Grand Rounds Recap 8/26

M&M with Dr. LaFollette

Case 1: Troponin Use in ESRD

  • Evaluating cardiac ischemia in ESRD patients can be difficult due to baseline troponin elevations. However, all is not lost...
  • Troponins can be used as a reliable marker of ischemia, even despite its collection in proximity to dialysis, if you take some things into account:
  • Studies vary widely on troponin levels during dialysis, consensus being that troponin levels do not vary significantly vary with dialysis.
  • Although the baseline may be abnormally elevated, ESRD patients nonetheless have a new baseline. Changes above this baseline and especially up trending troponins should trigger alarms that the patient may be having active ischemia.  
  • Troponin elevation in ESRD patients, even if at their baseline, is an independent risk factor for short term mortality

Case 2: A Medically Complex Patient with Inferior Myocardial Ischemia

  • Remember to keep Inferior MI on your differential for hypotension. Helpful diagnostic criteria to remember include aVL inversion is a sensitive marker of inferior ischemia and 7.5% of inferior MIs will show aVL inversion as only sign early on.
  • Drinking from the fire-hose: A study shows EPs followed and recorded failed to return to 18% of the tasks that they were interrupted from. 
  • The SRU gets chaotic and the management of multiple critically ill patients at the same time is challenging. Despite the chaos, an individualized, systematic approach of reviewing patient status and data is necessary. 

Case 3: Subtle EKG Findings / MI Equivilants

  • Left main disease
    • Most LM Occlusions do not make it in as these people come in coding...
    • ST Elevation in aVR > 1mm
    • ST Elevtion in aVR > V1 (absence indicative of proximal LAD lesion)
    • Diffuse ST Depression

Case 4: Large Anterior Circulation Occlusion

  • 7 positive studies have been published in the last year for the use of intra-arterial embolectomy for confirmed anterior circulation large vessel occlusions

  • MR CLEAN was the first RCT showing positivity in 233 IA patients vs 267 'standard care' patients, 89% of all got tPA. Important things to remember were they were selected patients with good baseline functionality and confirmed ICA, M1, M2, A1, A2 occlusion by CTA. There were no age limitations and broad NIHSS of anything >2 (median 18). 33% vs 19% functionality at 90 days.

  • This was followed by EXTEND-IA, ESCAPE, SWIFT PRIME, REVASCAT, THRACE, THERAPY which were stopped for midterm analysis and showed similar efficacy.

Case 5: Posterior Circulation Stroke

  • Hemiparesis, asymmetric hypertonia and hyper-reflexia can all represent presentations of posterior ischemia.
  • Often mistaken for seizure, they can progress to a locked-in state so early identification is key
  • AMS + any ocular findings=posterior circulation stroke until proven otherwise.
  • Have a low threshold for vascular imaging in these patients, 2 studies have showed CTA without knowing renal status is very unlikely to precipitate CIN and neither reported inducing ESRD.

Case 6: Atypical Causes of Back Pain

  • Consider infectious endocarditis in fever of unknown source, especially in those at higher risk of hiding the manifestations of systemic disease (young, old, immunocompromised) or at high risk from indwelling catheters, IVDU history or known structural lesions

Calling Consults in the ED with Drs. Axelson, Denney, Grosso, and Ostro

  • Calling consultations is something we do on an hour-by-hour basis in the ED and something that is critical that we do well
  • Despite the millions of times you will do this it is important to remember your basic tenants of courtesy when communicating over the phone: "Hi, this is Dr. EM calling from the ED," is a good place to start. Every time. 
  • Clarify with whom you are speaking (no one from Urology likes hearing about stroke symptoms intended for Neurology) and then state the purpose of your call again up front: this is a consult/courtesy call/curbside.
  • When calling a consult, formulate your focused question for your consultant and have an idea of what they can offer and your plan for the patient once their evaluation is complete
  • Don't throw a weak pitch. Your consultants need to be as concerned as you are about your patient. Build your case via pertinent info from the H and P, labs and studies and come to the phone prepared and knowing what you need and what you are asking of your consultants. 
  • All consulting services are not created equally. Know to whom you're talking, what information they want and need, and how they want it delivered. 
  • Clarify (politely) the time frame in which your consultant will see your patient and/or formulate a plan to re-engage them as needed

Approach to Abdominal Pain with Dr. Baxter

Four types of abdominal pain patients in the mind of Dr. Baxter:

  1. Not sick - H&P, no labs - going home
  2. Probably not sick - H&P, labs - probably going home unless exam changes or labs dictate further evaluation
  3. Maybe sick - H&P, labs, imaging - going home if imaging is negative
  4. Sick - H&P, labs, consult +/- imaging - coming in regardless

Can't miss diagnoses to consider for any of the above patients: Ectopic, AAA, mesenteric ischemia, perforation, peritonitis, obstruction, volvulus, malrotation, intussuseption, pancreatitis, SBP, torsion, incarcerated hernia, non-abdominal source

Challenging populations: Very young, very old, immunosuppressed, and those with psychiatric disease - essentially if there is something limiting their history and/or physical (communication barriers, immunosuppression, altered mental status)

Repeat visit? As always, these are hard stops. Always take the time to re-think these patients. What could we be missing? Should we do the  "next best test" which may or may not be indicated though worth taking the time to consider. 

Nojov et al 2012:

  • Retrospective review of 659 scans in 200 patients>60
  • 22.5% initial scans were positive
  • 8.4% second scans were positive
  • Take home point: Take elderly patients with abdominal pain seriously as they often present atypically and frequently require intervention

In situations of diagnostic uncertainty excellent discharge instructions (and well documented) are particularly important for both you the provider and the patient

Clinicopathologic Conference with Drs. Titone and Palmer

  • The case: Teenage male, MSM, otherwise healthy presents with sore throat and lip swelling x 2 months with inability to swallow solid food and a feeling that his throat is closing up. The lip swelling has been becoming increasingly painful and more swollen. Physical examination reveals normal vital signs and a benign exam other than an 8mm-in-diameter, superficial ulceration of the upper lip that is not tender or draining as well as significantly hypertrophic tonsils without sign of abscess. He also has bilateral anterior cervical chain lymphadenopathy. 
  • CT of the neck: "diffuse soft tissue swelling that impinges on the airway; infectious vs malignancy are on the differential--correlate clinically."
  • ENT performs NP scope which reveals no concerning findings
  • Dr. Palmer summary: Diffuse swelling and tender lymphadenopathy with an ulcerated upper lip with progressive, borderline airway compromise: Is it syphilis? Acute retroviral syndrome? His dollar lands on secondary syphilis with need for an RPR and FTS-abs...
  • Dr. Titone: Winner. Syphilis.
  • Question: Aside from the patient, who cares? Answer: Cincinnati. Syphilis is here, increasing in incidence, and does not appear to be going away. At present Cincinnati is at epidemic status. 
  • Risk factors: MSM, prostitution, IVDU
  • Screening with non-treponemal tests: VDRL, RPR
  • Confirmation with treponemal tests: FTA-ABS, MHA-TP, TP-PA, TP-EIA
  • History of prior syphilis and now concern for re-infection? No problem. Remember, the FTA-ABS will remain positive for years and is not helpful in this situation. Use VDRL/RPR to evaluate titers and compare to prior
  • Treatment: These Troponema Pallidum spirochetes are highly sensitive to penicillin G (2.4 million units IM) with primary, secondary, and early latent syphilis-- as a single dose. Late latent--dose once per week x 3 weeks.
  • Alternative therapy: doxycycline 100mg PO BID x 14 day
  • Tertiary syphilis: depends on body system involved--talk to the indicated specialist

Quick Hit on UCEM Global EM with Dr. Wright

  • There continue to be a number of exciting avenues for our EM residents to explore within the sub-discipline of Global EM and the list of accomplishments abroad in the last year alone by our residents is impressive.
  • If you have a particular interest in Global EM as a UCEM resident, please reach out to Dr. Winston-Bush or Dr. Wright.