Grand Rounds Recap 11/11

Sepsis - R4 Simulation with Drs. Betz, Doerning, Mann and Niziolek

Bugs and Drugs in Sepsis

Let’s get the coverage appropriate

  •  Gram Stain – about 50% accurate in the setting of blood cultures
  • When we inadequately cover bacteremia – 22% mortality
  • When we inadequately cover pneumonia – 31% mortality

Timing of antibiotics (Kumar et al 2006)

  • For every hour of delay – mortality increases approximately 10%

When do we double coverage for pseudomonas, acinetobacter and gram negatives?

  • Neutropenic / other HCAP risk factors

  • Previous culture positivitiy

  • Severe sepsis

In a paper by Chastre et al 2003, it was shown that 8 and 15 days had equal efficacy in prevention of VAP in intubated pneumonia patients

  • Remember guidelines should be institution (and even unit) dependent due to sesitivities

    • 90% sensitivity to cephalexin for E.Coli, 80% for trimeth-sulfa at UCMC, 

Why do my antibiotics have varying infusions and timings? It depends on what level of antibiotic you need for what duration of time

  • Time depedent (60% at least time at MIC)

  • Peak dependent (think aminoglycosides)

  • AUC/MIC (vancomycin)

Make sure to check out Fighting the Bugs (case 1), Sepsis Under Fire (case 2) and soon-to-be-posted curated summary of comments on their two prior posts on sepsis!

Occam's Dull blade - ClinicoPathologic Conference (CPC) with Drs. Gorder and Bohanske

19y M with no PMHx presents with flu-like illness x 10 days after having travelled in Europe for the last several months. He looked in the mirror and thought that he had pus in the back of his tonsils and diarrhea x 1 day with 'worms in it'. He has tonsillar exudates despite prior tonsillectomy. Unremarkable labs and 2 diagnostic tests were ordered...

Giardia + HIV? Occum's Rasor does not always apply...

  • Have a high suspicion for HIV in patients with fever, pharyngitis and painful mucuocutaneous ulcerations
  • A fourth generation immunoassay that tests for both IgG and IgM against HIV1/HIV2 as well as p24 is the current recommended screening test
  • This is confirmed with a rapid immunoassay that differentiates between HIV 1 and HIV2... no more Western blot
  • These tests can be negative or equivocal early in the disease so when in doubt send an RNA viral load
  • Diagnosing acute HIV in the ED is of critical importance for public health measures as well as for the patient's ultimate morbidity and mortality
  • Patients should be started on ART as soon as possible and starting ART in the ED may be coming soon...

Case Follow up with Dr. Latimer

Pediatric Oropharyngeal Trauma

One liner - don't run with a pen in your mouth

  • High risk injuries are more posterior, where the soft palate, retropharyngeal spaces and carotids are potential targets
  • To stop the bleeding, try direct pressure, topical TXA and even combat gauze which worked in this case
  • Consider antibiotics and observation based on mechanism and propensity to re-bleed

The Swollen Traumatic Knee

  • Consider tibial plateau fracture, especially with a mechanism of axial loading (extended brake foot in MVC)
  • If the patient can't bear weight - consider further imaging
  • Plain 2 view XR only 79% sensitive for tibial plateau fractures

The Limping Child - Pediatric EM with Dr. Overmann

2 year old male presents with an atraumatic R limp over the last 24 hours and now refuses to bear weight

Normal childhood gait - something to be observed by watching them walk towards their parents, not towards yourself...

The child should bear weight on any given leg for about 60% of the stride

  • 10-12 months - cruises holding onto objects
  • 12-14 months - walking short distances and standing unassisted
  • 17-21 months - stands on one foot enough to walk up stairs
  • 1.5-3 years - balance for a few seconds on one leg
  • 3 year -  normal gait and balance with normal arm swing

Abnormal gait can be secondary to pain, weakness or structural abnormalities

Antalgic Gait

  •  Decreases stance phase on the painful side - think trauma, infection

Trendelenburg - Downward pelvic tilt

  • LCP
  • SCFE
  • DDH

Vaulting Gait

  • Hyperextended knee creates large swing phase in affected leg

Stooped Gait

  • Bilaterally increased hip flexion
  • Pelvic, abdominal pain (The PID shuffle)


Toddler's Fracture 

  • Nondisplaced fracture of the distal third of the tibia 
  • Trivial mechanisms
  • Splint (long leg) with ortho follow up in 5-7 days

Osgood -Schlatter

  • Chronic avulsion apophysitis of the tibial tuberoscity
  • 9-14y athletes
  • Bilateral or unilateral
  • Expectant management with wide range of time to improvement

Sever's Disease

  • Calcaneal apophysitis
  • Heel pain in 8-12y athletes

Nonaccidental Trauma (NAT)

  • Historical contradiction (severe injury, minimal mechanism)
  • Delay in seeking care
  • Attributed to sibling or other party
  • Injury inconsistent with age

Mechanical Issues

Legg-Calve-Perthes (4-9y) - more frequent in males, avascular necrosis on XR with high degree of suspicision

Slipped Captial Femoral Epiphysis (SCFE) (9-14y)- lack of internal rotation

  • Non weight bearing
  • Ortho follow up

Development dysplasia and leg length difference

  • Bent knees and evaluate knee height


Septic arthritis

  • Risk factors of joint surgery, immunosuppression

Transient synovitis

  • Unclear etiology, diagnosis of exclusion
  • Usually after URI with well appearing child and negative exam
  • 3% incidence in childhood, resolve spontaneously

Kocher Criteria- 1 factor has 3%, - 2 has 40% chance of septic arthritis

  • Fever
  • No weight bearing
  • ESR > 40
  • WBC > 12

Not externally validated but the only useful criterion and when in doubt - tap the joint and engage your consultants