Grand Rounds Recap 11.29.23
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morbidity and mortality WITH dr. stark
Fever and immunosuppression
In patients with recurrent visits, consider expanding your workup, especially in the setting of vital sign changes or laboratory trends.
Patients with immunosuppression and fever should increase your concern for infection.
Patients with RA are at particularly increased risk for infections due to inherent cellular immunity problems and immunosuppressive medications.
Subarachnoid hemorrhage
Subarachnoid hemorrhage is a can’t miss diagnosis which carries significant morbidity and mortality if misdiagnosed.
There is growing evidence that negative NCHCT + CTA outside of traditional 6-hour window is sufficient for diagnosis.
Lumbar puncture with xanthochromia or > 2000 RBCs in tube 4 should increase suspicion for SAH.
Complex trauma resuscitations
Blunt cardiac injury represents a range of conditions from clinically silent to fatal injuries.
Workup with a negative troponin and EKG reliably rules out BCI.
Remember to repeat primary and secondary surveys with any change in clinical status.
Physical exam for pelvic instability has poor sensitivity.
Hemorrhagic shock is the most common etiology of instability in trauma and should always be highest on the differential.
Stridor and emergent surgical airways
Presence of stridor in an adult represents upper airway obstruction and should be treated as an airway emergency.
Consider simultaneous oral look and surgical airway in patients with upper airway obstruction.
Stop advancing ETT once the balloon is fully advanced into the trachea and no longer visible to avoid mainstem intubation.
Posterior circulation stroke
Patients with posterior strokes will likely have a low NIH. Ambulation is key during physical exam.
HINTs Exam is often used on patients who do not meet criteria for the test, therefore caution should be used when ED providers apply this test.
Involve the stroke team if posterior circulation stroke is suspected, as they may be a candidate for TNK, or more rarely, EVT.
Recurrent vertigo may represent vertebrobasilar insufficiency rather than peripheral vertigo.
Lemierre syndrome
Lemierre syndrome, or septic thrombophlebitis of the IJ, is a rare complication of bacterial pharyngitis.
Sore throat with worsening fever and systemic symptoms after one week should increase one’s suspicion.
Workup includes blood cultures and CT neck. Consider obtaining further imaging if clinical concern for septic emboli.
Beta lactamase resistant antibiotics should be used for treatment. Anticoagulation is not routinely recommended.
Clinical pathologic case: Bezoars WITH drs. wolski and broadstock
Bezoars are undigested, often indigestible boluses found within the GI lumen. They come in several well-recognized varieties: phytobezoar (plant matter), trichobezoar (hair), pharmacobezoar (medications), lactobezoar (milk products), and randobezoar (we made this word up but it's the "other" category).
Presenting symptoms for gastric bezoar are abdominal pain/fullness, nausea, vomiting, and bloody stool.
Complications include gastric/duodenal ulcers, bowel obstruction, and bowel perforation.
Diagnostic test of choice for bezoar is CT.
There are multiple treatment options for bezoars. Surgery has a high success rate but also a high complication rate (~33%). Endoscopic fragmentation is an excellent option with a lower complication rate (~12%). The simplest option is GI lavage with Coca-Cola, which can be effective in 50% of cases when used alone and 93% of cases when used in combination with endoscopic fragmentation
r1 Diagnostics and therapeutics: troubleshooting tubes WITH Dr. newton
Difficult tube replacements are a high burden of time and cost in the ED; most can be addressed by the Emergency Physician without need of consultation services
G-tube dislodgement should be addressed promptly by placing a foley or red-rubber tube in the mature (>4-6 week old) tract to maintain patency
A thorough history and physical exam can help clinicians identify patients at risk of difficult urethral catheterization and allow them to adjust planned technique
Suprapubic catheter placement and replacement fall under the scope of the Emergency Medicine physician based on circumstances; replacement is highly similar to G-tubes but performed with sterile technique
r3 small groups WITH drs. harward, moulds, and sobocinski
Austere Medicine Gamification with Dr. Harward
EXPOSURE AND ENVIRONMENTAL HAZARDS
The definitive treatment for all forms of acute altitude sickness is descent
Hypoxia at altitude is hypobaric (the air you are breathing is still 21% O2, but the pressure you are breathing it at is too low to achieve an adequate PaO2)
Acute mountain sickness can be temporized w/ acetazolamide & symptomatic management; steroids (dexamethasone) should be given for high altitude cerebral edema
Heat exhaustion typically occurs w/ a body temperature between 38-40C and is managed w/ evaporative cooling; heat stroke occurs >40C and is characterized by AMS & end organ damage, requires cold water immersion for rapid cooling
ENVENOMATIONS
Viperidae envenomations are cytotoxic & hemotoxic and result in location tissue destruction; Elapidae envenomations are neurotoxic and may result in respiratory failure
Brown recluse (Loxosceles) venom is characterized predominantly by local tissue necrosis; black widow (Latrodectus) venom is neurotoxic and results in sympathetic activation & severe muscle cramping
TOXIC INGESTIONS
Cholinergic crises are managed w/ atropine, anticholingeric crises are managed w/ physostigmine
Titrate atropine to drying of airway secretions
Amanita phalloides has 2 active toxins, phallotoxin and amatoxin, that result in acute GI toxicity & fulminant liver failure, respectively
Scromboid toxicity results from bacterial overgrowth leading to conversion of histidine to histamine and is managed with antihistaminergic medications (H1 & H2)
INJURIES AND INFECTIONS
Malaria treatment depends on the severity of infection & region in which infection was contracted
Uncomplicated, chloroquine-sensitive: chloroquine, hydroxychloroquine
Uncomplicated, chloroquine-resistant: atovaquone-proguanil, quinidine + doxycycline OR clindamycin, artemether-lumafantrine
Complicated: artesunate
Saltwater injuries are at high risk of Vibrio vulnificus infections; freshwater injuries are at high risk of Aeromonas & Pseudomonas infections
Pharmacotherapy with Dr. Moulds
Knowing how to set up your own IV drips and infusions is important in rural or austere environments, especially those without 24/7 ED pharmacy coverage
The concentration of a drug must be known in order to calculate the proper infusion rate
There are several "just-in-time" on shift resources available for drug mixing/preparation and correct dosing
Evidence Based H&P with Dr. Sobocinski
History and physical exam continue to be key to diagnosis for many pathologies, especially in austere environments with less diagnostic tools.
Certain physical exam maneuvers are more sensitive and specific for diagnoses and may be able to save you from expensive diagnostic or inaccessible tests.
