Grand Rounds Recap 04.07.21
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SUBSPECIALTY LECTURE WITH OBGYN: “DO NOTHING, DO SOMETHING, ASPIRATE: MANAGEMENT OF EARLY PREGNANCY LOSS” WITH GUEST LECTURERS DR. BENSON & DR. QUINLEY
Interchangeable terms:
Early pregnancy loss or failure / Spontaneous abortion / Miscarriage
Manual uterine aspiration / Manual vacuum aspiration / Uterine evacuation / Suction D&C
Early pregnancy loss (EPL) is a nonviable, intrauterine pregnancy <13weeks
Most common complication of pregnancy
Occurs in ~15-20% early pregnancies
2.7% of ED visits (>900,000 annual ED visits) for US women from 2006-2016 were related to concerns for early pregnancy loss
Risk factors for EPL
Age
Prior EPL
High gravidity
Maternal BMI <18.5 or >25
Endocrine disorders (thyroid disease, diabetes)
Maternal infection
Smoking, alcohol, cocaine
NSAIDs
Caffeine (>200mg/day)
Low folate levels
Environmental pollutants
Structural inequalities/race-associated inequalities
Etiologies:
Chromosomal abnormalities (50%)
Clinical presentation:
Bleeding
pain/cramping
Falling or abnormal hCG
Diagnosed on US
Ultrasound in early pregnancy
4 weeks - possible endometrial thickening
5 weeks gestational sac
6 weeks yolk sac
6.5 weeks fetal pole appears, possible FHT
Management options:
Expectant management
Patient selection
<13 weeks gestation
Stable vital signs
No evidence of infection
What to expect:
most expel within 2 weeks after diagnosis
prolonged follow-up may be needed
acceptable and safe to wait 4+ weeks post-diagnosis
Miscarriage is often painful - give analgesics!
NSAIDs +/- narcotics if needed
Add heating pad/hot water bottle
~80% effective
Can still have vaginal bleeding/+hCG up to 2-4 weeks after successful management
Medication management
Patient selection
<13 weeks gestation
Stable vital signs
No evidence of infection
No allergies to medications used
Adequate counseling and patient acceptance of side effects
Misoprostol
Prostaglandin E1 analogue
FDA approved for prevention of gastric ulcers
Used off-label for: labor induction, cervical ripening, medical abortion, prevention of postpartum hemorrhage
Can be administered by oral, buccal, sublingual, vaginal and rectal routes
Cost effective, stable at room temp
+ Mifepristone
Mifepristone: Progestin antagonist that binds to progestin receptor. Used with medical abortion to “destabilize” implantation site
RCT comparing mifepristone in addition to misoprostol
Efficacy 93-98% within 63 days
Improves outcomes, use mifepristone if you can
200mg PO and can redose for a second time if needed
No medical regimen for management of EPL is FDA approved
Uterine aspiration
Patient selection
Unstable
Significant medical morbidity
Infection
Very heavy bleeding
Anyone who wants a uterine aspiration
Benefits
Convenient timing
Observed therapy
High success rates (almost 100%)
Risks
Infection (1/200)
Perforation (1/2000)
Cervical trauma
Uterine synechiae (very rare)
Procedures
Electric vacuum aspiration
Manual uterine aspiration
Locking valve, portable and reusable, equivalent to electric pump
Efficacy same as electric vacuum (98-99%)
Advantages of MUA treatment in ED: simple, safe, fast, efficacious, $$ sparing, common, hospital admits, OR resources, improves ED flow
Oral pain medications
NSAIDs, benzodiazepines
Narcotics are not routinely recommended, doesn’t improve pain control, and increases vomiting
Paracervical block
Ancillary anesthesia: importance of psychological and social support
Best practices in miscarriage counseling
ACEP’s clinical policy on first trimester pregnancy focuses solely on ectopic pregnancy
EDs are a challenging location for miscarriage
Patients perceive that EM providers are not attuned to the magnitude of their loss
Good counseling can facilitate EPL care
EM providers are versed at delivery of bad and unanticipated news
Put aside preconceived notions
Remain silent
Ask open-ended questions, “what are your thoughts about your pregnancy?”
“Pregnancy” vs “baby”?
Use definitive language, “your pregnancy does not have a heartbeat,” “you’ve had a miscarriage”
Reiterate this is not the patient’s fault
Normalize miscarriage itself ~25% of women, 20% of pregnancies
Encourage the patient to seek emotional support from others
DON’T guarantee that “everything will be alright.” DO reassure “you’re going to get through this”
Leave management options open to OBGYN input
THINGS YOU DON’T KNOW YOU DON’T KNOW WHEN YOU GRADUATE WITH DR. ROBBIE PAULSEN
Case 1: Elderly female with dementia who is chronically ill presenting with sepsis/septic shock and hypoxia
Delivering bad news
PRE-SPIKES mnemonic
Preparation - planning the beginning and the end
Setting - get rid of your phones, sit down
Perception - ask what they know
Immediate concerns - acknowledge emotion/concern
Knowledge - delivery the news directly, use data if you can
Empathy - pause first, then address emotion
Second touch - summarize next steps, set up next contact
Geriatric sepsis
Overall in-hospital mortality for sepsis and septic shock is 48.8%
65-79 years: 47.4%
>79 years: 54.2%
Geriatric COVID rates of hospitalization and death are hundreds to thousands of times more than the “baseline”
Goals of care at end-of-life
Establish goals early
Be direct about options and prognosis
Trust your team at the bedside
Know your resources
Case 2: Elderly female with a history of COPD presenting with SOB x3days
Billing for critical care time
“Impairs one or more organ systems”
“High probability of imminent or life-threatening deterioration”
“Frequent personal assessment and manipulation”
Many more conditions quality for critical care billing than routinely recognized
NIPPV, heparin and insulin infusions, etc.
National rate of billing for critical care is 8.1% of what actually qualifies
Active bedside management
Ventilator management
Chart review
Conversations: EMS, SNF, patient/family, admitting
Chart completion
*Need at least 30mins of dedicated time to bill for critical care with gradation of billing criteria based on total time spent (>75min is billed for more)
Can only bill once every 24 hours for critical care time
Case 3: Elderly male who presents with abdominal pain, found to have urinary retention and gross hematuria
Foley catheters insertion tips:
Use lubricating anesthetic (lidojet) for 3-5 min before - will need to sit for a bit for effect, consider using penis clamp to assist if available
Elongate penis at 60deg angle
Have patient take slow, deep breaths - not only helps calm the patient, but can help relax the urethra for easier insertion
Insert to Y-hub to ensure catheter is past urethra
If there is pain early - STOP
False passage likely, consider US
If first attempt is not successful:
Switch to 18-french coude tip at 12 o’clock
Use 18-french coude tip at 9 o’clock, 3 o’clock
Switch to 12-french silicone catheter
3-way irrigation
When do you insert a 3-way catheter?
You have already confirmed correct placement of foley
Gross hematuria with clots AND retention
Manual irrigation breaks up previous clots
Continuous irrigation prevents new clot formation
Manually irrigate first - 3 syringes in, 3 syringes out
Irrigate until urine is transparent and there are no clots
Order 3L NaCL for irrigation
If UOP <130cc/hr, then manually irrigate
Stop if the patient has pain! Risk of bladder rupture
Case 4: Young child with nasal foreign body
Removal techniques
Angel’s Kiss/Parent’s kiss
Position is flexible.
Occlude opposite nostril with finger, get good mouth seal around mouth, and have the parent give a forceful puff of air
Success rate 80%
Suction
Positioning: sitting upright, leaning slightly forward, head down
Attach suction tubing to wall air/O2
Place tubing with suction adapter in the contralateral/unaffected nostril
Titrate wall o2 flow to 10-15L/min
Dermabond at the end of a Q-tip - can only use this method if foreign body is visible
KATz extractor if available - only useful if object is non-obstructive...need to pass extractor past object, inflate balloon, and then be able to remove it
Pediatric sedation - consider PO, atomized IN options in addition to IV/IM if needed
TAMING THE SRU WITH DR. COLLEEN LAURENCE
Elderly female with history of multiple myeloma on immunomodulators and steroids who presents with abnormal labs of Cr 7.8, K 6.8 and tachycardia in the 200s
Tumor Lysis Syndrome (TLS)
Malignant cell lysis leads to release of intracellular contents → increased uric acid, potassium, and phosphorus → calcium phosphate forms and deposits in the kidney tubules causing acute kidney injury
Most common oncologic emergency
High mortality ~14-21% in hospital, 21-66% 6-month
Most common in patients with rapidly proliferating, high solid tumor burden
TLS in the setting of novel and targeted agents in patients with hematologic malignancies is not well understood, and it is thought their improved antitumor activity may increase risk.
Data demonstrates incidence of 0.4-4.3% with rates as high as 50% in particular agents
Diagnostic criteria:
Labs: K>6, phos >4.6, calcium <7.0, uric acid >8.0
Laboratory criteria: malignancy + at least 2 of the above lab abnormalities
OR
Laboratory syndrome + at least one of these clinical findings:
AKI
Cardiac arrhythmia
Seizure
Patients require treatment of hyperphosphatemia prior to hypocalcemia to prevent further exacerbation of calcium phosphate crystal formation - likely require HD in consultation with nephrology specialists
Medical errors:
6-8.5% of cases have a medical error with the majority of them being preventable
A qualitative study demonstrated that EM residents often times have negative emotions associated with 68% feeling remorse, 63% with emotional distress, 58% with inadequacy, 55% with frustration, and 53% with guilt
Some positive changes were a result of the medical error with some increasing information seeking behaviors, increased attention to details, reach out to colleagues/mentors
For us and providers and learners
Look at it from the perspective of those we serve
Consider disclosure and apology as professional obligations
Talk about it
Seek to learn from the mistake and make constructive changes
Normalize and contextualize emotions and errors
Encourage sensitive, timely, and complete disclosure
Promote metacognition and root cause analysis
Link emotional support to quality improvement programs
R4 CASE FOLLOW UP WITH DR. EILEEN HALL
Elderly female who was in her normal state of health at noon during lunchtime. She was found to have a right facial droop two hours later. Her baseline is neurologically intact and she is able to converse and ambulate without difficulty.
Guardianship
Court appointed
Must obey orders and judgements of probate court
Guardian report
Best interest of the patient
Safety of thrombolytics in stroke mimics
IV tPA given in stroke mimics leads to 0.4% with symptomatic ICH
Is it a stroke?
Yes
Abnormal eye movements
Diagnostic blood pressure >90
History of atrial fibrillation
Symptoms with exact onset
Less likely
Decreased level of consciousness
Cognitive dysfunction
Normal eye movements
Without risk factors
Right atrial thrombi
Embolic, low-flow states
Clinical presentation: pulmonary emboli, paradoxical emboli with PFO
Left atrial thrombi
Thrombus v myxoma, low-flow states, mitral valve disease
Clinical presentation: infarction or ischemia, pre-syncope/syncope, sudden death
Mobile atrial thrombi
Management: anticoagulation, fibrinolysis, thrombectomy
QUARTERLY SIMULATION WITH DRS. GLEIMER, LANG, LAFOlLETTE, AND ADAN
New temporary oral boards format: 6/7 are 1-on-1 single patient encounters. There will also be a structured interview format for some of the single patient encounters where the examiner asks open-ended questions to probe for thought-processes.
Oral Boards Case:
The standard oral boards format is lo-fi simulation and very different than how we think in real clinical practice
Stick to a script, especially at the beginning with ABC, IV, O2, monitor, glucose, pregnancy
Remember that if your are considering a test and/or procedure, it’s probably easiest to just do it
Consider combining steps in the process so you feel less rushed, such as updating the patient/family while simultaneously verbalizing your differential.
Simulation Case:
Myxedema Coma
Hypothyroidism causing organ failure
Most patients are >60yo, female, often present in winter
1:1000 patients with hypothyroidism go on to develop myxedema coma
Usually after a precipitating factor
60% mortality if treated, 100% if untreated
50% discovered after admission, but may be a first-time presentation
Clinical presentation: shock, hypothermia, bradycardia, hypotension, hypoventilation, hypercapnia, hypoxia, pericardial and pleural effusions, altered mental status due to CO2 narcosis, hypoglycemia
coma is rare; hypoactive delirium is most common, hyperactive delirium is possible but rare
Physical exam findings:
Look for goiter, thyroidectomy scars
Non-pitting edema of face, hands, ankles
Macroglossia, hoarseness
Hair loss on scalp and lateral eyebrows
Precipitants: trauma, burn, surgery, cold exposure, speiss, MI/CHF, PE, DKA, CVA, GI bleed, medications, medication non-compliance
Amiodarone
Beta-blockers
Antipsychotics
Sedatives
Differential diagnosis: Sepsis, meningitis, adrenal crisis, stroke, toxidrome
Diagnosis:
Signs of organ failure
FT4 is low
TSH is high but can be low if central hypothyroidism
Cortisol may be low
Supportive care:
Intubation : airway protection, hypoxia, hypercapnea. Macroglossia may complicate intubation
Fluid resuscitation: CHF can be present so administer measured fluids. Consider D5. They may not respond to fluids in the absence of thyroid hormone, and correct hyponatremia carefully.
Rewarming: passive only as it can precipitate peripheral vasodilation and worsen hypotension
Stress dose steroids
T4 200-400mcg, consider T3 in consultation with endocrinology
Pressors: may not work without thyroid replacement
Treat precipitating factor, this may masquerade as sequelae
Summary
Rare but devastating illness
Classically occurs in an elderly female who is altered, cold, and bradycardic
Maintain high degree of suspicion in all sick patients
Consider if a thyroid patient is sick from another cause
Treat precipitating factors, this may masquerade as a sequela
T4, hydrocortisone, +/- T3, empiric antibiotics, and supportive care
Fiberoptic Intubation
Glycopyrrolate - administer 0.2mg IV - takes 20min to work, give it as early as possible
Blow nose, suction as tolerated
Afrin 2 sprays in each nostril for vasoconstriction
Atomized 4% lidocaine helps numb the oro/naso/hypopharynx to prevent gagging, coughing, emesis. Wears off rapidly, works poorly in secretions, re-apply closer to intubation
7.0 NP airway lubricated with 2% viscous lidocaine
Consider retromolar space if nose not available
Subtotally intubate with 6.5 ETT to 12-15cm
Start at 0.5 mg/kg ketamine, can always give more
Have paralytic and cricothyrotomy kit ready
