideration of systemic thrombolytics?
Massive PE (SBP<90mmHg for 15+mins or needing inotropic support)
High Risk Submassive PE--immediate treatment in controlled manner favored over delayed treatment upon clinical deterioration
Radiographic evidence of right ventricular strain
Elevated troponin
Elevated BNP (>90) or NT-pro (>500)
Elevated Shock Index
Supporting evidence for this practice
MOPETT Trial, 2013
Compared 50mg or less of tPA + heparin/lovenox vs heparin/lovenox alone
Significantly lower rate of pulmonary hypertension seen in tPA group at 14 days
Decreased mortality, recurrence of PE and long term pHTN in tPA group as well with no increased bleeding risk
MAPPET Trial in 2002 with similar variables and findings
Bleeding Risk with System tPA
Overall low risk of hemorrhage and extremely low risk of ICH
MOPETT investigators compared rates of ICH and major hemorrhage between heparin alone and heparin + lytic
Risk of major hemorrhage in both groups ~4%
Risk of ICH in both groups <0.5%
What dosing?
Half life of tPA is short (4mins) and pulmonary circulation sees 100% of cardiac output (compared to 20% seen by the brain) therefore overall PE treatment can have lower dosing
Additionally desired outcome is simply reducing clot burden, not dissolution of all clot
tPA continues to work via activated plasmin after metabolism (hepatic), so full effects are not immediately seen
Trials have compared 50mg to 100mg (the current package insert recommended dose for PE treatment) with similar clinical improvement
Higher dose had significant increase in resultant bleeds
The Dr. Walsh (Mostly Evidenced Based) Opinion regarding tPA dosing in PE
>50kg: 50mg tPA over 2 hrs with initial 10mg bolus
<50kg: 0.5mg/kg over 2 hours with initial 10mg bolus
>100kg: use the same dose as >50kg pts but can consider extended infusion time or repeat dosing
Visiting Professor: Global Emergency Medicine with Dr. Oteng
Majority of Global Health projects currently have goals including collaboration and sustainable but the definition of what this actually means on the ground is murky
Funding oftens supported projects with these taglines
Global health often has/had initiatives really only around issues with consensus--maternal/fetal medicine, pediatrics, malaria, communicable diseases, etc.
State of health care systems in developing countries currently:
Health care infrastructure has a huge cost, often being pushed and financially supported from external sources (WHO, UN SDG3, etc)
World bank estimates 4-7% of GDP of African continent is spent on healthcare and is increasing
Resources are siloed/funneled towards specific patient populations or disease processes without similar attention paid towards the population at large
Ex: a hospital may have no penicillin but has significant obstetric and NICU capabilities
NGOs reign
Emerging concerns/trends
Populations are increasingly urban
Increase in wealth is leading to increased car traffic and therefore MVCs
Increasing western foods and sedentary lifestyles
First contact with health systems is often in an emergency
Global burden of disease
WHO estimates ~90% of road traffic related injury deaths occur in low and middle income countries with the highest rates occurring in African region
Suicide and Homicide rates are also climbing globally
Emergency Medicine from global health perspective--Overall the scope of practice of emergency physicians is unknown in most of the world and therefore education and integration is extremely hard
Starting an Emergency Medicine residency and system in Ghana: Lessons Learned
Requires culturally honest communication and interventions
For example, residency training was previously often conducted without in person presence of attendings real-time
In a complete change of culture and model--the residency program initiated by Dr. Oteng requires 24/7 attending presence
Emphasis on respect and true interdependence with goal of creating a self-sustaining team train environment which can foster generations of physicians and subsequent care of the populace
Career planning, mentorship, leadership opportunities
Required advocacy for health care workers as a limited resource to increase work incentives, strategic placement, fair compensation, appropriate education and retention, etc.
Remind stakeholders that “winning” i.e. perceived benefits and successes occur in succession not simultaneously and also require investment of time without immediate tangible results
Investment in databases and research, both to validate contribution of the world into the academic space but also to help health systems and outcomes improve
The relative value of money is obviously very different across the world enabling similar research to be conducted a potentially significantly lower cost
