Grand Rounds Recap 11/18

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MORBIDITY & MORTALITY WITH DR. LI

Case 1: Compartment Syndrome from Contrast Extravasation

  • Intravenous contrast extravasation is relatively rare

  • In patients who experience contrast extravasation, most have mild symptoms and very rarely need surgical intervention

  • Measuring compartment pressures may be helpful and also misleading 

    • Normal is < 10 mm Hg

    • Concerning is > 30 mm Hg

    • Delta pressure (diastolic pressure - compartment pressure) can be more helpful than absolute pressure 

  • Compartment syndrome remains a clinical diagnosis 

Case 2: Subarachnoid Hemorrhage (SAH)

  • Sentinel headache can precede overt aneurysmal rupture 2-8 weeks in advance, though some argue this could be recall bias 

  • Traumatic LPs often have RBCS in the 0-500 range in tube 4 and/or 70% RBC clearance from tube 1 to tube 4

  • Lack of xanthochromia and RBCs < 2000 was found to be 100% sensitive in 1 study

Case 3: Emergency Radiology 

  • The number of radiographic studies ordered has increased steadily over time, which can increase errors in radiograph interpretation

  • Perceptual errors occur in the initial detection phase, when an abnormality is later to be determined to be present that wasn’t seen initially 

  • Interpreted errors occur when the abnormal finding is noted but the implications are incorrect typically due to lack of clinical context 

  • Create your workflow for assessing imaging: put in where the patient’s pain is located when ordering imaging to help out the radiologists, try to look at imaging yourself, scan the body of the report and not just the interpretation, call radiology if something doesn’t make sense 

Case 4: Cardiac Arrest + Left Ventricular Assist Device (LVAD)

LVAD components: 

  • Ensure driveline is connected, as this links the internal device to external world

  • Check the controller for alarms

  • Verify a power source, such as a battery, is connected

What to do if an LVAD patient is unresponsive? 

  • Unlikely to have a pulse with continuous flow of new LVAD models

  • Doppler a MAP

  • Auscultate for whir (i.e. hum) 

  • Perform CPR if in cardiac arrest (no BP/whirl/unresponsive), though with some risk of device dislodgment

  • At UCMC, simultaneously call LVAD coordinator, CVICU charge nurse, and CVICU fellow

Case 5: Insulin Prescriptions & Hypoglycemia 

  • It is important to note peak onset times of the various types of insulin 

  • Renal function and weight are important factors in insulin dosing 

  • Goal glucose level prior to discharge may be less important than helping our patients access care 

  • Double check your prescriptions of potentially dangerous medications, especially if it’s not a medication you commonly prescribe

Case 6: Antibiotic Prophylaxis in Open Fracture

  • Per Gustilo-Anderson Classification, there are 3 different grades of open fracture:

    • Type I: < 1 cm clean laceration and minimal soft tissue damage

    • Type II: 1-10 cm clean laceration without extensive soft tissue injury, flaps, or avulsion

    • Type III: Extensive soft tissue damage including muscle, skin, and neurovascular structures; traumatic amputation; arterial injury; heavily contaminated

  • We are using ceftriaxone monotherapy in place of cefazolin & gentamicin, stemming from the literature (Rodriguez L, J Trauma Acute Care Surg, 2014). However, EAST guidelines and other on-shift guides have not yet updated their recommendation. 

Case 7: Droperidol & Prolonged QTc

  • Had a FDA black box warning for QTc prolongation and fatal arrhythmias in December 2001, albeit at significantly higher doses than we currently use in the ED 

  • A screening EKG is not mandated at lower doses (i.e. < 2.5 mg) 

  • Be appropriately cautious in patients with known QT prolongation or if administering with other QTc prolonging agents 

Case 8: Torsades de Pointes

  • This is a ventricular tachycardia that can be fatal: if pulseless, defibrillate; if unstable, cardiovert. 

  • In addition to electricity, give high dose magnesium, starting with 2g IV loading dose and repeat another 2g IV if no clinical effect followed by infusion watching for signs of hypermagnesemia 

  • For refractory torsades, consider chronotropy and increasing heart rate via isoproterenol - albeit contraindicated in congenital prolonged QTc; external overdrive pacing can also be considered 

EKGS FOR THE ED WITH CARDIOLOGY CONSULTANT DR. AHMAD

  • Hyperkalemia: peaked T waves that look painful to sit on, sine wave is a late finding

  • Hypokalemia: flattening of the T wave, PR prolongation, T wave inversion, U wave (extra bump after T wave in V4-V5)

  • Hypocalcemia: Prolonged QTc

  • VT versus SVT with aberrancy: Stepwise approach via Brugada Algorithm 

    • Absence of RS complex in all precordial leads (i.e. leads V1-6 are entirely positive, R, or entirely negative, QS)? If yes, then VT; if no, continue to next step (Sn 21%, Sp 100%)

    • In those leads with an RS complex, does it take over 100 ms to get to the bottom of the S (i.e. R to S interval >100 ms)? If yes, then VT; if no, continue to next step (Sn 66%, Sp 98%)

    • AV dissociation (i.e. discrete P waves seen)? If yes, then VT; if no, continue to next step (Sn 82%, Sp 98%)

    • Morphological criteria for VT present in V1-2 and V6? If yes, then VT (Sn 99%. Sp 97%); if no, then SVT (Sn 97%, Sp 99%)

  • Modified Sgarbossa’s Criteria to assess STEMI in the setting of a LBBB; only one criteria required to be positive (Sn 91%, Sp 90%)

    • ST elevation > 1 mm and in the same direction (concordant) with the QRS complex

    • ST depression > 1 mm in leads V1-V3

    • ST elevation to S wave amplitude ratio >= 0.25 (which replaces previous designation of > 5 mm of discordance)

  • Chapman’s sign can also be used to diagnose AMI in the setting of LBBB, which consists of a notch in the upslope of the R wave in Lead I, aVL or V6. Sensitivity is low but specificity is about 90%. 

  • Wellen’s wave is biphasic (Type A) or deeply inverted (Type B) T waves in V2 and V3 when pain free, which requires urgent but not necessarily emergent catheterization

  • De Winter’s pattern is 1-3 mm upsloping ST segment depression at the J point in leads V1-6 that continue to tall, positive symmetrical T waves, which should be treated as a STEMI equivalent

  • SHOCK II Trial demonstrated that cardiogenic shock with need for intraoartic balloon pump is dependent on vessel that is occluded: LAD 44%, RCA 27%, Circumflex 19%, Left Main 10%

  • Pericarditis can mimic a STEMI but ST elevation is typically more diffuse with other signs such as PR depression and should never have reciprocal changes

R1 CLINICAL TREATMENT: OPIOID WITHDRAWAL WITH DRS. STARK & GOTTULA

See Dr Stark’s full Opioid Withdrawal post here 

Horrifying statistics: 

  • 10.3M Americans misused prescription opioids in 2018, which represents 13% of all those prescribed opiates 

  • 130 people die daily from opioid misuse related deaths

  • 30% increase in ED visits related to opioid use disorders between 2016-17

Clinical Opiate Withdrawal Scale (COWS): 11 questions using Likert scale 

  • < 5 = no withdrawal

  • > 7 = indication for treatment in the ED

  • > 25 = severe withdrawal 

Buprenorphine

  • Partial opioid agonist binding to the mu receptor with high affinity 

  • Duration: 72 hours; peak action: 30-60 minutes

  • Administered via sublingual tablet, 4-8 mg 

  • Adverse effects: Misuse, respiratory depression, sedation, headache, GI symptoms

  • More effective at ameliorating withdrawal symptoms, increasing treatment retention, and minimizing adverse effects compared to alpha2-agonists but equivalent to methadone in alleviating symptoms and adverse effects 

Methadone 

  • Synthetic opioid agonist binding to the mu receptor 

  • Duration: 24 hours

  • Administered via IV and PO formulations, up to 40 mg per day in divided doses

  • Adverse effects: Misuse, respiratory depression, QT prolongation, sedation, headache, GI symptoms, weight gain 

  • More effective in reducing withdrawal symptoms and resulting in completion of therapy as compared to alpha2-agonists

Naloxone

  • Opioid antagonist with high affinity for opioid receptor 

  • Administered via IV, IM, or IN formulations 

  • Required to be prescribed to all patients with substance use disorder or when prescribing opiates in the ED in Ohio 

R4 CAPSTONE WITH DR. MAKINEN

Honorable soapbox mentions: 

  • Half dose etomidate is not a thing; your patients are awake

  • Normal saline is (usually) poison water

  • Bronchoscopy should be an EM procedure

  • Subclavian is the preferred site

Neglected: Emergency Medicine in Rural America 

  • 60M Americans live in rural America, representing ~20% of the US population

  • Patients in rural areas are typically older (17.5% over 65), poorer (16.4% with nearly half Medicaid or uninsured), and sicker (increased cumulative mortality rate)

  • What is a critical access hospital? 

    • 25 beds or less

    • 24/7 ED

    • >35 miles from closest hospital

    • Transfer agreement 

  • Critical access hospitals get 101% of Medicare reimbursement in attempt to overcome unfavorable financial position

  • There are 1338 hospitals that meet the critical care hospital designation but these are decreasing over time, increasing access issues across the country 

  • Creative solutions, including freestanding EDs, microhospitals, and telemedicine, and federal legislation are needed to solve this problem