Grand Rounds Summary 8/5

Taming the SRU Case Follow-Up: GSW to the Head with Dr. Grosso

  • In one census: 66% of violent deaths are suicide, with 30k suicide deaths annually in the US
  • ~50% of suicide attempts include firearms
  • GSW to head mortality is 80%, and 71% die on scene
  • ~40% of those who survive to hospital have favorable outcomes
  • Favorable prognosis: GCS>8, normal pupillary reaction, absence of coagulopathy of trauma/hemodynamic instability
  • Your exam matters! Do a good exam off paralytics as further intervention, management and aggressiveness may be based off the GCS you render--it is important that you get it right as part of your advocacy for the patient
  • According to one 2013 trauma study, aggressive care regardless of prognosticators resulted in improved mortality from 11% to 46% (Aggressive care= hyperosmolar treatment, PCCs, blood products)
  • Like much within the realm of neurointensive care, it is not easy to prognosticate early in a disease process. Be aggressive in the ED and allow others to prognosticate.

R2 Case Follow Up: Testy Testis with Dr. Thompson

  • Torsion: 6 hours from start of symptoms to get to a surgeon before irreversible harm  
  • Epididymitis is most common cause of testicular pain. Gradual onset, usually relief with testicular elevation. Gonorrhea/chlamydia are most common causes
  • Hydrocele. Scrotal fluid collections that transilluminate. "Tight whitey's"->home.
  • Varicocele. Bag of worms. Usually painless. “Tighty whitey’s”->home. 
  • Testicular carcinoma. Most common malignancy in young men. Can have pain due to rapid growth though usually painless. 
  • Testicular trauma. Can have contusion or rupture of testicle. Treatment for contusion: athletic support, ice, NSAIDs. Rupture needs surgical evaluation.

Consultant of the Month: Dermatologic Emergencies with Dr. Flores

  • Always ask about medications when working up rashes! Most drug rashes begin within days to weeks of starting a medication
  • Penicillins, sulfonamides, and anticonvulsants are frequent culprits, with 1-5% of their use causing cutaneous drug reactions. 2% of these are “serious” aka death or hospitalization. 
  • What follows are 7 drug reactions you need to know:

1. TEN and SJS

  • Mortality is 5% for SJS, 25-50% for TEN which are both predominantly drug reactions
  • Lesions are usually tender
  • 92-100% SJS and 100% TEN have buccal involvement
  • TEN and SJS can have systemic symptoms: ocular, pulmonary, renal involvement predominantly
  • Risk is highest during initial weeks of therapy. With anticonvulsants, during first 2 months.
  • Rate of progression is extremely variable from hours to days within patients.
  • Distinguishing SJS and TEN is based on TBSA; SJS<10%, TEN>30%
  • Lesions initially erythematous and dusky, red, painful macules that will coalesce-> fill with fluid and desquamate
  • Remember that scrotal, vulvar, or penile involvement is included as mucosal involvement
  • Death mainly 2/2 infection due to skin breakdown: do not debride/peel bullae. 
  • Healing starts within days and usually takes 3-4 weeks to complete
  • Treatment: DISCONTINUE offending agent + Supportive care. IVIG literature is conflicting and at UH you cannot obtain for this indication

2. Erythema Multiforme

  • Typically occurs in young adults and caused by bacteria/virus, although can be drug related
  • Presents with “target lesion” with central, dusky zone surrounded by pale/pink zone that is surrounded by a red ring. Atypical variants however are common. 
  • Dinstinguished by presence (major) or absence (minor) of mucosal involvement, with major associated more with medications.
  • Course: Self limited, develops within a few days of exposure and will go away in 2 weeks
  • Tx: Topical antiseptics for mucosal erosions, systemic steroids if severe

3. DRESS: Drug Reaction with Eosinophilia and Systemic Symptoms

  • 10% mortality
  • Morbiliform presentation most common, though DRESS is the most variable drug reaction 
  • Course: 2-6 weeks after starting drug
  • Systemic complications are common with hepatitis most common amongst them. Peripheral eosinophilia may be there however is not always seen and not reliable on lab examination
  • May persist for weeks after drug stopped.
  • Treatment: Mostly supportive and withdrawal of drug. Systemic corticosteroids are first line

4. Acute Exanthematous Pustulosis

  • 90% drug induced
  • Present as small, monomorphic pustules that present on erythematous/edematous skin that start on face or intertriginous areas and then spread to rest of body. Can have fevers.
  • Occur within 4 days of starting a new drug and lesions spread rapidly over hours!
  • Tx: Withdrawal of drug, topical corticosteroids

5. Morbilliform Drug Reactions

  • Most common drug reaction
  • Most commonly presents as macular lesions that start out as discrete and then coalesce.
  • Usually start on trunk and upper extremities and may initially look like urticaria
  • NO involvement of mucus membranes and no erosions or ulcerations
  • +/- severe pruritis
  • Usually starts 1-2 wks after starting medication and disappears spontaneously after 1-2 wks
  • No complications or sequelae
  • Treatment is supportive
  • There is the possibility of progression to SJS/TEN although very rare.

6. Urticaria

  • 10% caused by drugs
  • Usually immediate type hypersensitivity mediated by IgE
  • Transient wheels (<24hr) are very pruritic and can occur anywhere on the body
  • May or may not be associated with anaphylaxis; best to conceptualize them as their own rash

7. Fixed Drug Eruption

  • Lesions occur at exactly the same spots every time the drug is ingested
  • These are sharply demarcated and edematous plaques that are localized
  • May occur on the genitalia recurrently—do not mistake for STI
  • Leaves a post-inflammatory hyperpigmentation that may take months to go away

10 Things You Need To Know About TBI with Dr. Knight

TBI is a heterogenous disease entity for which we do not have a lot of solutions. The one piece of level one evidence in TBI: Do not give steroids. As for the rest, well, here's the top ten things you should know according to Dr. Knight:

10.     Mechanical Support. Don't forget the easy stuff: Don’t make the C collar too tight, keep head in midline and upright, HOB @ 30 degrees.

9.     Anticoagulation reversal. If they need to be reversed, reverse them. 

8.     AnalgoSedation. Treat them adequately as pain increases ICP and TBI is painful. Ketamine is probably safe and likely does not increase ICPs significantly.

7.     Avoid Extremes. Maintain normothermia, normo-glycemic, normal BP, normal HR, etc

6.     Do things EARLY. Get them eating, walking, trach/PEG and closer to normalcy as early as you can.

5.     Mechanical Ventilation in the ED. What we do matters downstairs and has repurcussions for treatment upstairs. Do not hyperventilate and give appropriate tidal volumes. 

4.     Monitoring. Continuous EEG, EVDs, Licox etc. These are important to guide management but are not management within themselves. Know the importance of the information you are getting and integrate it within the context of the patient.

3.     Surgical Management. Rely on our colleagues to determine when and who to go.

2.     Early aggressive care. In the ED Our job is to be aggressive, not to prognosticate. Avoid self-fulfilling prophecies and see GSW to the Head above. 

1.     There is no number one. Yet. Some day there will be a number 1 that ups our game in the treatment of TBI. But we haven't found it yet. 

ICD 10 Training

  • Take home point: Make sure your diagnoses are supported by your MDM/patient charting. 
  • You are all expected to read the 1,000 page ICD-10 fact sheet. There will be a quiz.
  • .wetread is the epic dot phrase that will pull in radiology reads to your note. Use it.

Department Photo

You all looked wonderful. Great job. 

Thank you to everyone who lectured and participated in another week of educational excellence!