Grand Rounds Summary - July 15

Oral Boards

African Tick Borne Illness

  • Rickettsial illnesses (specifically Africae)
  • Empiric doxycyline & ID consultation for presumed tickborne illnesses
  • Rickettsia africae classically presents 4-7 days post exposure with thromobocytopenia and hyponatremia

Hypothermic cardiac arrest

  • Fixing the temperature is the most critical thing
  • EKG findings of Osborne waves in hypothermia
Dr McKee getting put in an extraction litter

Dr McKee getting put in an extraction litter

Skills Station - Injuries in Austere Environments

  • Stabilize and prioritize transport out of the environment
  • Be prepared but also creative with the materials you have with you
  • We learned about traction splints from hiking poles, creating a litter out of rope, and C-spine precautions out of your hiking backpack. See the attached links for more demos

http://wms.org/
https://www.youtube.com/watch?v=f1PYnel1g14
https://www.youtube.com/watch?v=KIhyRXrE__U

Simulation: Critical Care in Severely Limited Resource Environment

  • Understand the culture in which you are working
  • Resource management is important in any environment, but may be felt more acutely in outside the confines of a tertiary care ED
  • Sometimes doing less is what is right for the patient and the patient's family
     

Survival Tactics in the ED for Transplant Surgery Patients: Dr. Cuffy

  • Access Selection: AV fistula first, distal to proximal, prefer non-dominant limb
  • PD catheter can be used ~24 hours post placement, other forms of access 4+ weeks
  • 30% failure of access site at one year
  • Patients with CrCl < 25, save non-dominant arm for dialysis access
  • Failure rates of fistulas are increasing because fewer surgeons specialize in access surgery

Determining Graft vs Fistula

  • Graft will be superficial and narrower
  • Loop or U shaped = graft
  • If placed in LE = most likely graft

Complications:

Bleeding

  • Typically post dialysis
  • May need fistulogram for evaluation of venous stenosis increasing pressures
  • Consider ddavp, typically uremic
  • Direct pressure normally sufficient, stitch is absolutely necessary

Infection

  • AV fistula infection rates are very low
  • Grafts with purulence or abscess need OR drainage

Distal Ischemia

  • Difficult to detect because is gradual in development
  • Normally develop chronically with coldness or weakness, pain worsening with elevation
  • Mild transient steal is unavoidable

Venous Congestion

  • High flow through fistula
  • Pain/color improved with elevation

Thrombosis

  • Most common reason for failure and results from neointimal hyperplasia

Pseudoaneurysm

  • Be wary if the skin looks thin, may be near rupturing

Cardiac Failure

  • AV fistulas can have high flow (>5L)
  • Leading to high output cardiac failure
  • Elevated diastolic pressure in left ventricle

Cardiac Risk Stratification with Dr. Palmer

Isolated CP is 6% of all ED visits

ACS = STEMI, NSTEMI, unstable angina

  • Determined by EKG, troponins, and clinical history
  • DM, Smoker, HTN, HLD are risks for CAD, not ACS/major adverse cardiac events
  • It's not ACS, what do you do next?

Risk Scores
TIMI

  • Used to determine inpatient clinical management (Chase et al 2006)
  • Not designed for ED population but has been validated
  • Used in a number of studies with 2 hour rule out in low risk patients (TIMI 0, normal EKG) (Than et al 2012) with expansion to TIMI 1 (Cullen et al 2013)

Grace

  • Developed for inpatient management of patients with ACS

HEART

  • Used to determine risk of major cardiac events in 6 weeks (Backus et al 2013)
  • Dependent on physical gestalt

UC Chest Pain Protocol is a combination of scoring systems and CAD risk factors - emergencykt.com

Low Risk Options:

  • Resting Myocardial Perfusion
  • Home with outpatient stress testing
  • Observation

Stay tuned for a follow up lecture on stress modalities 9/2


Bites and Stings with Dr. Roche

Copperhead Snake Public Domain from https://commons.wikimedia.org/wiki/File:Agkistrodon_contortrix_mokasen_CDC.png

Copperhead Snake

Public Domain from https://commons.wikimedia.org/wiki/File:Agkistrodon_contortrix_mokasen_CDC.png

Black Widow Spider By Shenrich91 (Own work) [CC BY-SA 3.0 (http://creativecommons.org/licenses/by-sa/3.0)], via Wikimedia Commons

Black Widow Spider

By Shenrich91 (Own work) [CC BY-SA 3.0 (http://creativecommons.org/licenses/by-sa/3.0)], via Wikimedia Commons

  • Look for hourglass shape = bad. This exists on on black widow spider and copperhead snake
  • These are the only significant poisonous local snake or spider (why are you looking closely?!)
  • Crofab is readily available polyvalent antivenin for snakebit NOS
  • Call the Zoo/Poison Control/Otten for assistance obtaining rarer antivenins
  • If you have no antivenin for a neurotoxin envenomation, consider physostigmine
  • Rebound coagulopathy is common, almost never symptomatic though

Important History/Labs to Obtain:

  • Close documentation of location/time of edema
  • CBC/Coags/Fibrinogen, BMP, UA, T&S
  • Tetanus
  • Irrigation