Grand Rounds Recap 8.28.19


Spontaneous Bacterial Peritonitis

  • Mortality 31.5% at one month

  • Emergency medicine physicians are poor at diagnosing SBP clinically in the emergency department (Chinnock 2008).

    • Sensitivity 76%, specificity 34% based on history and physical examination

  • Indications for diagnostic paracentesis per American Association for the Study of Liver Disease:

    • Hepatic encephalopathy

    • Worsening ascites

    • Abdominal pain

    • Fever

    • Leukocytosis

    • Renal failure

    • Patients requiring hospital admission for any reason

  • Treatment

    • Third-generation cephalosporin

    • Albumin

      • Reduces mortality from 29% to 10%

      • Indications include creatinine > 1, BUN > 30, total bilirubin > 4

      • Dosing 1.5 g/kg

Infected Kidney Stones

  • Urinalysis interpretation for culture-positive UTI (Marques 2017)

    • Leukocyte esterase (LE) positive: 79% sensitive, 84% specific

    • Nitrite positive: 28% sensitive, 99% specific

    • Sediment (includes all debris, but specifically looking at > 10 WBC/hpf): 92% sensitive, 71% specific

    • LE + nitrites: 85% sensitive, 84% specific

    • (LE or nitrites) + sediment: 94% sensitive, 85% specific

  • False positive nitrites can be caused by:

    • Prolonged time to analysis

    • Dipsticks stored in open air

    • Red urine (including gross hematuria, reagent tests)

  • For infected kidney stones, cover with appropriate antibiotic therapy and talk with urology about stenting or stone removal.

Euglycemic Diabetic Ketoacidosis

  • Appears similar to alcoholic ketoacidosis on laboratory testing

  • Becoming more common with the use of SGLT-2 inhibitors

  • Keep a broad diagnostic work up for patients with an anion gap metabolic acidosis.

    • Renal panel

    • Blood gas

    • Lactate

    • Ketones

    • Special testing: salicylates, toxic alcohols, serum osmolarity

Delays in Antibiotic Administration

  • The definition and management of sepsis continues to evolve with time and new data.

  • If you are concerned a patient has shock that may be sepsis, order broad spectrum antibiotics early as this has consistently been shown to improve mortality.

Task Saturation

  • Task saturation occurs when the number or complexity of tasks exceeds the ability to execute them at a high level.

  • Behaviors that occur when providers experience task saturation (Davis 2014):

    • Shutting down: quitting the task or taking frequent breaks

    • Compartmentalization: acting busy without accomplishing much, linear task completion

    • Target fixation: focusing intensely on one single task at the expense of all else, allowing new tasks to accumulate

  • Task saturation is associated with breakdowns in teamwork, communication, and mutual accountability.

  • Strategies to reduce task saturation:

    • Plan ahead

    • Have a wingman to delegate tasks

    • Check your execution gaps, or the potential space between your strategy and its execution


Grab Bag

  • Le Fort fractures

    • Le Fort I: floating palate

    • Le Fort II: floating maxilla

    • Le Fort III: floating midface

  • Adults have 32 teeth.

  • Maximum lidocaine dosing in lidocaine with epinephrine is 7 mg/kg

  • The thyroid cartilage lies on the inferior margin of Zone III of the neck.

  • Phenytoin, calcium channel blockers, and leukemia are all associated with gingival hyperplasia.

  • Green tea has been found to be non-inferior to Peridex mouthwash in the treatment of pericoronitis.

Corneal Foreign Bodies

  • Assess for intraocular foreign body.

  • Methods for superficial foreign body removal include irrigation, moist cotton Q tip, or the tip of a needle.

    • Numb the cornea prior to intervention.

  • Consider tetanus and prophylactic antibiotics.

Ear Foreign Bodies

  • Assess for perforated TM.

  • Methods for ear foreign body include, irrigation, alligator forceps, Katz extractor, currettes, Q tip with superglue in limited settings.

  • Minimize iatrogentic damage.

  • Hydrogen peroxide can break up impacted cerumen.

  • If there is a live bug, use mineral oil or viscous lidocaine to drown the bug first.

Dental Emergencies

  • Concussion occurs when there is tenderness to palpation of a stable tooth.

    • Can follow up routinely with dentist

  • Subluxation occurs when there is tenderness and mobility without displacement.

    • Splint if significantly mobile.

    • Soft diet

  • Extrusive luxation occurs when there is a partial avulsion of the tooth out of the alveolar bone.

    • Detnal block, reposition, splint, follow up within 24 hours

  • Lateral luxation occurs when there is lateral displacement of the tooth in its socket.

    • If there is significant alveolar bone fracture, consult dental emergently.

    • If there is minimal fracture but extrusion, attempt block and reposition.

    • If there is neither fracture or extrusion, splint and follow up within 24 hours.

  • Intrusive luxation occurs when the tooth is displaced into the alveolar bone.

    • Liquid diet, follow up in 24 hours

  • Avulsion

    • Re-implant and splint if dry time < 60 minutes.

    • Follow up within 24 hours, consider antibiotics and tetanus.

    • Prehospital storage in Hank Solution or milk

  • Fractures:

    • Ellis I: smooth with emory board, routine follow up

    • Ellis II: calcium hydroxide and soft diet, follow up within 24-48 hours

    • Ellis III: calcium hydroxide, liquid diet, follow up in 24 hours, tetanus, antibiotics

Auricular Hematoma

  • Anesthesia with auricular block

  • 1cm incision vs aspiration of convex area in ear area with maximal clot

  • Remove clot and irrigate

  • Can bolster with Xeroform to prevent reaccumulation

  • Complications include infection and “cauliflower ear”


Carotid Blowout Syndrome

  • Most cases of carotid blowout syndrome are related to head and neck cancer, often squamous cell carcinoma.

  • These patients have extremely high mortality at about 40% and 60% require emergency intervention.

  • Call for help!

    • ENT if available, but if you are in the community without ENT coverage, anesthesia and general surgery may be of assistance

  • Know your patient’s anatomy.

    • You will be unable to orotracheally intubate a patient who has undergone total laryngectomy.

  • Classification

    • Threatened: carotid artery is exposed through skin breakdown or direct invasion of a tumor

    • Impending: a sentinel bleed has occurred but is now hemostatic without surgical intervention

    • Acute: active bleeding is present

  • Treatment

    • Open surgical repair (falling out of favor as high incidence of complications)

    • Embolization for those with low risk of stroke

    • Stenting for those with high risk of stroke


  • There are 5.8 million deaths from trauma worldwide annually.

    • This outnumbers HIV/AIDS, TB, and malaria combined.

    • Greater than 90% of these occur in low-middle income countries (LMICS).

  • Road traffic injuries are the leading cause of death in people aged 15-29 in LMICs.

  • Patients with life-threatening but salvageable injuries are 6x more likely to diet in a low-income setting than in a high-income setting.

  • Attempts are being made to improve trauma prevention and care in LMICs with the initiation of helmet laws and alcohol regulation.

  • In Tanzania, the mortality rate from trauma is about 15% at national referral centers (compared to approximately 4% in the US).

    • Poorly enforced alcohol laws

    • No helmet laws

    • No national standards for trauma care

    • No pre-hospital infrastructure


  • Indications

    • Diagnostic arthrocentesis

      • Fluid analysis

      • Evaluate for traumatic arthrotomy

    • Therapeutic arthrocentesis

      • Drain effusion

      • Inject steroids

        • Most commonly triamcinolone

        • If performing injections, know most local anesthetics can cause eventual cartilage damage and arthritis, consult with orthopedics or ensure follow up for these patients.

        • By injecting steroids into a joint, you will likely delay potential replacement for 3-6 months.

  • Little data exists about complications or safety of performing arthrocentesis through cellulitis.

  • Bursitis

    • Approximately 1/3 are septic

      • Half of these occur in immunocompromised patients

      • There are mixed opinions about aspiration, but most would recommend just covering with antibiotics and assessing clinical response.

  • Knee

    • Konda 2013

      • Traumatic arthrotomy saline load test (SLT) with 76cc was 94% sensitive and 91% specific.

    • Another article from Konda 2013

      • Using CT to diagnose free air in the joint and traumatic arthrotomy was 100% sensitive and specific (although 32 patient study, this is a promising alternative to a painful intervention).

    • Can perform arthrocentesis at any of the four quadrants of the knee but be sure to avoid neurovascular bundles.

  • Elbow

    • Arthrocentesis: approach at the center of the triangle made by the radial head, lateral epicondyle, and lateral aspect of the tip of the olecranon

    • SLT: 40cc is 95% sensitive for traumatic arthrotomy

  • Ankle

    • Arthrocentesis: approach laterally (anterior to the tip of the lateral malleolus with needle directed medially) or medially (in the sulcus anterior to the medial malleolus and medial to the EHL and TA tendons)

    • SLT: 30cc is 95% sensitive for traumatic arthrotomy

  • Wrist

    • Arthrocentesis: between extensor pollicis longus and common extensor tendons, ulnar to the radial tubercle

    • SLT: 2.5cc is 99% sensitive for traumatic arthrotomy

  • Shoulder

    • Arthrocentesis: if dislocated, enter in divot laterally; if not, can use anterior (between the coracoid process and humeral head) or posterior (inferior to the acromion with needle directed toward the coracoid process) approach

    • SLT: 68cc is 95% sensitive for traumatic arthrotomy