Grand Rounds Recap 02.10.2021
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Ultrasound Grand Rounds: Respiratory Distress WITH Dr. Duncan
Point of Care Ultrasound in M&M Cases in EM: Who Benefits the Most?
In cases where POCUS was not used, retrospective review determined it could have prevented 45% of M&M cases
Cardiac and lung ultrasounds were thought to have the most potential
1% of total cases (9% of cases selected for presentation) where POCUS possibly had adversely affected the outcome
Respiratory Distress in Ultrasound, cases and pearls
60 year old female with shortness of breath. HR 110, BP 240/110, RR 40, SpO2 90% on 15L NRB
POCUS shows B-lines, you have concern for flash pulmonary edema and start patient on nitro and bipap.
B-lines replace A-lines, extend throughout the edge of the screen, represents an interstitial process
Focus position (setting on US machine): for this POCUS application place it at the parietal surface for image optimization
Angle of Insonation: you MUST see either A lines or B lines in lung ultrasound, if you don’t then you need to change the angle
55 year old male with shortness of breath. HR 110, BP 180/110, RR 40, SpO2 85% on NRB
A-lines generally mean normal lung (though sometimes pneumothorax can have A lines)
A-lines are equidistant from each other
Curvilinear/phased array probe
Lower frequency, deeper structures beyond pleural line
Better for B lines, pleural effusion, PNA
Linear
Higher frequency, best for artifacts at pleural line
Lung sliding, PTX, subpleural consolidations
63 year old female with shortness of breath. HR 90, BP 180/110, RR 30, SpO2 95% on 4L NC
POCUS echo shows severely depressed LVEF and pleural effusion
POCUS lung shows large anechoic pleural effusion
Concern for CHF
Literature: Diagnosing Acute Heart Failure in the ED: A systematic review and meta-analysis
Lung US +7.4 LR
Reduced EF +4.1 LR
CXR +4.8 LR
BNP +0.11, +0.29
Lit: Diagnostic Accuracy of POC Lung US and Chest Radiography in Adults with Symptoms Suggestive of Acute Decompensated Heart Failure: A systematic Review and Metaanalysis
Lung US is more sensitive and specific than CXR
70 year old male with SOB. Hx of lung cancer on chemo. HR 115, BP 90/50, RR 30, SpO2 95% on 4L NC
POCUS shows large pericardial effusion
Rapid effusion is more problematic than slow effusion over time
Signs of tamponade: valves closed RA collapse, plethoric IVC <50% collapse, valves open and RV collapse, MV inflow variation >25%
Lit: Emergency department POC ultrasound improves time to pericardiocentesis for clinically significant effusions
Time to pericardiocentesis
POCUS 11.3 hrs
Non-POCUS 70.2 hours
85 year old male with hx of CHF and CAD.
Lung US shows B lines
Right lung base shows a consolidated lung and small pleural effusion
How to differential PNA vs atelectasis?
Dynamic air bronchograms - highly sensitive for PNA
Shred sign - irregular pleural surface
Lit: Accuracy of Lung US versus Chest radiography for diagnosis of adult community aquired PNA: Review of Lit and meta-analysis
Lung US sensitivity 95%
CXR sensitivity in the 70s%
Also better sensitivity in pediatric settings when reviewing pediatric literature
40 year old male in MVC. Has SOB. HR 115, BP 90/50, RR 30, 95% on 4L NC
You include lung in your E-FAST
No lung sliding on the left, concern for pneumothorax
Bar code sign on M-mode
Lung point
Lung pulse sign: contraction of heart moving the lung tissue, can see small pulsations along the pleural line. Not consistent with a pneumothorax
False positive pneumothorax: beware in certain conditions such as COPD or poor ventilation, will see less lung sliding
Lit: Accuracy of US in dx of PTX: Comparison between neonates and adults
Absence of lung slide: sens 87, spec 99.4
Lung point sens 82, spec 100
Accuracy of CXR? A different study showed pooled sens ~30-50%
56 year old F with hx of ovarian cancer on chemo/radiation. HR 115, BP 80/50, RR 36, 95% on 2L NC
POCUS shows left ventricle D sign
Signs of right heart strain, concern for pulmonary embolism
Paradoxical septal motion
Enlarged RV
D-sign
False D-sign can occur if you have poorly optimized image
35 yo F with shortness of breath. Hypoxic and in respiratory distress
POCUS shows B-lines
Note some irregularity to pleural lines
Covid 19 and Lung US
Subpleural consolidations
Multifocal B lines
Literature shows Lung US sensitivity 97.6%, CXR 69.9%
Lit: POCUS for Evaluation of Acute Dyspnea in the ED
Time to US diagnosis: 24 min +/- 10 min
Time to standard diagnosis: 186 min +/- 72 min
How to clinically integrate?
R4 Case Followup WITH Dr. Iparraguirre
Elderly female who fell and developed a headache. She took aspirin at home which helped with her symptoms. She then developed slurred speech and that her hands were weak/clumsy. Vitals were normal. Exam was normal except for a slight limping gait (she stated she felt off balance).
The physician-patient relationship
Four models
Paternalistic: give patient treatments based on our point of view. Lean towards their wellbeing rather than their autonomy
Informative: we provide all the data, but we allow the patient to guide their management
Interpretative: we provide data, but we take patient’s beliefs and values into consideration and help them interpret to better guide their care
Deliberative: Similar to interpretative, but we help the patient make the best decisions for their care
What constitutes a good doctor? (From patient’s point of view)
A study out of Mayo found that patients valued:
Empathy, humane, personal, forthright, confident, respectful, thorough
How do we move Beyond Empathy?
Engagement, competency, imagination, care, active listening
Patient had metastatic cancer on head CT
SPIKES
Delivering bad news to the patient
Setting Up (S)
Perception (P)
Invitation (I)
Knowledge (K)
Emotions/Empathy (E)
Strategy and Summary (S)
Takeaways
Clear your head
Our patients are human too
Educate, inform, and guide
Go beyond empathy
Bad news, good doctor
Treat our patient
You have more impact than you think
R1 Clinical Knowledge: VP Shunts WITH Dr. Klestel
CSF made by choroid plexus
Mainly in lateral ventricles
Flows into 3rd ventricle by foramen of monro
Into the 4th by aqueduct of sylvius
Enters subarachnoid space and bathes spinal cord and brain
Reabsorbed by arachnoid villi
About 500cc/ day is made
Hydrocephalus is excess quantity of CSF
Communicating
Decreased absorption
Defect with arachnoid villi
Inflammation
Fibrosis
Increased production
Noncommunicating
Obstruction of CSF flow
Congenital such as Arnold-Chiari
Acquired such as a tumor
Subtypes:
Normal pressure hydrocephalus
Urinary incontinence, dementia, ataxic
No signs of increased ICP
Hydrocephalus ex vacuo
Not true hydrocephalus
Ventricles appear to be enlarged due to atrophy
ICP and CSF flow is normal
Monro-Kellie Doctrine
Skull is a fixed, rigid space
Must accommodate CSF, blood, brain
Increase in one component without compensatory reduction in another will lead to increased ICP
Hydrocephalus clinical signs
Morning headache
Vomiting
Papilledema
Focal neuro deficits
Abducens nerve palsy
Cushings phenomena
Herniation
Decreased consciousness
Oculomotor nerve palsy
Posturing
Infants have fontanel
Look for bulging of fontanel
Increase head circumference
Separation of cranial sutures
Definitive treatment: cerebral shunt placement
Indwelling catheter
Moves excess CSF to systemic circulation
Typically in lateral ventricle
Distal tip can vary in location, mostly VP
CSF flow is controlled by one way valve
Differential pressure valve: When CSF goes above set pressure, it will be drained
Can also set a physiologic pressure valve
Distal tubing travels within subcutaneous tissue
Distal catheter tip enters peritoneal cavity
Left free floating
Complications
Commonly occur shortly after placement
Pediatric patients:
Signs of failure for peds patients within 5 months of placement
Decreased LOC PPV 100%
Bulging fontanel PPV 92%
Nausea and vomiting PPV 79%
Irritability PPV 78%
If between 9 months to 2 years
Decreased LOC PPV 100%
Loss of milestones PPV 83%
Verbal patients have signs of increased ICP
Morning headaches
Ataxia hyperrfelexia, spastic
Nausea and vomiting
Reduced responsiveness, cushings
Undershunting
Shunt obstruction: may occur at proximal ventricular catheter, the valve, or the distal catheter
Vast majority occur due to proximal obstruction
Distal obstructions are less common, about 14%
Mechanical failure
misplacement/ migration/ disconnection
Shunt series XR and head CT can be used for evaluation
These patients get a lot of radiation throughout their life
Infection
Second most common cause of shunt failure: incidence of 8-10%
Tend to occur within first 6 months
Due to contamination from intraop due to skin flora
Staph epidermidis, staph aureus, pseudomonas, gram negative rods
Need to tap the shunt
Usually performed by neurosurgery
Done sterilely and needle may damage the system
CSF labs evaluated the same as you would from an LP
Adults: vancomycin and cefepime (to cover pseudomonas)
Children: vanc and cetriaxone
Overshunting
Shunt draining too much CSF, leads to extra axial fluid collections
Need adjustments to their valve
Slit ventricles can occur in children
EM approach
Unstable?
Intubate, mannitol/hypertonic, HOB >30, consult NSGY
Infection?
NSGY to tap shunt
Empiric antibiotics
Visiting Professors Lecture WITH Drs. Koyfman and Long
Cerebral Venous Thrombosis
Most commonly at superior sagittal sinus and transverse (lateral) sinus
Oftentimes patients have multiple areas involved
85% have underlying risk factor for thrombosis
Headache is most common presentation
Chronic, gradually worsening, worsens with valsava
Focal neurologic abnormality
Vision change, motor weakness
Seizures (generalized or partial)
Encephalitis with AMS
Scenarios warranting investigation
Headache in patient with risk factors and focal neuro findings
Stroke without typical risk factors or in setting of seizure
Unexplained intracranial hypertension
Multiple hemorrhagic infarcts, or if it does not fit a arterial vascular distribution
‘Dense triangle sign’ on non con CT can be seen, do not depend on this
CT venogram >95% sens and spec
MR venogram is best test
Treat elevated ICP, antiepileptics if seizing, anticoagulation
Ludwigs Angina
Infection of submandibular face that can lead to airway occlusion
Odontogenic (mandibular molars), piercings, diabetes, immunocompromising disorders
Beware of tripod positioning, trouble with secretions, cannot lie flat, protruding tongue and lower chin
This is a clinical diagnosis, CT may be helpful but patient may have trouble laying flat and compromise airway
Airway
Awake intubation
Topicalize, ketamine, prep for cric
Supraglottic airway likely will not work
Cauda Equina syndrome
Often have a delay in diagnosis (11 days from symptom onset)
CES stages
Suspected
Incomplete
Retention
Complete
History: don’t forget about on bladder, bowel, sexual dysfunction
Physical: motor, sensation, postvoid residual
Post void residual volume
If patient has <100 cc, probably not advanced cauda equina
MRI is diagnostic modality of choice
Treatment: surgery
Urinary problems at presentation = poor outcome
Acute Cholangitis
Bacterial infection of the biliary tract as a result of obstruction
Common bile duct obstruction
Extrinsic (stricture or mass)
Gallstone
Mortality reaches 100% if obstruction is not decompressed
Charcots Triad and Reynold’s Pentad
Charcot <25% of patients
Reynolds even more rare
WBC, GGT, Alkaline phosphatase, LFT, blood cultures
Tokyo Guidelines for Acute Cholangitis, on MDCalc
Source control, fluid resuscitation, broad antibiotics
Fournier’s Gangrene
Risk factors include diabetes, immunocompromised, alcohol use disorder, hygiene, trauma to area
Sources: GI and GU track, cutaneous injuries
Most are polymicrobial
Clinical diagnosis
Don’t rely on fever, bullae, crepitus
POOP: pain out of proportion
LRINEC Score
Cannot be used to rule out disease, generally a poor tool
POCUS and CT can be helpful
Treatment: surgery, resuscitation, broad antibiotics, glycemic control
R2 QI/KT: Hypothyroid and Myxedema Coma WITH Drs. Gressick and Meigh
Myxedema coma
Severe life threatening manifestations of hypothyroidism
It is a critical physiologic state
Name from the non-pitting edema seen in this condition
Patient does not need to have a coma, often just AMS
Epidemiology
0.22/million/year
80% female
Peak incidence in 7th decade of life
90% in winter months, less common in tropical areas
Mortality is 30-60%
Factors associated with morality
State of consciousness on admission
APACHE II Score
Bradycardia, hypotension, need for mechanical ventilation, hypothermia, sepsis, lower GCS, higher SOFA score
T4 and TSH was not statistically significant
Systemic Effects
Nervous system
AMS/confusion
Likely multifactorial
Seizure (hypoglycemia or hyponatremia)
Delayed relaxation of DTR (Woltman Sign)
Cardiovascular
Decreased ionotropy and chronotropy
Prolongs cardiac action potential → risk for torsades
Peripheral vasoconstriction
Diastolic HTN
Decreased cardiac output
Respiratory
Hypoventilation
Renal
Hyponatremia
Impaired free water excretion
Impaired sodium reabsorption
Other
Decreased vWF → coagulopathy
Pleural and pericardial effusions from increased vascular permeability
Decreased GI motility
Inciting Events
Hypothermia
Infections and sepsis
CVA
CHF
GI bleed
Raw bok choy
Trauma
Drugs (anesthetics, sedatives, tranquilizers, narcotics, amiodarone, lithium)
Withdrawal of thyroid supplements
Presentation
This is a clinical diagnosis
Physical exam findings:
Facial edema, skin changes, peripheral edema, past surgical scars on neck, laryngeal edema, tongue edema, AMS
Vitals
Hypothermia in 90% of patients
Respiratory depression/hypoxemia
Diastolic hypertension → hypotension
Bradycardia
TSH may be high, low or normal
T4 usually low
Send cortisol level in altered hypothermic patients
Treatment
Thyroid hormone replacement
T4 vs T3 treatment
Studies recommend T4 monotherapy
UC does not carry IV T3
T4 dosing
PO T4 has multiple factors that affect bioavailability
IV T4 is recommended
200-400 micrograms IV T4
No RCTs, mostly case series, very little has changed in the past half decade
Glucocorticoids
Empiric hydrocortisone 100mg IV q8hr is recommended by some groups since hypopituitarism and hypoadrenalism can mimic myxedema coma and can also occur simultaneously
Airway Management considerations
Watch for edema in the mouth, such as the tongue
Can have lung pathologies such as edema and effusions
Neuromuscular weakness
Hypotension
IV fluids
Consider POCUS echo
Pressors
Hypothermia
Slow more gentle approach with passive rewarming
Treat hypoglycemia
Manage inciting factors
Consider blood cultures and antibiotics
Correct electrolyte abnormalities
Consider DDAVP for bleeding issues
Do not await for thyroid studies to begin treatment
MIS-C and Kawasaki WITH Dr. Krack
Three phenotypes of children with MIS-C
Group with shock with evidence of myocardial injury
Group that met AHA criteria for KD
Group with fever and inflammation that did not have shock or did not meet clinical criteria for KD
Kawasaki Disease: Epidemiology
Cause is unknown
Estimated incidence in North America ~25 cases per 100k in children <5 years of age per year
Japanese incidence ~10x higher
Ratio males to females is 1.5:1
KD affects predominately young children
More common in winter and early spring in North America
Pathology
Affects muscular arteries
Coronary often affected, but can affect other areas too
Systemic inflammation in all medium sized arteries and in multiple organs during acute febrile disease
Diagnosis
Classic KD
5 or more days of fever (typically high spiking and remittent)
AND 4 or more of the 5 principal clinical features
Can also be 4 days of fever and 5/5 clinical features
Atypical KD
Fever 5 or more days
AND 2-3 clinical criteria and classic lab changes
Infants less than 6 months are unique: with unexplained fever for 7 or more days
KD treatment
IVIG 2g/kg given as a single IV infusion
Reduces absolute risk of coronary artery lesions from 25% to 4%
Treatment is relatively benign, delayed treatment is not
CDC case definition for MIS-C
<21 years presenting with fever, lab evidence of inflammation, and evidence of severe illness requiring hospitalization with greater than 2 organ system involvement
Covid exposure
No other plausible diagnosis
MIS-C features
Mean age 8-10 years
Seen more in children of African, Caribbean, and Hispanic Descent
Clinical: abdominal pain, diarrhea, vomiting, multi-organ involvement
Cardiac features
About half show moderate to very severe myocardial involvement, much greater than KD
Younger kids have more KD-like features
Older kids have more GI symptoms, cardiac features, shock
MIS-C Treatment
IVIG
Constantly changing recommendations
