We had another excellent Grand Rounds this week! Dr. Carleton started us off with some thrilling airway cases in his continuing Airway Grand Rounds series. Next, we were transported to Africa for a case based discussion on Global Health with Drs Owens, Sabedra, Ventura, and Murphy-Crews. Dr. Skrobut and Chris Shaw then took us through a deep dive of the current literature on the management of upper GI bleeds. Dr. Ham then taught us about ACE-I induced angioedema through the lens of an amazing case of a patient who required a cricothyrotomy to save her life! Next up, we had Dr. Gleimer go up against Dr. Faryar in our Clincal Pathological Case series where we a classic presentation of Addison’s disease in a pediatric patient. Dr. Hunt then led us through small group discussions on the application of the HEART Score in patients presenting to the ED with chest pain. We wrapped up the day with Dr. Isaac Shaw who presented a the management of SVT in a complicated patient.Read More
This week started with our monthly Morbidity and Mortality conference where we discussed posterior MIs, tough dissections and more tough cases. We then heard a debate on the use of D-Dimer in the diagnosis of aortic dissection. Finally, we were led through a simulation of a sick GI bleed requiring Minnesota tube placement, and we discussed optimal management of these challenging patients.Read More
Dr. McKean kicked off this week with another great M&M where he taught us about the utility of stress testing to predict coronary artery disease, otomastoiditis, and much more. Dr. Brenkert joined us for an hour on pediatric musculoskeletal ultrasound and then Dr. Mudd reviewed transfusion strategies in upper GI bleeding. Dr. Ventura taught us about CSF analysis and Drs. Stettler and Whitford rounded out the day with a CPC about acid-base disturbances.Read More
This week Dr. Axelson took us through great DKA in pregnancy, hyponatremia tips, and prioritization in UGIB in this month's M&M. Critical Care bound Dr. Renne laid out some intra-arrest tips and Dr. Brown from Cincinnati Children's talked about Adult Congenital Heart Disease. Small groups covered everything from ACLS logistics to shoulder US to Minnesota tube insertion.Read More
It’s late on a Saturday night and you are moonlighting as the single provider at a community hospital about 15 minutes from UC. You’re trying to disposition five current patients when a new patient is brought in by EMS with a complaint of vomiting blood. The patient smells of alcohol and states that he drinks daily, though he may have “overdone it” the last 2-3 days since he has had friends in town...Read More
Morbidity and Mortality Conference with Dr. Curry
Acute Coronary Syndrome in Pregnancy
- Incidence reported at about 6/100,000 deliveries
- Maternal mortality is between 5-9%
- 75% are STEMI
- 2/3rds are anterior wall MI (LAD or LM as the culprit vessel)
Many of these are typical ACS risk factors but are less prevalent in the pregnant population
- Older age (>35 years old for pregnancy is considered older age....yikes)
Management of the GI bleed (a review of the Cochrane Reviews):
- PPI drips have been shown to decrease the rate of rebleed in patients with known peoptic ulcers. It has not been shown to decrease mortality, hospital stay, transfusion need. It also has not been shown to be beneficial in the undifferentiated upper GI bleed and may have a trend toward harm.
- Octreotide doesn't improve mortality but on average decreased transfusion requirement by 1/2u product.
- Antibiotic coverage (treating for gut translocation with ceftriaxone) has been shown to have lowered mortality from infection and all-cause mortality.
- Prophylactic intubation: 2 retrospective chart reviews came up with contrasting results on mortality outcome after intubating for prophylactic reasons (patient was protecting their airway).
It is 2am on a cold, dark, winter night and you are dispatched to a small rural hospital to transport a patient by ground with a GI bleed back to UCMC medical ICU. Enroute dispatch notifies you that your patient has deteriorated and is profoundly hypotensive. The ED physician at the outside hospital is attempting intubation for airway control. On arrival you find a middle-aged male with all the classic stigmata of end-stage liver disease. More importantly he has a systolic blood pressure of 60 and a HR of 130. A literal fountain of blood spews from the patients mouth, around a successfully placed endotracheal tube, and is now beginning to pool on the floor. You know this patient needs massive resuscitation from his likely bleeding esophageal varices... but you are 55 minutes by ground to UCMC and know that your patient will not survive the transport unless something is done to control the bleeding...Read More