Grand Rounds Recap 4/20

Simulation with Dr. Hill

Transitions of care can be a high risk time for our patients, especially amidst the chaotic environment that can be the SRU. 

Pre-planning sign out is an effective strategy to make the transition smooth. One to two hours out from the shift's end, take them time to start getting things in order for the end of the shift.

As emergency medicine physicians we have the tendency to want to wrap up our patients at sign out as nicely as possible. This is a good habit, realizing that it can predispose to premature closure, and, particularly in the case of an unpredictable SRU, should be applied with caution.

For more information on how to optimize your Transitions of Care, check out this link

Oral Boards with Dr. Hinckley

Patient #1: Elderly male with PMH alcoholism presents to the ED with fever, tachycardia, and altered mental status. Rectal temp is 105. Chart review reveals he has a history of depression and holds a prescription for olanzapine. Physical examination pertinent for increased tone of his extremities. 

  • Remember that in patients with the potential for significant hypo or hyperthermia to obtain a rectal temperature. There can be a large discrepancy in what is obtained between rectal vs oral. 
  • The patient's urinalysis reveals large blood without any RBCs... diagnosis? Rhabdomyolysis until proven otherwise. 
  • This patient has neuroleptic malignant syndrome. Keys to treatment are reducing the temperature (cooling fans), stopping the medications, and giving benzos. Consider bromocriptine, a dopamine antagonist, although the evidence for this is limited. 

Patient #2: Elderly male on lisinopril presents to the ED with apparent angioedema as seen by his enlargened tongue and stridor. This patient clearly needs to be intubated.

  • Nasopharyngoscopy with a pre-loaded Ett is a reasonable first approach. Be sure to have that Cricothyrotomy tray at bedside. 
  • Pre-treatment for fiberobtic intubation may include glycopyrolate to reduce secretions (time allowing), nebulized or aerosolized albuterol, and finally ketamine for an awake look. 

Patient #3: Middle aged man presents with chest pain. The pain is severe and is associated with a rash in a dermatomal distribution concerning for herpes-zoster.

  • Send this guy home with acyclovir, adequate pain control, and consider a steroid taper to reduce the probability of post-herpetic neuralgia (although the evidence for this is controversial). 

Oral Boards with Dr. Paulsen

Patient #1: Restrained driver presents from an MVC in which he was T-boned. The patient is hypothermic, tachycardic, hypotensive and has crepitus of the left chest with decreased breath sounds. FAST is positive in the LUQ. He also has an open tib/fib of the RLE with a pulse. 

  • This patient requires needle decompression followed by tube thoracostomy as well as intubation and blood products. He remains hypotensive and ultimately will require OR intervention.
  • Antibiotics, bedside reduction, and orthopedics consultation are needed for the open tib/fib. 

Patient #2: Elderly female presents with altered mental status. She is tachycardic, mildly hypertensive, and significantly agitated, a change from her baseline of normal 4 days ago. Physical exam reveals a fungating mass affixed to the right chest wall. CT chest strongly suggests metastatic disease to her spines. A calcium suggests significant hypercalcemia. 

  • Hypercalcemia: remember the old "stones, bones, groans, moans and psychiatric overtones." This patient is altered due to her elevated calcium.
  • Treatment? IV bisphosphonates and calcitonin to acutely lower Ca. Lasix can be given as well provided the patient can tolerate the volume loss. 

Taming the SRU R3 Case Follow Up with Dr. McKean

  • All bleeding stops... eventually. Clearly our number one objective is for it to stop under our control rather than divinity's/entropy's/insert-belief-system-here's. 
  • The go-to is direct pressure. If this fails you can always apply a tourniquet as a temporizing method, keeping in mind close track of Tourniquet Time. Suturing or pressure dressing can also be employed.
  • AV fistulas can bleed significantly and hemostasis may be difficult to obtain.

R2 Case Follow Up with Dr. O'Brien

  • Mycotic aneurysms can be devastating and difficult to diagnose unless they are on your radar: keep them in mind in at-risk patients--IVDU, immunocompromise. 
  • Mycotic aneurysms may be intracranial and are prone to rupture unless acted upon.
  • Treatment: consider vancomycin for MRSA + gram negative coverage. Further treatment options include the size and location of the aneurysm. Obviously, those in the brain are more concerning and may require embolization, although smaller aneurysms may resolve with IV antibiotics alone. 
  • In IVDU patients with mycotic aneurysms, the patient has endocarditis until proven otherwise. 

R1 Diagnostics with Dr. Merriam

For an in-depth primer on forearm and elbow radiographic interpretation check out this link

R4 Case Follow Up with Dr. Mann

Young, otherwise healthy male presents with chest tightness and "I do not feel right." Vitals are normal as are EKG, chest X ray, and laboratory evaluation. Clearly, however, something remains undiscovered. CTPA reveals Stanford Type A Dissection. 

  • Frighteningly, 5-15% of patients with ascending dissections do not present with chest pain. Those with pain do not necessarily have the characteristic "tearing" pain--pain may be sharp and intermittent. 
  • Ten percent of chest X rays are completely normal, and only 60% have an abnormal mediastinum.
  • EKG likewise may be normal
  • Seven percent of dissections occur in people less than 40 years of age. In these people, prognosis is not any better than their older cohort. Fifty percent of these are estimated to have connective tissue disorder. Twenty-five percent will have no risk factors. There is a 38% miss rate. 
  • The odds of a young person complaining of chest pain... one in a million
  • Evidence based medicine certainly has its place in emergency medicine. However, in the end, follow your gut.