Grand Rounds Recap - 4/29/15

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Morbidity and Mortality Conference with Dr. Stull

1. Pericardiocentesis tips and tricks

  • Your needle should be at a 45 degree angle when entering the chest at the xyphoid process, aim to the L shoulder/scapula
  • Use a spinal needle and keep the stylet in while entering the skin in order to prevent needle clogging
  • Keep head of bed at 30 degrees to encourage the fluid to drain inferiorly
  • Can attach an EKG lead to the needle by an alligator clip. You will get an ST elevation in that lead if you hit the myocardium
  • Can use an A.line kit to place a catheter into the pericardium for continuous drainage
  • US probe position: subxyphoid
  • How to Video on TamingtheSRU - http://www.tamingthesru.com/blog/acmc/pericardiocentesis

2. Hemorrhagic shock

  • Class I: 15% of blood volume loss. 
    • Pt may be completely asymptomatic and have normal vital signs
  • Shock without vital sign abnormalities is difficult to recognize
    • Mental status change (agitation, anxiety) may be your first sign
  • ESRD patients have a baseline uremia, which makes them coagulopathic
    • Check a TEG
    • These patients have abnormally functioning platelets, so their MA will be            abnormal
    • DDAVP is the reversal agent for platelet abnormalities

3. Pain Control in the ED

  • This is obviously very individual, however be internally consistent. If the patient requires IV pain medication in the ED for a legitimate reason, they will probably need something for pain on discharge
  • There are studies that have shown that patients leave the ED in severe pain very frequently
    • Lack of education
    • Lack of rigorous studies
    • Concern for opioid abuse
  • We consistently underdose morphine. The appropriate dose is 0.1 mg/kg of actual body weight
    • Higher side effect rate than dilaudid
  • Fentanyl is also a good choice for first line medication for acute pain
  • Pain and anxiety are connected, if you address one, you are usually addressing the other

4. Cellulitis and Abscess

  • Complicated cellulitits (large area, DM, HIV, toxicity, location on face or hand)
    • Consider admission vs observation
  • Abscess + cellulitis should be treated with antibiotics

5. Cyanide Poisoning

  • House fire is the most common cause. Wood and plastic releases cyanide when burning.
  • Clues to suspect cyanide toxicity
    • Smoke/fire exposure and quick deterioration
    • Significant anion gap metabolic acidosis
    • High pvO2 on VBG
  • Treatment is with cyanokit: 5 g drip of hydroxycobalamine
  • TamingtheSRU podcast on Cyanide toxicity - http://www.tamingthesru.com/blog/prehospital-medicine/cnpoisoning?rq=cyanide

6. TB meningitis

  • LP findings: markedly high protein, mid range WBC count (<500) and low glucose
  • Do not talk yourself out of doing an LP. A new onset headache in an adult probably needs an LP
  • Viral meningitis: 5-100 WBC cells, lymphocyte predominant
    • Glucose is normal-slightly low
    • Protein slightly high
  • Bacterial meningitis: > 1000 neutrophils
    • Low glucose and high protein
    • Give dexamethasone: improves outcomes
  • Extrapulmonary TB: lymphatics, bone, hepatic, meningitis
  • TB risk factors (5 Is): immunocompromised, immigrants, incarcerated, in the streets (homeless), indolent course

Airway Cases with Dr. Carleton

Case 1 - The Awake Look

  • Predictors of difficulty: LEMONS (difficult direct laryngoscopy), MOANS (bagging), RODS (EGD), SMART (cricothyrotomy)
  • Awake look: need a cooperative patient
    • Anesthetize the airway
    • Method of choice in pts with predicted difficult airway but not forced to act
  • 7Ps: preparation, preoxygenation, pretreatment (will likely go away in next installment), paralysis and induction, positioning, placement and proof, post intubation care
  • Anticipate hypopharyngeal edema in patients with King airway
  • Always optimize ventilation and 1st pass success
  • Even in patients with predictors of difficulty for BVM, you can usually bag through an EGD 

Case 2 - Trouble Passing the Tube

  • If you encounter difficulty in passing the tube past the vocal cords (e.g. subglottic obstruction), you can always pass a scope through the tube and visualize the obstruction
  • If you are NP scoping somebody for the purpose of looking at the airway pre-intubation, use the long scope so that you can intubate through it or look subglottically
    • Be prepared to anesthetize the cords and intubate
  • Be careful with bougies, they are stiff and can easily dissect soft tissues and create a false passage

Case 3 - Intubating through an iGel

Clinical Controversies: Trauma Pan Scan with Drs. McDonough and Moellman

Caveat: this pertains to the moderately injured trauma patient

Top 5 reasons to Pan Scan

1. Conventional approach is not good enough: exam, gestalt, plain films

  • Our gestalt is not very good in picking up injuries if we don't think the pt is sick
  • Physical exam misses 50% of abdominal injuries
  • CXR is not good at picking up chest trauma. Chest CT not only picks up missed injuries, but also changes therapy
  • C spine x-rays miss injuries. CT leads to change in therapy

2. Cost effectiveness

  • Pan scan here is charged approximately $16,000
  • This cost is probably worth it for moderate severity patients because the missed injuries will incur a high cost to the patient and health care

3. Pan scan saves time: time to diagnosis and disposition

4. Decreased morbidity, length of stay and complications

5. Decreased mortality

Counterpoint: When did we stop thinking? - you should not pan scan based on mechanism or location alone

Literature mentioned before is not very rigorous. All retrospective, trauma driven, with lots of bias, a lot of patients are actually sick and hemodynamically unstable, which is not the patient we are talking about

Missed injuries that lead to an intervenable critical action in a stable patient are very rare (< 0.5%)

  • Trauma is uncomfortable with diagnostic delay and missed minor injuries
  • They are biased: they do not see minor injuries, mostly activated for moderate-severe injuries

ED physicians are exposed to broader severity and are more aware of resource limitation

Radiation exposure: 10-30 mSv per pan scan

  • > 20 mSv of radiation leads to 1 in 1000 risk of cancer in lifetime

Most scans  (> 80%) come back normal

NEXUS Chest CT decision rules

  • Age > 60 
  • Rapid deceleration mechanism
  • Chest pain
  • Intoxication
  • AMS
  • Distracting injury
  • Tenderness on chest wall exam

If the patient does not meet any of the above criteria, they do not need a CT chest: sensitivity 98.8

Low risk characteristics for T spine injuries

  • Exam: pain, midline tenderness, deformity, neuro deficit
  • Age > 60
  • High risk mechanism