Grand Rounds Recap 2.14.24
/ENRICH Trial - the leadership journey - EMS grand rounds - r4 capstone - r1 clinical knowledge - pediatric lecture
ENRICH Trial WITH visiting professor Dr. david wright
ICH makes up only 10-15% of all strokes
yet has a higher mortality than ischemic strokes and SAH
Current 2022 AHA/ASA guidelines for spontaneous ICH (prior to ENRICH Trial)
minimally-invasive evacuation may reduce mortality compared to medical management
it may be reasonable to choose minimally-invasive evacuation over conventional craniotomy to improve functional outcomes
Rationale for clot evacuation (relevant for ICH volume >30cc)
Relieve ICP
there is blood in the brain, yet surrounding brain tissue is relatively intact shortly after the initial insult
goal is to evacuate the clot and decrease the ICP
this improves cerebral perfusion pressure (remember CPP = MAP - ICP)
hopefully preventing ischemic injury to the peri-hematoma area
Prevent re-bleeding
achieves hemostasis
also reduces the associated inflammatory cascade
Conventional craniotomy for ICH
STICH Trial
failed to demonstrate superiority of surgical over medical management
STICH II Trial
showed a trend towards superiority, yet still not statistically significant compared to standard medical therapy
Minimally-invasive clot evacuation in ICH
MISTIE III Trial
primary outcome of mRS did not change significantly compared to control
yet revealed a lower risk of death with intervention, as well as fewer serious adverse events than controls
notably, goal clot evacuation (<15cc of remaining clot) was only reached in 59% of patients enrolled in this trial
Ideal surgical procedure for ICH
immediate impact on mass effect
maximizes clot removal
minimizes iatrogenic injury
direct visualization of hemostasis
New technology for minimally-invasive clot evacuation
image-guided technique to allow clot evacuation while avoiding iatrogenic injury to the critical neuronal networks
ENRICH Trial
multicenter, randomized, adaptive clinical trial
1:1 block randomization stratified by
ICH location
Index GCS
this was an adaptive trial
best chance for overall success of minimally-invasive procedure compared to medical management was found to be in the lobar ICH group (rather than the basal ganglia ICH group)
outcomes
lower-rate 30 day mortality in patients undergoing procedure, compared to medical management
ICH reduction was seen in 87.7% of patient in procedure group
additional outcomes
reduced ICU LOS
reduced need for rescue craniotomy
subanalysis
most improvement seen in females, patients >65yo, and those with a GCS equal to or greater than 9
conclusion
first clinical trial to demonstrate functional benefit of a minimally-invasive surgical intervention to compared to medical management in patients with spontaneous lobar ICH
The leadership journey WITH visiting professor Dr. david wright
The environment makes the phenotype
leaders aren’t just born
rather your surroundings and experience help mold you as a person and therefore as a leader
Leadership can not be taught, rather has to be learned
you need to internalize those experiences and adapt them as your own
Luck should not be a strategy
when an opportunity presents itself, you need to be prepared to take advantage of it
opportunity does not come without risk, yet you still need to be open to the opportunity
Keys to being a great leader
show up
step up when you’re needed
work hard
finish the job
Four core qualities of great leaders
Self-awareness & Emotional Intelligence
need to be aware of your strengths, but also your weakness & always be honest with yourself about those qualities
it can be beneficial to have a confidant/partner who helps hold you accountable
People Skills
leadership is about being able to motivate others to get the job done
usually starts with simply listening to people and internalize what they are saying
this allows those around you to be valued
Vision
recognize when the status quo is simply not acceptable
visualize the end-goal for the future when you are dissatisfied with the current situation
the ability to visualize “where we need to go next” is the difference between a manager and a leader
Execution
overall goal is to create a vision and then have others in your team work towards achieving that vision
to do this, you need a clear strategy to implement your vision that you can communicate with others
set clear goals/metrics
set accountability for others, but also yourself
remain inspirational to those around you
EMS Grand rounds: EMS Handoff WITH Dr. Cheetham
In a study performed in 2016, the average academic medical center was found to have 4,000 handoffs per day
relating to 30% of malpractice claims and 1,744 deaths
therefore handoff is important for patient safety
Joint commission has specific handoff process requirements
interactive communication
limited interruptions
a process for verification
an opportunity to review any relevant historical data
Tips for high-quality handoffs
state what is important
use a standardized protocol/checklist/tool (such as I-PASS)
ideally the communication is verbal, face-to-face communication (avoid written and/or electronic communication as only source of a handoff)
combine different sources of information into a single verbal discussion
avoid interruptions during handoffs
include all team members involved in patient’s care
use electronic medical records to augment the handoff
What is unique about EMS handoff?
environment tends to be chaotic
patients tend to have higher acuity
stress (especially when dealing with sick and/or pediatric patients)
participants vary in their level of training
significant variability (especially in experience/comfort-level)
There is no single validated handoff tool, yet key components should include
chief compliant
prehospital interventions
physical exam
vital signs
Components of an adequate EMS handoff
succinct, structured
relevant information transmitted
appropriate personnel in the room
limiting interruptions
receiving person is attentive, listening active, and using closed-loop communication
involves mutual respect and a positive relationship between providers and EMS personnel
Future ways to improve EMS handoff
standardized tool for EMS agencies to use
EMS education initiatives directed at handoffs
EMS EMR changes
r4 Capstone: Golden rules at the golden arches WITH Dr. Martella
Appreciate and recognize every ED employee’s value and contribution. Sometimes even the smallest contributions can make the biggest difference in patient experience and overall ED quality.
People are complicated. Just because you may get yelled at, or feel down from something a patient said to you, it’s often a reflection of their vulnerability and their acute stress rather than anything you did. Learning how to not take that personally is essential for your mental health.
Your actions affect others. Be a team player, trust each other. This is vital to patient care.
People work outside the standard 9-5 job. Recognize that working non-standard hours is hard. Flipping from days to nights, working weekends. But you’re part of a group much larger than you think. Embrace those off times and make the best of it.
Time is invaluable. Respect everyone’s time in the ED. Your co-workers, the patients, etc.
It could always be better. Implementing a growth mindset is paramount to a successful career.
Patience; see the big picture. It takes time to get to where you want to go.
A thankless job. Some days in the ED are hard, and you may feel like you have a thankless job. Try to find meaning even on the bad days, practice mindfulness, self-care.
r1 clinical knowledge: SCAPE WITH dr. lewis
Sympathetic Crashing Acute Pulmonary Edema (SCAPE) is a severe presentation of acute decompensated heart failure resulting in life-threatening "flash" pulmonary edema
Usually is a result of systemic catecholamine release, vasodilation, and increased pulmonary capillary permeability and hydrostatic pressure.
Patients will typically present in acute respiratory distress.
They tend to be hypertensive, tachycardic, tachypneic, and hypoxic.
Do not always appear volume overloaded on exam.
Providers should use ultrasound as early as possible to evaluate for cardiac dysfunction, pulmonary edema, and fluid status.
Early recognition and prompt treatment is key.
non-invasive positive pressure ventilation and IV nitroglycerin infusion have been shown to reduce morbidity (intubation rates, ICU admission) & mortality.
consider IV diuretic administration as well if signs of systemic overload
pediatric lecture: the limping child WITH dr. alexander from CCHMC
Gait could be affected by
pain
weakness
structural abnormalities
Main categories to consider when encountering a pediatric patient with a limp/abnormal gait
trauma
mechanical
infection
other
Trauma
Toddler’s Fracture
non-displaced spiral fracture of the distal 1/3 of the tibia
typically involves a trivial mechanism
x-ray could be normal in almost half of cases
ED management includes leg splint with ortho eval in 5-7 days
if convincing history, yet negative x-ray, typically still apply splint with plans for ortho follow-up to repeat imaging
Osgood-Schlatter
typically seen in 9-14 year-old athletes
chronic avulsion apophysitis of the tibial tuberosity (bilateral or unilateral)
no need for imaging
supportive care, with activity limitation and NSAIDs, is the mainstay of treatment in the ED
Sever’s Disease
typically seen in 8-12 year-old athletes presenting with heel pain
apophysitis of the calcaneus (commonly found to be bilateral)
supportive care, with activity limitation and NSAIDs, is the mainstay of treatment in the ED
Non-accidental trauma
red flags include inconsistent history
injury pattern does not fit with reported mechanism
injuries are not consistent with child’s developmental stage
injuries attributed to sibling
other red flags include delay in seeking care
Mechanical
Slipped Capital Femoral Epiphysis (SCFE)
typically seen in adolescents (9-14 years-old) with underlying obesity
present with hip/knee pain
x-ray shows “ice-cream falling off a cone”
this is the femoral head “slipping” off of the femur
strict NWBS status and typically require admission for orthopedic surgical intervention
Legg-Calve-Perthes (LCP)
typically seen in a younger age range (4-9 years-old) with normal body habitus
present with deep hip pain
x-ray imaging is typically normal
can be discharged from the ED with activity limitation, pain control, and plans for outpatient ortho follow-up (may need bracing, surgery, etc. in the future)
Infection
Transient Synovitis (aka Toxic Synovitis)
present with pain/limitation of joint mobility in a otherwise well-appearing child
typically 3-8 years-old
thought to be caused by preceding viral/bacterial illness and/or trauma
bilateral in 5% of cases
exam is usually reassuring
may have some limited ROM, subtle limp, non-specific pain
symptoms usually last less than a week
yet can recur in about 20% of patients
managed with supportive care
NSAIDs, RICE
Septic Arthritis
present with fever, joint pain, swelling over joint
typically involves hip, knee, or ankle (yet may affected multiple joints in about 10% of cases)
risk factors for infants/children
immunodeficiency, diabetes
arthritis
prior joint surgery
hemoglobinopathy
use Kocher Criteria to help distinguish septic joint from transient synovitis
Other
Growing Pains
ill-defined aches and pains
usually worse at night
management includes RICE and NSAIDs
