Grand Rounds Recap 12/12/18

EMS Grand Rounds - Lecture 2 - Lecture 3 - Lecture 4 - Lecture 5

EMS Grand Rounds WITH DR. Curry

Patients with infections who are brought in by Emergency Medical Services (EMS), in general, are older, more tachypneic, and have higher mortality rates overall.1 This presents a unique opportunity for advancing sepsis care by addressing the illness in the prehospital setting. There was a survey in 2012 investigating prehospital providers’ understanding of sepsis and its care. They found less than 50% of prehospital providers recognized some of the crucial management items in sepsis care, such as fluid resuscitation and antibiotic administration.2 Nonetheless, prehospital recognition of sepsis shortens time to antibiotics and time to early goal-directed therapy.3

Identification of sepsis in the field can be aided with the use of end-tidal CO2 (ETCO2). There are several studies showing that ETCO2 levels less than 25 mmHg correlate with increased mortality and elevated lactate levels.4 Based on this data, Southwest Ohio has adapted a new sepsis protocol for care of the septic patient in the prehospital setting.

If an adult (>/= 16) patient with suspected infection has the following:

  • SBP </= 90

  • HR>/= 90

  • Visible tachypnea

  • Acute altered mental status (AMS)

Place the patient on continuous ETCO2. Record a temperature. Check a fingerstick glucose if the patient has AMS. Call the receiving hospital and give them a “sepsis alert” notification. Initiate 500 cc of IV fluid and transport the patient.

The entire 2019 Southwest Ohio EMS Protocol can be found here. There are a number of protocol updates that should be reviewed.

  1. Wang H, Weaver M, Shapiro N, Yealy D. Opportunities for Emergency Medical Services Care of Sepsis. Resuscitation, 2010; 81(2): 193-197.

  2. Seymour C, Carlbom D, Engelberg R, Larsen J, et al. Understanding of sepsis among Emergency Medical Services: A survey study. J Emerg Med, 2012; 42(6): 666-677.

  3. Studnek J, Artho M, Garner C, Jones A. The impact of emergency medical services on the ED care of severe sepsis. Am J Emerg Med, 2012; 30(1): 51-56.

  4. Widmeier K, Wesley K. Assessing and Managing sepsis in the prehospital setting. Journal of Emergency Medical Services, 2015.

EM-Neuro Conference: Guillain-Barre WITH DRS. Neel and Smith

Signs and symptoms suggestive of a peripheral nervous system disorder include numbness, tingling, weakness, atrophy, and often pain. Patients may also report cramping, fasciculations, orthostasis, sexual dysfunction, and bowel/bladder issues. The neurologic exam would reveal hyporeflexia in the setting of a peripheral nervous system disorder. This is a crucial finding that is often missed by providers but can help localize neurologic complaints.

Guillain-Barre syndrome, also known as acute inflammatory demyelinating polyradiculoneuropathy, is a peripheral demyelinating disorder. It is often characterized by ascending weakness and affects male slightly more often than females. Most cases have an antecedent infection a few weeks prior to symptom onset. URIs are most common, but HIV, CMV, leukemia, surgery, pregnancy, and immunizations can precede symptom onset as well.

Most cases present with pain initially, and this is usually low back pain with radicular symptoms. Then patients will note ascending weakness. 30% of patients become tetraplegic and bed-bound during the course of the disease. The nadir of weakness is four weeks from symptom onset. Areflexia is usually the first objective examination finding. Sensory deficits, oculomotor abnormlalities, and respiratory symptoms may develop as well.

During the course of the illness, many patients develop ileus, urinary retention, and labile vital signs. Respiratory involvement is seen in 1/3 of patients with Guillain-Barre and is often seen within the first seven days of the disease. The overall mortality rate is up to 5%, but it causes significant morbidity with often indolent recovery courses. The Miller Fisher variant includes ophthalmoplegia, ataxia, and areflexia. It is usually follows a more benign course, and these patients tend to have more complete recovery.

The differential for this clinical presentation includes spinal cord injury, myasthenia gravis (usually does not have sensory symptoms), hypophosphatemia, botulism, tick paralysis, heavy metal poisoning, etc. The diagnosis is time dependent, and respiratory compromise can occur rapidly. Treatment should be considered as soon as the diagnosis is suspected, and neurology consultation should be pursued. The classic diagnostic test is albuminocytologic dissociation seen in CSF studies, but this is not present in about 50% of patients very early in the disease course. Ultimately, this makes it more of a clinical diagnosis and should be highly suspected in young patients with diminished lower extremity reflexes.

The treatment involves plasmapheresis and/or IVIG. Plasmapheresis removes antibodies and generally shortens hospitalization and the course of the disease. The mechanism of IVIG is not entirely known.

Operations Update WITH Dr. Palmer

-Be on the lookout for alternatives to Foley catheters in the ED to help reduce catheter-associated infections. Options include condom catheters for men and PureWick catheters for females.

-There will be a push to improve time to pain medications for patients with long-bone fractures.

-There will be changes coming to imaging orders in order to select appropriate reasons for cross-sectional imaging.

Clinical Knowledge: Esophagitis WITH DR. Gawron

Reflux esophagitis (GERD) is the most common form of esophagitis. It affects up to 27% of people in North America and is usually described as a burning sensation in the chest. The American Journal of Gastroenterology recommends the initial management of GERD includes an eight week trial of any proton-pump inhibitor (PPI) once daily. If a patient still has symptoms after eight weeks, the PPI should be increased to twice daily. H2 blockers have actually been shown to be inferior to PPIs in GERD management but are superior to placebo. There is no difference in efficacy between PPIs. Omeprazole (Prilosec) is the cheapest and may be an effective initial therapy for patients with GERD.

Medication-induced esophagitis is more rare and is more common in females. Medications associated with development of this includes antibiotics (tetracycline, doxycycline, clindamycin), bisphosphonates, potassium chloride, non-steroidal anti-inflammatories, and more. The management for this type of esophagitis includes stopping the medication if possible. Liquid forms of the medication may be an effective alternative.

Eosinophilic esophagitis requires endoscopy for a definitive diagnosis. It often presents with dysphagia and has a strong association with other allergic conditions. Food impaction is a common complaint which can distinguish it from other types of esophagitis.

Infectious esophagitis can be seen in immunocompromised patients. Candida is most common, followed by HSV and CMV. It is unique in that it often presents with odynophagia. The definitive diagnosis requires endoscopy, but treatment is often started empirically in the appropriate clinical scenario. The presence of oral thrush should increase suspicion for esophageal candidiasis in patients presenting with odynophagia.

Pediatric Cases WITH DRS. Valentino, Zamor, & Dean

Case 1: 3 year old female with difficulty walking and fevers. Labs reveal a new anemia, lymphocytic predominance, and 5% bands. LDH and uric acid were both elevated, and the patient was found to have neuroblastoma and diffuse metastatic disease in the bone marrow. It is not uncommon for neuroblastoma to present with changes in movement such as trouble walking. The key in this case was the new anemia prompting further investigation with LDH and uric acid. These are both good initial screening tests for new malignancy in children.

Case 2: 4 year old male with back pain. Exam with diminished lower extremity strength, hyporeflexia, and diminished rectal tone. Found to have transverse myelitis. It often presents with URI symptoms or vaccinations a few weeks before the development of objective neurologic findings.

Case 3: 6 month old female who was found pulseless and apneic after co-sleeping. Unable to revive the patient, and the code was ultimately called. Assigning a person to help talk with family and manage family expectations can be beneficial in managing responsibilities during a hectic situation. Having parents at the bedside during resuscitation can help them see everything that is done for the patient in an effort to revive them, and it can help in grief processing. Use clear and concise language when informing families that a loved one has died.