Grand Rounds Recap 12.18.19
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Morbidity and Mortality WITH Dr. Ham
Discharges Against Medical Advice
These are very high risk discharges - patients have higher morbidity rates and there is higher medico-legal risk to treating physicians
Capacity assessment - CURVES
Choice - can the patient make and communicate a choice without coercion?
Understand - does the patient understand the risks, benefits, alternatives, and consequences of their decision?
Reason - is the patient able to reason and provide logical explanations for their decision?
Values - is the decision consistent with the patient’s values?
Emergency - is there a serious or imminent risk to the patient’s well being?
Surrogate - is there a surrogate decision maker present or available?
Documentation
Include the signs, symptoms, and state of the evaluation up until that point
State the current plan and risks of foregoing treatment
Also include alternatives to current treatment plan
Fill prescriptions prior to the patient leaving and attempt to contact the patient’s primary care provider
Mechanical Ventilation and Inhalation Injury
The majority of patients who are mechanically ventilated for suspected inhalation injury are extubated within 48 hours
In quaternary centers with 24/7 ability to intervene on airways, EPs are likely over aggressive when intubating patients with suspected smoke inhalation
Patients who are mechanically ventilated following a burn have a significantly higher mortality rate which is independent of other confounding variables (such as age, comorbidities, etc.)
When to intubate a patient with suspected inhalation injury
Patients with systemic cyanide or carbon monoxide toxicity should be intubated
Lactate levels greater than 10 are predictive of systemic cyanide toxicity with about 85% sensitivity
Imminent airway obstruction, failure of non-invasive ventilatory support, or altered mental status without ability to protect the airway are all hard indications for intubation
Facial burns, singed nasal hairs, and carbonaceous secretions have a high false positive rate and only reflect exposure to smoke and not necessarily inhalation injury
Errors in Radiology
4% of radiology interpretations contain errors
Most common misses in neuroradiology
Stroke is the most commonly missed diagnosis in patients discharged with non-specific headaches
Be thoughtful when ordering specific imaging studies and follow up on the results of those tests
Make sure you communicate effectively with our radiology colleagues as well as the patient to reduce errors
Quadriceps Tendon Rupture
Results from an eccentric stress on a bent knee
Often occurs in older patients
Patient’s will present with pain and swelling of the knee, a supra-patellar gap, and inability to extend the knee
MRI is the gold standard for diagnosis
Ultrasound can also be used and can have higher sensitivity than x-rays
Management: pain control, knee immobilization, and no weight bearing of the affected extremity
Torsades de Pointes
Irregular wide complex tachycardia with baseline long QTc
If the patient has a pulse, treat with 2-4 grams of magnesium
If pulseless, defibrillate while also administering magnesium
If the patient does not have a baseline long QTc, cardioversion or defibrillation immediately and treat with standard anti-arrhythmics (procainamide, amiodarone) as the cause is unlikely torsades
For refractory torsades, case reports exist suggesting that lidocaine may be useful
R1 Clinical Knowledge: Male GU Disorders WITH Dr. Chuko
Sexually Transmitted Infections
Urethritis
Gonorrhea (30%) and chlamydia (15-40%) are the most common infectious agents
There is an approximately 20% transmission rate following a single episode of vaginal intercourse with an infected female
Symptoms typically occur within 2-5 days following exposure
Dysuria and mucopurulent discharge are the most common symptoms
The diagnosis is made clinically and can be confirmed with NAAT testing of the urine or urethral discharge
Treat empirically with 250 mg of intramuscular ceftriaxone and 1 g of azithromycin
Trichomonas is an uncommon cause of male urethritis
Treat for trichomoniasis if the patients partner has confirmed trichomoniasis or if symptoms are refractory to ceftriaxone and azithromycin
M. genitalium is a growing cause of refractory or prolonged urethritis, and can be treated with 400 mg of oral moxifloxacin for 7-10 days
Epididymitis
Most common in sexually active males age 14-35
Presents with testicular pain and swelling
The onset is more gradual than urethritis
If untreated, patients may develop infertility and chronic pain
Treat with 250 mg of ceftriaxone and doxycycline for 10 days
Pain can be treated with scrotal support and elevation, ice, and NSAIDs
58% of patients will also develop orchitis, but treatment remains the same
Urinary Tract Infections
“Uncomplicated” complicated UTIs
The male urethra is significantly longer than the female urethra, making urinary tract infections much less common in males
The prostate also releases antibacterial secretions contributing to the lower incidence of UTIs in males
Risk factors for urinary tract infections in males
Prostate enlargement
Bladder tumors
Bladder dysfunction
Immunosuppression
Treatment
Standard first line agents (e.g. cephalosporins)
Acute bacterial prostatitis
More common in males > 45 years of age
The prostate will be enlarged and exquisitely tender to palpation on rectal exam
Treatment
Bactrim or ciprofloxacin for a prolonged course (4-6 weeks)
Genital Lesions
Chancroid
Painful genital ulcer with tender lymphadenopathy
Treat with ceftriaxone or azithromycin
Genital herpes
Treat with acyclovir for 7-10 days during an acute flare
Suppression therapy with daily acyclovir reduces the recurrence rate by about 70%
Granuloma Inguinale
Highly vascular, beefy red lesion with no lymphadenopathy
Treat with azithromycin empirically
Balanitis
More common in uncircumcized males
Often caused by candida species
Topical antifungals (clotrimazole) are first like treatment
R1 Clinical Diagnostics: STEMI Equivalents WITH Dr. Frankenfeld and Dr. Humphries
Please see Dr. Frankenfeld’s fantastic post here for additional information
Wellen’s Syndrome
Classically represents critical LAD stenosis (>95% stenosis)
Patients will often be chest pain free at the time of the EKG
Troponin will usually be normal or only minimally elevated
Obtain repeat EKG’s and look for pseudo-normalization
These patients do not need an emergent cardiac catheterization if symptom free but should not undergo stress testing and should have an urgent cardiac catheterization
Causes of pseudo-Wellen’s EKG changes
Drugs: PCP, marijuana, cocaine
Pulmonary embolism
Left ventricular hypertrophy, right bundle branch block
Intracranial hemorrhage causing neurogenic T waves
ST-elevation in aVR (> 1mm) with diffuse ST depression
Occurs with left-main coronary artery occlusion, proximal LAD occlusion, severe triple vessel disease, and diffuse subendocardial ischemia from a non-cardiac cause (e.g. sepsis, hemorrhagic shock)
If ST elevation is greater than the elevation in V1, this is much more likely a left main occlusion
PCI is often performed but only diagnostic, as many patients will need a CABG
Consider holding off on additional anti-platelet agents until discussing with interventional cardiology
CPC WITH Dr. Gawron and Dr. Betz
Traumatic Rhabdomyolysis
Caused by muscle necrosis and release of intracellular contents into the vasculature
Myoglobin precipitates in the renal glomerulus and leads to renal failure
There are 3 causes of rhabdomyolysis
Non-traumatic, exertional
Non-traumatic, non-exertional
Traumatic
Falls with prolonged down time, prolonged restraints, electrical shock injuries
Classic triad: muscle pain, weakness, and dark colored urine
Diagnosis: history/exam findings with an elevated CK
> 5 times the upper limit of normal is considered the cutoff for diagnosing rhabdomyolysis
CK levels usually peak at 24-72 hours
CK then gradually declines over the next 3-4 days
Urinalysis - heme positive with no RBCs, cola colored urine
Electrolytes abnormalities
Hyperkalemia
Hypocalcemia
Hyperphosphatemia
Management:
Address electrolytes, especially hyperkalemia
Fluid resuscitation - target a urine output of 250-300 mL/hr
Consider renal replacement therapy if renal failure progresses to anuria
McMahon Score
Predicts risk of renal failure requiring renal replacement therapy
Based on the patient’s age, sex, creatine, calcium, phosphate, bicarbonate, CK level, and if the rhabdomyolysis is suspected to be from a seizure, syncope, exercise, statins, or myositis
EMS Grand Rounds: Protocol Updates and Review WITH Dr. Crook
The full 2020 Southwest Ohio EMS Protocol can be found here for additional information
2020 Protocol updates
Epinephrine
Standard code epinephrine is now 1 mg/10 mL and anaphylaxis epinephrine is now 1 mg/mL
Determination of death
Now highlights that isolated penetrating trauma should rarely be considered incompatible with life and should be transported
Scope of Practice
Ketamine (for pain) is now available for use by paramedics and some advanced EMTs
Altered level of consciousness/altered mental status
New emphasis on syncope as a potential cause - 12 lead EKG should be routinely obtained to assess for prolonged QT, delta waves, brugada syndrome, and HOCM
Symptom based chest pain and acute coronary syndrome
Updated to target a SpO2 of 94% when administering supplemental oxygen to avoid hyperoxia
Asthma/COPD
Now recommended to give corticosteroids if multiple albuterol doses are anticipated
Magnesium is now recommended in asthma patients only
Signs of impending respiratory failure have been added
Nausea/vomiting
Ondansetron is now available for pediatric patients > 12 months of age
Toxicology
Streamlined algorithm to focus on more commonly encountered overdoses
Maximum naloxone dose has been increased to 4 mg (previously 2 mg)
Sepsis
“Sepsis alert” criteria
Emphasis placed on early and rapid administration of a fluid bolus
Hemorrhagic shock
Recommends consideration of tension pneumothorax in trauma patients that do not respond to fluids
Hypothermia prevention is now emphasized
Pre-hospital pain management
Acetaminophen has been added for patients who can swallow and maintain their airway
Morphine dosing: 2-10 mg every 5-15 minutes for moderate to severe pain
Ketamine: 0.1 mg/kg which can be repeated for one dose after 15 minutes
Pediatric seizure
Capnography should routinely be used to monitor ventilation
Tension pneumothorax
Indicated for markedly decreased breath sounds, respiratory distress, severe/progressive tachypnea, or traumatic cardiac arrest
Longer 10 gauge 3.25 inch needle length recommended
Anterior axillary line approach is emphasized as first line, however the anterior approach still remains an option
Hemorrhage control
Tourniquets should be clearly exposed and marked with time of application
An additional section on junctional tourniquets has been added
New Protocols
Pregnancy complications
Discusses importance of maternal positioning during transport, routine transport of trauma patients even if they are well appearing
Includes detailed management of pre-eclampsia and eclampsia
Do not resuscitate
Copy of Ohio DNR form included to help standardize approach to patients with DNR forms (both comfort care and comfort care arrest)
EMS is not permitted to follow a standing DNR form signed by a non-physician (nurse practitioner, physician’s assistant)
Actions that EMS will and will not perform based on the patient’s code status are clearly defined
A health care power of attorney cannot revoke a DNR if the patient already has a signed form
