Grand Rounds Recap - 12/3/2014

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EMS Protocol Updates for 2015 with Dr. Leblanc

Use of EMS units as transport units

  • If pt is transported to a facility that is not capable of taking care of the pt, you may be able to use the same squad to transport the pt to another facility
  • Need to have an accepting doc
  • May need to send additional personnel with the squad

Hypotension/Shock protocol

Bradycardia: Versed for external pacing

Toxicology

  • No more activated charcoal
  • Cyanide: give cyanokit  when both decreased level of consciousness and hypotension
  • Narcan: can give IN, no more than 1mL per nostril per dose 

OTC medications: if pt requests OTC med for minor medical concern and they have no signs or symptoms of significant medical condition

Imminent delivery

  • Viability = 24 wks
  • Do not suction baby unless respiratory distress
  • Mom and baby go to SAME hospital whenever possible

Head or spinal trauma: can use hypertonic saline if pupil difference, decreased level of consciousness and evidence of head trauma

TXA: there is now a protocol for adults (only for trauma)

  • Emphasis on vital signs  (SBP < 90, HR > 110) and timing (within 3 hours from injury)
  • Not for peds

Peds submersion in ice water

  • If there is ice, the patient has to be transported to CCHMC on Burnet (ECMO availability)
  • < 30 minutes, no ice on water and no signs of life can be transported to closest ED

Spine immobilization

  • AMS, intoxication, distraction, midline spine tenderness, neurologic injury à need backboard

Airway Protocol Updates

  • The term "rescue airway" is gone.  Replaced by "supraglottic airway"
  • No more than 2 intubation attempts…for now
  • Do not stop compressions if CPR in progress 

Hemorrhage control

  • Tools: tourniquet, wound packing, hemostatic gauze, TXA

Medication Changes

  • Removed medications: lasix, dopamine
  • Added medications: TXA, hypertonic, LR, narcan autoinjectors

Termination of resuscitation of trauma: transport if ROSC or may benefit from ED thoracotomy

  • Bag, manual C spine immobilization, bilateral needle decompression, IV/IO with saline, then put on monitor
  • PEA > 40 should be transported transport
  • PEA < 40 or asystole should be pronounced

The 2014 Southwest Ohio EMS Protocols can be found here on tamingthesru.com/hems-and-ems

We will post the 2015 SW Ohio EMS Protocols once they are finalized!

Bell’s Palsy with Dr. Stettler

History and Physical         

  • Isolated unilateral facial paralysis/weakness that is rapid onset, though not instant
  • Can have associated neurologic symptoms: taste disruption, vague sensory disruption (tingling, numbness, pain), mild HA, change in hearing
  • Has to be both upper and lower face
    • Detect subtle upper face weakness by testing rapid blink: affected eye does not work appropriately

Prognosis related to severity, treatment and Increasing age

  • 50-70% recover no matter what you do
  • Typical duration of symptoms 3-4 months

Treatment

  • Steroids
    • Everybody should get them, the earlier the better
    • Regardless of timing of onset
    • Increase likelihood of recovery by 20%
    • 25 mg prednisolone PO BID x 10 days  OR
    • 60 mg prednisone x 5 days, then taper over 5 days
  • Antivirals??? You can give them, probably does not help

Disposition

  • Consider ENT follow up if complete paralysis, otherwise PCP or if there is no recovery by 3 months

Imaging in Neurologic Emergencies with Dr. Stettler

 CT head

  • Useful for early ischemic changes
    • Loss of insular cortex
    • Loss of grey-white differentiation
  • Gold standard for evaluation of hemorrhage?
    • T2 MRI may better visualize a hemorrhage while CT head is normal

 Diffusion MRI - Sensitivity of 14-67% in TIA,Higher rate of positive study with longer duration of symptoms

CT perfusion: CT with contrast bolus

  • Tracks passage of contratl bolus and shows hypoperfusion
  • May help stroke team make decision on whether to treat if outside the window
  • Positive within minutes of stroke onset
  • Much more sensitive than CT head < 6 hours

Facial Trauma with Dr. Krishnan

Penetrating injury: usually midface/zygoma and due to high velocity

Blunt injury: usually nose and mandible

60% of facial trauma pts have some other traumatic injury

  • 20-50% have head injury
  • 1-4% have C spine injury
  • Blindness in 0.5-3%
  • 25% of women with facial trauma are victims of domestic violence

Open wound management:

  • Laceration behind line of outer limbus à watch out for parotid duct and facial nerve injuries
  • Suture choices
    • Absorbable in kids (plain gut)
      • Minimal scientific data
    • Ethilon/prolene for skin 
    • Silk to tie off vessels
    • Gut for mucosa (3 or 4)
    • Vicryl for deeps
  • Do not use soap: use a prep agent or betadine
  • Be careful to remove all foreign bodies
  • Establish contours and margins: lip, eyelid, nasal and ear margins should be reapproximated as closely as possible
  • Facial nerve injury should go to OR

Scalp wounds: wash out aggressively

  • Minimal tissue elasticity
  • Drain or pressure dressing to minimize hematoma formation (high risk of infection)
  • Large avulsions will need some sort of graft/flap repair

Periorbital/eyelid lacs

  • Align eyebrow border
  • Eval for globe, lacrimal duct/gland injury

Nose

  • Can have difficult to control bleeding
    • Anterior: pressure, afrin and packing
    • Posterior: consult, Foley bulb
  • Make sure to drain septal hematoma as it can cause septal perforation and necrosis
  • Close in layers: mucosa, cartilage, skin
  • Align alar rim
  • Ok to use vasoconstrictors

Lip

  • Repair muscle if involved
  • Approximate vermillion border
  • If > 1/3 of lip missing à needs a flap

Ear

  • Large defect may need a flap for coverage
  • Always cover cartilage
  • If cartilage defect, obtain 24 hour follow up

Ok to close facial lacs later: 24 hours probably safe

  • Can delay if will be used for surgical access to underlying fracture

Facial fractures

  • Zygoma and nasal bones will fracture with low impact injuries
  • Supraorbital, mandible and frontal bones require higher impact
  • Skeletal buttresses determine fracture pattern

Key history questions: pain with eye movements, numbness/tingling in face, pain with biting down

PE important nuances: septal hematoma, count teeth, CSF leak, face stability

Imaging: panorex, CT

Nasal fracture: most will require some sort of repair

  • No nose blowing when go home
  • Outpatient follow up

Zygomatic arch fracture

  • Can impinge on corner of mandible and pt won't be able to open their mouth

Lefort fractures

  • I: upper jaw horizontal
  • II: upper jaw and nose
  • III: skull and face separated

Mandible fractures: trismus and malocclusion, numb lip

  • Need antibiotics
  • Usually bilateral

Dental trauma

  • Assess for occlusion: underlying facial fracture
  • No need for antibiotics, but make sure tetanus UTD
  • Do not disrupt periodontal ligament
  • Dentoalveolar fracture
    • Arch bars

Useful FOAMed Resources for Lacerations and Dental Trauma

Pericarditis/Myocarditis with Dr. Shah

Pericardium = serous and collagenous layers with fluid filled space in between

Keeps heart in mediastinum and protects from infection

Many different causes of pericarditis:  VINDICATE

  • Vascular: post-MI (immediate vs delayed (dressler))
  • Infectious/idiopathic: usually viral, TB
  • Neoplastic: lung ca
  • Degenerative
  • Iatrogenic: procainamide, hydralazine
  • Congenital
  • Autoimmune: lupus, connective tissue dz, RA
  • Trauma
  • Endocrine/metabolic: thyroid, uremia

Diagnosis

  • Clinical: CP radiating to back due to diaphragmatic irritation
  • PE: friction rub
  • Testing: ECG, CXR, Echo

 EKG is abnormal in 90% of acute pericarditis

http://lifeinthefastlane.com/ecg-library/basics/pericarditis/

http://lifeinthefastlane.com/ecg-library/basics/pericarditis/

  • Stage 1: PR depression in II, aVF, V4-V6 with ST elevation in I, V5-V6

  • Stage 2: PR depression, T wave inversion, normal ST segment

  • Stage 3: T wave inversions

  • J point notch: benign early repolarization

  • ST:T ratio > 0.25 is highly suggestive of pericarditis

  • No reciprocal ST depression (except aVR and V1)

  • PR elevation in aVR

 CXR: look for cardiomegaly/waterbottle heart to detect effusion

Echo:  Subxyphoid/apical 4 chamber views the best

Treatment

  • Treat underlying cause
  • NSAIDs: ibuprofen, ASA, indomethacin
    • Give GI prophylaxis
  • Colchicine: 0.5 mg BID x 2-3 months
    • Decreases recurrence rate
    • May be used for prophylaxis in pts with recurrent pericarditis
  • Glucocorticoids
    • Increases recurrence
    • Indicated: autoimmune, renal failure, failure of standard therapy

Hospitalize if:

  • Immunocompromised
  • Anticoagulation
  • Large effusion
  • Non-idiopathic etiology

Pericardiocentesis only if tamponade, no role for diagnostic

Great FOAMed Resource for more information about Pericarditis - LITFL with Amul Mattu video

Myocarditis: inflammatory cardiomyopathy

  • Frequently associated with pericarditis
  • Can have signs of CHF
  • Diagnosis: endocardial biopsy
    • Frequently have troponin elevation, though not diagnostic
    • Echo
  • Treatment: underlying cause
  • Treat CHF symptoms: ACE, diuretics, salt restriction, digoxin
  • Red flags: tachyarrhythmia, heart block, CHF

Case Follow up with Dr. Betz

45 yo M, unhelmeted ATV roll over, + EtOH.  He has significant facial trauma, L flank and L thigh.  He also has notable left eye swelling with mild proptosis and can’t open his left eye spontaneously

  • GCS 12, hemodynamically stable
  • CT head: diffuse SAH, bilat SDH and multiple contusion

No visual acuity and IOP 60-90 after a lateral canthotomy IOP pressure down to 30

Retrobulbar hematoma: postseptal hemorrhage

  • Usually post traumatic but also seen after eye surgery
  • High risk of permanent blindness: 50%
  • Can cause orbital compartment syndrome and proptosis on exam
  • Leads to orbital nerve ischemia
  • Clinical diagnosis: APD, elevated IOP, decreased vision, proptosis
  • Treatment: lateral canthotomy
    • Cut lateral canthus and inferior canthus
    • Need: lido with epi, hemostat, scissors, forceps
    • Local anesthesia, devascularize with needle driver/hemostat and cut down horizontally to orbital rim, then look for inferior canthus and cut vertically
  • Give PO antibiotics (augmentin)
  • Eye drops to lower IOP
  • Steroids if optic neuropathy

P-values with Dr. Strong

Conventional Clinical significance – 0.05

Determining p value

  • Depends on type of data
  • Needed variables: Degrees of freedom and chi squared
  • Chi squared = comparison of observed result to expected result
  • Degrees of freedom = measure of variability
    • Based on number of categories/variables you are looking at

What matters when interpreting the data?

  • Your knowledge of the subject matter 
  • The effect of size 
  • Replication 
  • Alternative hypothesis: how plausible is your alternative hypothesis
  • The exact p value

CPC with Drs. Richardson and Benoit

13 yo F presenting with difficulty breathing x 6 days though on further history has had it for 3 months.  Also complains of pleuritic pain, no cough, no fever.  The symptoms are worse when lying down and some choking episodes when lyingdown

  • ROS: RUE weakness, hoarse voice
  • Normal vitals
  • PE: tachypnea with diminished breath sounds
  • Neuro: difficulty looking up with proximal BUE weakness

During the course of her care she becomes more tachypneic and tachycardic, has pooling of oral secretions with a notable respiratory acidosis on VBG.  She is placed on NIPPV but ultimately fails and ends up requiring intubation

Diagnosaurus app: very helpful in coming up with differential diagnosis

  • GBS: no ascending paralysis, normal reflexes, timing doesn’t fit (usually days not months), no preceeding infection
    • Though kinda fits Miller Fischer variant, but still no hyporeflexia
  • Botulism: hyporeflexia, should be acute, fixed and dilated pupils
  • Myasthenia gravis: everything fits
  • Tick paralysis: ascending paralysis, hyporeflexia, tick exposure, less chronic
  • Poliomyelitis: flaccid paralysis, hyporeflexia, preceding viral illness
  • MS: hypereflexia, visual loss, decreased sensation
  • Hypothyroidism/myxedema coma
  • Organophosphate poisoning 

Winner:  Myasthenia Gravis: 20 per 100,000 people

Disorder of NMJ: Antibody against AcH receptor à decreased muscle cell depolarization, or Ab against MuSK receptors

Diagnosis = tensilon test

  • Edrophonium = cholinesterase inhibitor
  • 1-2 mg, if no response can give up to 10 mg (0.15 mg/kg)
  • Reversed with atropine if the patient develops bradycardia
  • Should improve neurologic deficits and usually easiest to see in ptosis
  • Need to have objective neurologic findings to perform the test

Symptoms: worsen as day progresses

  • Bulbar weakness: dysphagia or hoarseness
  • Eye: ptosis
  • Respiratory distress
  • Weakness

 Physical exam

  • Abnormal CN, strength exam
  • Normal reflexes and sensory exam
  • Provocative tests
  • Ice pack test: for ptosis
  • Repetitive nerve stimulation with EMG: repetitive stimulation decreases muscle action potential

Myasthenia crisis

  • Usually precipitated by infection or other physiologic stressor
  • Drug interactions: abx, antipsychotics
  • Do a NIF to evaluate respiratory function
    • Intubate if -30 or worse
    • BiPaP can be useful in early crisis
  • Succinylcholine is safe to use for intubation but use higher dose (2 mg/kg) as efficacy is less predictable
  • Roc/vec: use half dose as effect prolonged
  • Treatment

    • Pyridostigmine: Ach-e inhibitor

    • Immunosuppresion
      • IVIG
      • Plasmapheresis