Grand Rounds Summary 01.18.2017

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R4 Simulation with Dr. Betham, Kircher, Scupp, and Thomas

Simulation: patient is a young female G1P0 @ 39wks who had her membranes rupture at home who got in an MVC on the way to the hospital. Presents tachycardic, normotensive with abdominal pain. +FAST with imminent delivery complicated by a shoulder dystocia. Baby with APGAR of 4, breathing but limp and bradycardic upon delivery. 

Trauma in Pregnancy: Stick to your trauma evaluation, resuscitating mom is resuscitating baby initially. 

Shoulder dystocia:

Chart interpreting the 2015 NRP Guidelines, formally in effect as of 1/1/2017

  1. Have mom stop pushing and call for help
  2. McRobert's maneuver (legs hyperflexed)
  3. Suprapubic pressure (not fundal) to disimpact the anterior shoulder
  4. Manually deliver the posterior arm

Neonatal resuscitation

Oral Boards: Post-partum pre-eclampsia and HELLP syndrome: Consider pre-eclampsia in women who are 6 weeks or less from delivery who present with RUQ pain or headache, even if they did not have preeclampsia during pregnancy (<1%). 

  • Diagnosis of preeclampsia requires two BP >140/80 + proteinuria (though proteinuria can be absent if other signs of severe preeclampsia are present - https://www.acog.org/~/media/Task%20Force%20and%20Work%20Group%20Reports/public/HypertensioninPregnancy.pdf)
  • Severe preeclampsia requires evidence of end organ dysfunction as manifested by headache, RUQ pain, visual changes, hyperreflexia, and signs of HELLP syndrome (low platelets, elevated AST/ALT). 
  • Treatment of postpartum preeclampsia consists of BP control (labetalol and hydralazine first line) and magnesium infusions (4g over 20min initially), and then admission to an ICU or L&D floor. 
  • HELLP should be treated similarly, add on DIC labs 

CPC with Dr. Continenza and Dr. Paulsen

Case: Elderly man with slurred speech, left sided weakness worked up for TIA at an OSH, transferred for further work-up. Has dysarthria, left sided facial droop, tongue deviation to the right. Normal MRI at the OSH, normal lab work up. 

Neurologic complaint approach sorted by emergency and localization:

  • Is the patient experiencing respiratory failure?
  • Level of AMS?
  • Global v Focal Deficit?
    • Non-neurologic (Infection, toxic, iatrogenic, metabolic, ACS, adrenal insufficiency, hypothyroidism, anemia)
    • Neurologic (post-ictal, myasthenia gravis, Guillain-barre syndrome, botulism toxicity, tick paralysis)
  • Unilateral or Bilateral?
  • Sensory, Motor, or Both?
    • Motor (multiple CNS lesions, polyneuropathy)
  • Proximal v Distal
    • Proximal>Distal (neuromuscular disorders ie myasthenia gravis, lambert-eaton, botulism)
    • Distal>Proximal
  • Bulbar signs?
  • Sudden onset?
    • Sudden (vascular, toxic metabolic, infectious, autoimmune)
    • Gradual (autoimmune, mass, neurodegenerative)
  • Localize the lesion

Our patient's constellation of syndrome fits the neuromuscular junction and peripheral nerves. Test ordered: Ice Pack Test for Myasthenia Gravis. 

Myasthenia Gravis: antibodies to acetylcholine receptor causing muscle weakness and fatiguability.  

Epidemiology: 0.9-2.1 per 100,000

Presentation

  • Ocular symptoms (~50%)
    • Ptosis
    • Diplopia
  • Generalized symptoms
    • Weakness
    • slurred speech

Diagnosis:

  • Serum antibodies to acetylcholine receptor
  • Ice pack test: sensitivity 96% specificity 88% (apply ice pack to 1 eye for 2 mins which improves the ptosis)
    • May work by decreasing the action of the acetylcholine esterase to leave more ACh in the synapse
  • Tensilon test

Causes of Crisis:

  • Infection
  • Drugs
    • Antibioics
    • Magnesium
    • Beta Blockers

Treatment of crisis: corticosteroids, immunomodulators initially. Consider thymectomy if applicable.

Intubation

  • Distress
  • Respiratory Acidosis
  • Unable to handle secretions
  • FVC <20ml/kg
  • NIF (aka MIP) < 30 cm H20

Paralytic Pearls:

  • Depolarizing: resistant
  • Non-depolarizing: sensitive

NIPPV

  • Avoid if PCO2 >45, secretions

R4 Clinical Soapbox with Dr. DeVries

First US was in the 1960s, was a huge machine that cost $300,000.

Fraction of overall ED US from 0.2->3%. From 1992-2012 increased by >4000%.

Potential Pitfalls for US:

  • Physician competency
    •  ACEP defined goals
  • Consultant interaction
  • Ignoring clinical context

POCUS in patients admitted with respiratory studies: Increased diagnostic accuracy of POCUS v CXR at 4 hours with absolute increase in 24%. NNT about 4. Pts with CXR had:

  • Increased downstream testing
  • Trends towards harm
  • No change in hospital LOS

Future of POCUS

  • Critical time for the incorporation of POCUS

R1 Diagnostics with Dr. Golden: Foot and ankle x-rays

Take a look through Dr. Golden's introductory post for the basics

Lisfranc Injury: ligamentous injury +/- fracture dislocation

Management:

  • Rest, Ice, Compression, Elevation
  • Pain control
  • If <2mm displacement: 6-8 weeks NWB short leg splint
  • If >2mm displacement, fracture dislocations: surgical repair may be indicated
  • Urgent consultation: Neurovascular compromise or compartment syndrome

Fifth Metatarsal Injuries:

  • Zone 1: Tuberosity Avulsion (Pseudo-Jones)
    • No studies comparing operative v non-operative
    • Protected weight bearing (walking boots) does better than non-weight bearing
    • Outpatient follow-up within 2 weeks
  • Zone 2: Jones Fractures (peroneus longus tendon rupture)
    • NWB short leg splint
    • Operative repair: nonunion (20% of conservatively managed patients), re-fracture, athletes
    • Outpatient follow-up within 2 weeks
  • Zone 3: Diaphyseal stress fractures

Calcaneus Injuries:

Bohlers Angle (should be between 20-40 degrees): if angle lies outside of this, suspect a calcaneal injury

Management:

  • Surgical: compartment syndrome, neurovascular compromise, open, dislocation
  • Intra-articular fracture: urgent need for surgical consultation
  • Extra-articular fracture: okay for outpatient consultation