Grand Rounds Recap 8.23.23

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Morbidity and mortality WITH dr. stark

Case 1: Dog Bite Infections

  • Wounds from animal bites may become infected, however have similar rates of infection to primarily closed lacerations of all etiologies

  • Prophylactic antibiotics have not been shown to decrease infection rates with the exception of bites to the hand

  • If one chooses to provide prophylactic antibiotics, ensure that there is both GNR and anaerobic coverage to protect against Pasteurella and other species

Case 2: Patient Ownership

  • Sign out can be a dangerous time; extra attention should be paid to critically ill patients

  • ED boarding of critically ill patients leads to longer duration of stay, prolonged mechanical ventilation, worse neurologic outcomes, and higher mortality rates

Case 3: Malaria

  • Malaria can present with nonspecific symptoms. A thorough history and high index of suspicion is needed to diagnose

  • Thick and thin smear is the test of choice for diagnosis, however one negative test is not sufficient to rule out malaria

  • P. falciparum causes the most severe disease. If suspected, patients should be considered for admission and may need artesunate based therapies

  • Utilize the CDC website and hotline if infectious disease is not available

  • See the taming the SRU algorithm from 2020 for more details on workup and management here at UCMC

Case 4: Septic Bursitis and Serum Sickness Reactions

  • The gold standard diagnostic test for septic bursitis is needle aspiration of the bursa, however empiric treatment in the ED is likely sufficient

  • Antibiotic regimens should cover staph and strep species

  • Failed conservative management may require operative intervention with orthopedics

  • Serum sickness-like reactions may worsen with continued exposure and agents should be avoided indefinitely

Case 5: Lunate and Perilunate Dislocations

  • Lunate and perilunate dislocations are the result of a high mechanism injury where the patient’s wrist is forcibly extended and deviated

  • Complicated by median nerve injuries

  • Up to 25% of these injuries are missed on AP films

  • Often require surgical management by hand surgery

Case 6: RWMA

  • Emergency physicians with core training in TTE can identify RWMA with good sensitivity and specificity

  • TTE may help guide management in patients with suspect OMI

QI/kt: Acute liver failure WITH Dr. arnold and dr. Wilson

  • Acute liver failure is defined as development of hepatic encephalopathy and INR > 1.5 within 26 weeks in a patient with no history of underlying liver disease.

  • Imaging is not recommended for all-comers but is diagnostic if you suspect Budd-Chiari syndrome as the underlying cause. RUQ US with Doppler is the first line imaging modality. CT AP should be used if Radiology-performed US is not available.

  • N-acetylcysteine should be given in patients with low grade hepatic encephalopathy (Grades I-II per the West Haven criteria)

  • Corticosteroids should not be given empirically in the ED, especially in patients with a MELD > 40 at the time of presentation. Instead, discuss steroid initiation with Transplant Hepatology (GI) if you have concern for fulminant autoimmune hepatitis.

  • Transplant Hepatology (GI) should be consulted from the ED, and they will be responsible for contacting Transplant Surgery as indicated.

  • Lactulose is a widely accepted treatment for hepatic encephalopathy. Recent studies demonstrate that polyethylene glycol is also effective, and that these may have a synergistic effect when combined.

r4 Case follow up WITH dr. kein

  • Think about subacute bacterial infections (particularly endocarditis) in immunosuppressed/compromised patients with risk factors; may have only nonspecific symptoms

  • ESRD patients are functionally immunocompromised and have high rates of bacteremia with poor outcomes in setting of bacteremia/sepsis; think about gram positive coverage

  • Patients with recent BMT are at risk for anything and everything

  • Know your immunocompromised patient’s prophylaxis regimen and what they are at risk for if they’ve missed it

  • Think about empiric fungal coverage in the right patient

taming the sru WITH dr. moulds

  •  It is important to assess the QT interval in a patient with ventricular tachycardia, especially polymorphic ventricular tachycardia. If the QT interval is prolonged, give magnesium and avoid giving amiodarone

  • Torsades de Pointes (TdP) is a very rare complication of QT prolongation, and can be fatal by devolving into ventricular fibrillation. The QT nomogram can be used to rule out those who are at high risk of TdP, but unfortunately it is very difficult to predict who will develop TdP among those with known prolonged QT intervals

  • For refractory TdP, overdrive pacing increases the heart rate and shortens the QT interval. This can be accomplished with transcutaneous pacing, transvenous pacing, or with isoproterenol