Grand Rounds Recap 12/2/15

Air Care Ground Rounds

Dr. Hinckley - Air Medical Resource Management

Familiarity and complacency can lead to mistakes. Stay uncomfortable. A policy for preflight walk-a-rounds will be released shortly. 

E-poc blood gas analyzer is now on AirCare. Think about using it for all patients, but particularly those who are intubated or may be in a state of shock.

Dr. Powell - Minnesota Tube is coming to AirCare

Everything you need will be in the Critical Care bag. You can bring all the gear with you into the hospital without having to gather supplies there. No football helmet required.

Procedural details

AirCare Case Review:

Have a high clinical suspicion to give the cyanokit to patients with significant smoke exposure and suspicion for cyanide toxicity. Since introducing this kit on AirCare it has been used successfully multiple times, but a cyanide level will likely not be available in a practical time frame.

Patients with smoke inhalation and an elevated lactate almost certainly

Airway management. Consider ketamine awake look.

Pediatric sedation

Rocuronium may paralyze the elderly female for 85 minutes, but is likely to only last for 30 minutes on the pediatric patient. Recognize that the pediatric population may metabolize benzodiazapenes more rapidly that our typical adult patient.

Dr. Powell - Cricothyrotomy

You have to mentally prepare for the procedures that you don't routinely perform.

Dr. Hinckley - We generally don't load pulseless patients for transport. This is obviously case specific, and communication with the transferring center regarding their resources is critical.

CPC with Dr. O'Brien and Dr. Schaninger

43 yo female with altered mental status, hypothermia, HTN. Differentials focus on eclampsia, thyroid, encephalitis, and drugs of abuse.

Ultimate dx: myxedema coma and hypothyroidism. Key features include hypoventilation (decreased response to hypoxia and hypocapnea). BP derangements due to relaxed smooth muscle tone, neurologic deficits, hyponatremia, bradycardia, AKI, and pleural/pericardial effusions, and periorbital edema.

Treat with T4 with a 200-400 mcg IV loading dose, followed by oral or IV daily dosing

Consider stress dose glucocorticoids, but would be beneficial to draw serum cortisol level before starting

Check a temp, begin thyroid treatment before confirmatory testing finalized

Case Follow Up with Dr. Doerning

34 yo with dysfibrinogenemia and abdominal pain, found to have mesenteric vein thrombosis and mesenteric ischemia.

  • Have an elevated suspicion for mesenteric ischemia in patients with hypercoagulable conditions.
  • If there is no ischemia the treatment requires heparinization or catheter directed thrombolysis. This patient required exploratory laparotomy for ischemic bowel.
  • Lactic acid elevation is not sensitive, being elevated only 10-20% of the time in patient with mesenteric ischemia.
  • Patient with congential dysfibrinogenemia: 25% have increased bleeding, 20% have thrombosis.

Research Ignite

Kyle Walsh: Monocytes/ICH biomarkers

Intracerebral hemorrhage (ICH) is a devastating disease for which there is no approved treatment. There is known to be initial injury from the hemorrhage itself, and more interest recently related to a secondary inflammatory injury. White blood cells play a role in this secondary injury, although the specific mechanism of action of different white blood cells is not well defined. Higher monocyte count has been associated with higher 30 day mortality in ICH in two independent cohorts. Monocyte subtypes exist with different functions. Characterization of these monocyte subtypes, using techniques such as flow cytometry, could help reveal novel therapeutic targets in ICH.

Charlie Kircher: MRI Utilization

The most common uses of MRI in our ED/CDU are for stroke/TIA, spinal infections and concern for spinal cord or ligamentous injury. Time to perform the test is an area of improvement for ED/CDU throughput and we are actively working with radiology to evaluate potential solutions.

  • Our overall utilization of MRI is increasing out of proportion to our clinical volume. Further research is underway to explore the drivers of this trend.

Natalie Kreitzer: TBI

A Comparison of Satisfaction with Life and the Glasgow Outcome Scale after Traumatic Brain Injury: An Analysis of the TRACK –TBI Pilot Study

  • Most TBI research has focused on functional outcomes. Life satisfaction is measured in the TRACK TBI pilot study, and we wanted to look at the correlation between functional outcome and satisfaction with life. 
  • Ultimately determined that there was a weakly positive correlation between satisfaction with life and good functional outcome. Depression had a higher correlation. 

Tim Loftus: Septic Arthritis

Atypical Pathogens Cause a Clinically Significant Number of Septic Arthritis Infections in the Emergency Department

Retrospective review of 252 patients with suspected arthritis from Oct 2012 - Jan 2015
91/252 (36%) cases of septic arthritis. 24/65 (37%) culture positive cases were atypical pathogens (17/24 MRSA).
No significant differences in the prevalence of IVDU between those with typical vs atypical infections.
Bottom Line - arthrocentesis is the only thing that should help you diagnose septic arthritis. If choosing to utilize with antibiotics, strongly consider covering for atypical pathogens, most notably MRSA. 

Woods Curry: Prehospital Ventilation

We performed a retrospective, chart review of TBI patients intubated by AirCare and transported to UCMC.  We compared patients who got bag-valve ventilation versus mechanical ventilation with the transport ventilator.  Primary outcome was pCO2 on trauma panel VBG on arrival at UCMC. We compared proportions of eucapnia between the groups.

Advanced Neuroimaging with Dr. Bonomo

Non Contrast Head CT

Window and Level your NCCT ~ W35/L35. This may help to identify signs of ischemia as early as 45 minutes post ictus. Early signs we should look for include:

  • Blurring of internal capsule
  • Loss of insular ribbon
  • Loss of corticomedullary differentiation

ASPECTS score (Alberta Stroke Programme Early CT Score)

10 point scale with 1 point taken off for each area of large vessel ischemia. The lower the score the higher the risk of ICH following thrombolysis.

CTA in AIS, Get it when:

  • Diagnosis in doubt
  • NIHSS > 10 (consider for NIHSS 6-9 as well)
  • Suspected basilar occlusion

CTA with anterior circulation large vessel occlusion (LVO)

  • Standard of care is now tPA + consideration of endovascular therapy
  • If clot > 8mm, endovascular therapy likely required
  • Ischemia of the brain results in the death of 1.8 million neurons/minute

CT/MR Perfusion Studies

  • Imaging not yet commonplace, and requires more contrast and more radiation
  • May help to differentiate the dead core of the stroke from the salvageable penumbra. Requires more contrast and more radiation.
  • May identify "wake up strokes" with unsure time of ictus that are favorable for treatment.

Aneurysmal SAH

  • CT/LP sensitivity approaches 100%, whereas CT + CTA > 99%
  • Aneurysms < 3 mm can be missed on CTA