Grand Rounds Recap 7/27/2016

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Morbidity and Mortality Conference with Dr. Riley Grosso

Infective Endocarditis (IE)

  1. Epidemiology
    1. Incidence of IE is 3-7/100,000 person-years
    2. Mortality 15-40%, fourth most common life-threatening infection
  2. Diagnosis - Duke Criteria
    1. Major: Typical Blood Culture +, Evidence of endocardial involvement on ECHO
    2. Minor: Predisposition, Temp > 38C, Vascular phenomenon, Immunologic Phenomenon, Atypical positive blood culture
    3. New AHA Guidelines (Class IA Evidence): 
      1. Get 3 blood cultures with first and last at least 1 hour apart
      2. STAT ECHO if IE suspected
  3. Antibiotic Principles
    1. If possible (patient not unstable) get cultures first
    2. Target the most likely organisms: staph, strep, enterococcus
      1. IVDU: Vancomycin
      2. Native Valve: Vancomycin + Gentamicin
      3. Prosthetic Valve: Vancomycin + Gentamicin + Rifampin

Pituitary Adenomas

  1. 15% of all intracranial neoplasms
  2. Population prevalence is around 16% but most are subclinical
    1. Macro adenomas > 10mm are much more are (0.1-0.2%)
    2. Malignant tumors are extremely rare
  3. Presentation:
    1. Endocrine based symptoms
    2. ICP symptoms: headache, nausea, vomiting
    3. Vision changes: blurry vision, classic finding: bitemporal hemianopsia
  4. Location of tumor can lead to mass effect on the carotid arteries, optic chiasm, and cranial nerves responsible for ocular movement
  5. "Blurry Vision Exam"
    1. Neurologic Exam - Cranial Nerves
    2. Visual Acuity
    3. Visual Field Testing

 

Traumatic Tracheal Injury

  1. Radiologic signs are non-specific
    1. Pneumothorax
    2. Pneumomediastinum
  2. Iatrogenic
    1. Post-intubation tracheal rupture is most common
    2. More often with intubation occurs under stressful/emergent conditions
  3. Traumatic
    1. Penetrating or blunt trauma to neck/chest
    2. 80% are in the distal trachea within 2.5 cm of the carina
  4. Management
    1. Appropriate airway management
    2. Antibiotics to prevent mediastinitis
    3. 50% operative treatment
    4. 50% non-op: position ETT cuff distal to the lesion (be sure to drop the tidal volume if you're doing single lung ventilation)

Intimate Partner Violence (IPV)

  1. 1 in 3 women and 1 in 4 men will experience intimate partner violence in their lifetime
  2. 5-10% of women in the ED at any given time are experiencing IPV
  3. Risk factors/red-flags:
    1. Low socioeconomic status
    2. Age 25-34
    3. Injuries that take place in the patient's home
    4. Multiple injuries present
    5. Injuries to the head
  4. 44% of women who are ultimately murdered by their intimate partner have visited the ED within 2 years of the homicide
  5. Women and men in violent relationships go to the ED for reasons other than acute injury, this is the rationale for universal screening
  6. What to do: re-screen your patient if you are worried that they are high risk after you build your initial rapport.
  7. When to suspect IPV?
    1. Violence in the victim's home or presence of multiple injuries
    2. HEENT injuries, depressive symptoms, suicidal ideation, repeat visits, substance use disorders

Hepatic Encephalopathy

Pathophysiology

  1. Brain dysfunction directly caused by portosystemic shunting
  2. Cerebral edema is the cause of HE in both acute and chronic liver failure
  3. Increased ICPs cause 10-20% of deaths in acute liver failure and 4% in acute-on-chronic liver failure

Quick Neurologic Assessment

  1. Asterixis grading can be used to monitor progression of hepatic encephalopathy
  2. GCS has been used to monitor HE as well

What can precipitate HE?

  1. Excess Nitrogen Burden: GI bleeding, renal failure, excess dietary protein, constipation
  2. Infection and Inflammation: SBP, pancreatitis, sepsis, meningitis
  3. Compromised toxin clearance: dehydration due to diuretics, paracentesis, fluid restriction, AKI, hepatorenal syndrome, abdominal compartment syndrome
  4. Other causes of AMS - compromised neurotransmission and metabolism
    1. Benzodiazepine use
    2. EtOH withdrawal
    3. Opioid use
  5. Acute hepatocellular damage: hepatitis, malignancy
  6. Other confounders: metabolic abnormalities, neurologic injury (ICH)

Findings on MRIs in patients with severe hyperammonemia can mimic ischemia.

Carfentanil

It is a synthetic opiate, hence the similarity in the name to fentanyl, but otherwise the two are unrelated.

It is 10,000 times more potent than morphine.

Approved only for veterinary use putting down large wild animals (hippos, rhinos, elephants etc). Unfortunately it has now been found in the local heroin supply. Be suspicious if a large amount of naltrexone (Narcan) was used in the field to wake the patient up.

  1. Narcotic effects may recur 2-24 hours after treatment with naltrexone.
  2. Half-life is about 8 hours, if you suspect this the patient needs to be observed for a longer period of time
  3. Patients often require an abnormally large amount of naltrexone to reverse the effects of carfentanil and are often encaphalopathic even when the respiratory depression is reversed. 

Epistaxis

epistaxis.jpg
  1. 60% of people will experience epistaxis but only 6% will present for treatment.
  2. Causes:
    1. Most people who are admitted for epistaxis have some kind of systemic pathology.
    2. Systemic pathology: coagulopathies, ASA use, HTN (controversial - nosebleeds are likely not spontaneously caused by high blood pressure, but ENT recommends BP control in patients who have ongoing epistaxis to help control bleeding)
    3. Local pathology: digital trauma, mucosal trauma from topical nasal drugs or illicit drug use
  3. Locations:
    1. Anterior: caused from bleeding usually from Kiesselbach's plexus
      1. Local pressure + oxymetolazine is frequently effective
      2. Nasal packing may be needed in refractory or recurrent cases
    2. Posterior: usually from bleeding from the sphenopalatine artery
      1. Packing is almost always required as external pressure cannot reach posteriorly
      2. ENT prefers the use of inflatable balloon (foley or specialized device) which requires anterior pressure against the posterior septum to tamponade a bleeding posterior artery
      3. Posterior packing can be used as well but may not always be effective
      4. Be sure to look for posterior bleeding in the back of the oropharynx

Clinico-Pathologic Case: Dr. Colmer versus Dr. Denney

The Case:

Elderly male presents with "dizziness" and headache. Episodes occur on and off for the past 3 months without any real pattern. Felt like he was getting better until today. Associated with diffuse, throbbing headache. Also has room-spinning vertigo, nausea, but no vomiting. Symptoms started today while lying in bed. Not a thunderclap headache, but relatively rapid in onset. He's been told it was secondary to dehydration in the past, so he's drinking as much water as he can. Other ROS is negative.

PMH: Hyperlipidemia, hypertension, diabetes (type II), gout, DVT/PE

Meds: Warfarin, Lisinopril, Insulin, Allopurinol

Social: No tobacco, EtOH, or drugs

Exam:

  • Appears uncomfortable.
  • NCAT, PERRLA, EOMI, Nystagmus is present.
  • No saccades on head impulse testing.
  • CV/Resp: Normal.
  • Abd: normal
  • Neuro: A & O x 4, 5/5 strength throughout. Unable to assess gait due to symptoms.

Dizzy +

The HINTS Exam - EMCrit HINTS Exam Video

  • Head Impulse: if this test is normal (no saccades seen) this suggests primary CNS cause of vertigo
  • Nystagmus: Fast-phase Alternating
  • Test of Skew: Refixation in (alternate) Cover Test

DATA CAN Save lives: Pneumonic for dangerous headaches

  • Dissection
  • Aneurysm
  • Thrombosis (Dural Venous)
  • Arteritis
  • Carbon Monoxide
  • Angle closure glaucoma
  • Neisseria (Meningitis)
  • Stroke + SAH + SDU

Diagnostic Test Ordered: CTA

Diagnosis: Dural Venous Sinus Thrombosis

Venous thrombosis decreases CSF drainage causing increased ICP leading to cerebral edema. Can lead to intraparenchymal hemorrhage.

Symptoms are variable: Headache, AMS, focal neurologic deficits, seizures

Risk factors:

  • Prothrombotic conditions
  • Systemic illness (malignancy, sepsis)
  • Pregnancy, OCPs

Imaging studies:

  • CT with contrast (venogram 95% sensitive)
  • MRI venography

Vertigo

Peripheral Vertigo Differential

  • BPPV: watchful waiting, medication, rehab, epley maneuver
  • Vestibular Neuritis

Central Vertigo:

  • Cerebellar infarct
  • Vertebrobasilar insufficiency

HINTS Exam

  1. Why you should care to learn the HINTS exam?
    1. Cerebellar infarcts can present with isolated vertigo
    2. CT scans have low sensitivity for posterior fossa
    3. Time is Brain
  2. How to do the exam:
    1. Head Impulse Testing
      1. Ask patient to focus on a fixed target.
      2. Rotate their head laterally with rapid return to midline.
      3. Watch their eyes for saccades.
      4. If you see no saccades, peripheral vertigo is less likely, suspect central cause of dizziness.
    2. Nystagmus: any kind, spontaneous or elicited with movement should heighten suspicion
    3. Test of Skew
      1. Have the patient focus on a fixed target.
      2. Alternate covering each eye with your hand.
      3. Observe the eye immediately after uncovering for vertical movement as the eye corrects.
      4. If you see correction, be concerned for central cause of dizziness

Walk a Mile in My Shoes with Dr. Elizabeth Powell

Med School and Residency: Philadelphia, PA

Extracurricular Interests: EMS

EMS Fellowship: University of Cincinnati

Now: 

  • Mobile Care Medical Director
  • Air Care Assistant Medical Director
  • Medical Director: Blue Ash Fire Department and Union Township Fire Department
  • Officer, United States Air Force: Reservist - Critical Care Physician who specializes personnel recovery 

R4 Case Follow-up with Dr. Lucia Derks

The Case:

Middle aged female patient found hanging from a tree brought to the ED by air medical transport. Attempted intubation by paramedics on scene was difficult. Intubated by air medical crew using video laryngoscopy. Vitals remarkable for tachycardia but normal BP. After intubation they noted worsening hypoxia and secretions which improved with suctioning. Arrives to the trauma bay.

CXR demonstrates some mild pulmonary edema. About 1 hour into her trauma work-up including CT head, CTA head and neck, copious pink secretions begin pouring out of her ETT. Repeat CXR shows fulminant pulmonary edema. Blood gases show progressive worsening acidosis and hypercapnia. 

The patient suffers a PEA arrest with ROSC after aggressive suctioning of the ETT.

Typically injured in near hangings:

  • Thyroid cartilage and hyoid bone
  • Cerebral venous congestion leads to cerebral hypoxia

Trachea is typically not injured.

Pulmonary Complications from Hanging

  1. Neurogenic pulmonary edema
  2. Negative pressure pulmonary edema
    1. Normal intrathoracic pressures are -2 to -5 mmHg
    2. Breathing against an obstruction can result in pressures from -100 to -140 mmHg
      1. This can be seen when someone tries to breathe against a closed glottis or with laryngospasm
      2. In this case due to strangulation from hanging
    3. This causes increased venous return and thus increases pulmonary blood volume and hydrostatic forces
    4. Hyper-adrenergic state can cause increased secretions
  3. Acute Respiratory Distress Syndrome
  4. Aspiration Pneumonia

How to Call a Consult with Dr. Denney and Dr. LaFollette

Why do we call Consults?

  1. Clinical question (specialty knowledge needed)
  2. Procedural skill needed (surgery)
  3. Follow-up needed
  4. Courtesy (i.e. this is a patient you operated on two days ago who is back with a complication)

How do you call a good consult?

  1. Contact
  2. Communicate: give a brief, pertinent clinical context/1-liner
  3. Core Question: what do you need from the consultant (see above)
  4. Collaboration: identify what other work-up may help your consultant
  5. Close the loop: get everyone on the same page about the next steps and expectations for the consult

#whatsyourquestion

Know this before you call. Lead with your question! Cut to the chase, the consultant wants to know the reason for the consult up front.