Grand Rounds Recap 5.5.21
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Journal Club WITH Drs. Berger, Roblee, Thode
Paper 1 - Diagnostic test accuracy of the initial electrocardiogram after resuscitation from cardiac arrest to indicate invasive coronary angiographic findings and attempted revascularization a systematic review and meta-analysis by McFadden et al
In this systematic review and meta-analysis of the diagnostic test accuracy of the post-ROSC EKG to predict acute coronary lesion or revascularization on coronary angiography in adults after cardiac arrest, ST elevation was found to more specific than sensitive test characteristics and all groups and subgroups. The authors found a sensitivity of ST elevation on the post-ROSC EKG for discovery of an acute coronary lesion during coronary angiography of 0.70, with a specificity of 0.85. When evaluating the test characteristics of ST elevation on the post-ROSC EKG for revascularization during coronary angiography, they found a sensitivity of 0.53 to and a specificity of 0.86. Confidence intervals for these test characteristics were reasonable.
While the study is limited by heterogeneity in reporting on previous cohorts and a relatively small number of studies without significant bias in selection for CAD, the study’s methodology is complex but well described and follows established guidelines for this type of paper.
The findings of relatively high, but still imperfect, specificity and a lower sensitivity in all groups and sub-groups should caution clinicians in Emergency Department and ICU settings against reliance on the post-ROSC EKG as a stand-alone test to determine need or potential benefit from coronary angiography. Ideal selection and timing of patients for coronary angiography following cardiac arrest remains an area of controversy and active research.
Paper 2 - Comparison of the ST elevation myocardial infarction (STEMI) vs. NSTEMI and occlusion MI (OMI) vs. NOMI paradigms of acute MI by Meyers et al
This paper is one of several written by the group proposing a paradigm shift from STEMI vs. NSTEMI to OMI vs. NOMI in order to capture the group of patients that have occlusive disease but no STEMI. The goal of this study was to look at the differences between STEMI (+) OMI and STEMI (-) OMI with the hypothesis that despite similar characteristics, time to catheterization is different.
This was a retrospective review of prospectively collected data in the DOMI ARIGATO trial. Data was collected in a suburban academic hospital and included patients that had presumed ACS (both admitted to the cardiology service with plan for cath and also patients that had interventional cardiology engaged in the ED). Primary outcomes were troponin peak and time from presentation to catheterization.
They found that peak troponin levels for STEMI (+) OMI and STEMI (-) OMI vs. the group with no occlusion was statistically significant meaning that all patients with occlusion had elevated troponin levels. Time to catheterization for STEMI (+) OMI vs. STEMI (-) OMI was also significantly different with times being 41 min for the STEMI group and 437 min for the non-STEMI group.
Takeaways: Patients that presents to the ED with symptoms concerning for ACS may benefit from early cath despite not having a STEMI on EKG. We may even benefit from switching our teaching and thinking paradigm to OMI vs. NOMI instead of looking for that STEMI on EKG to get the patient to the cath lab
Paper 3 - Using ECG-to-activation time to assess emergency physicians’ diagnostic time for acute coronary occlusion by McLaren et al
This paper proposed a new quality metric: ECG-to-activation time (ETA time), which the reflects physician's role in shortening the door-to-activation and door-to-balloon time.
It was a retrospective chart review at two academic medical centers in Toronto. ETA time was measured in all cath lab activations from the ED over a 3 year period (244 cath lab activations).
The researchers found that for patients with STEMI, ETA time was 8 minutes, STEMI equivalent ETA time was 32 minutes, ECGs with signs of subtle occlusion had ETA time of 89 minutes, and ECGs with no diagnostic signs of occlusion had ETA time of 68 minutes. They also found that for ECGs with an automated interpretation of "STEMI", ETA time was 6.5 minutes and for ECGs with no STEMI automated interpretation, ETA time was 66 minutes.
There were several limitations - selection bias (did not include canceled cath lab activation), survivorship bias (pts who died in the ED were not included), and misclassification bias (patients who were admitted from the ED to the floor and went to the cath lab from the floor were not included).
Takeaways: ETA may be a valuable quality metric for physicians, EM physicians aren't great at identifying STEMI equivalents as quickly as STEMIs (although this may be confounded by the presence or absence of automated interpretation).
EMS Grand Rounds - Prone Air Transport WITH Dr. Sams
Prone Transport:
Protocol developed for covid and ARDS patients who are already proned in ICUs and require transport
Prone Physiology:
Has been used since 70s as a rescue therapy for patients with ARDS
Has been more relevant in past year due to Covid-19 pandemic
Proning can improve gas exchange via:
V/Q matching
Compression
Recruiting
Clearance
Multiple RCTs have assessed proning:
Many studies found improved oxygenation without significant mortality benefit
PROSEVA 2013 trial found mortality benefit
Limitations: patient groups not matched, supine patients had higher sofa scores and more pressors, more patients in prone group received neuromuscular blockade, the site had many years of proning experience, PEEP was not optimized prior to proning
Protocol Development Process:
Considerations: weight and space, personnel, safety
What could go wrong?
Complications: ETT obstruction, ETT dislodgement, nerve compression, vomiting, pressure sores, venous stasis, crush injury, arrhythmias
Cardiac arrest
Needs to be deproned eventually
Prone CPR
Reasonable alternative to supine CPR if supine CPR is not available immediately
All the case reports led to ROSC (acknowledge publication bias, patients who already had airway and monitors)
Heart pump vs chest pump theory
Compression on heart to cause flow vs. increasing intrathoracic pressure to cause flow
Studies available to suggest prone cpr may create better flow than supine cpr
Checklist, standard operating procedure, competency
Swimmer positioning (with face to the right, and right arm positioned up), airway and line protection, ease of deproning, utilize your sheets
Neuroimaging Part II WITH Dr. Knight
Case 1:
20’s year old F in MVC one month ago. Airbag hit face and she had brief LOC. She did not seek care after accident and has been doing generally well. Presented to urgent care with acute headache and vomiting. GCS was 15 but became unresponsive in the ED while getting a CT head. Pupils now unequal and nonreactive. She was intubated. CT showed possible hypodensities in the cerebellum
Immediate management
HOB >30 degrees, hyperventilate, sedation, analgesia, hyperosmolar therapy, disposition to neuro ICU
Patient gets neurosurgical intervention (suboccipital craniectomy), repeat CT with pneumocephalus, infarcts in posterior fossa more apparent, brainstem is crowded
Next diagnostic step?
Why does a young female have bilateral cerebellar infarcts?
Dissection (can be hard to get history, in the past month did you have any falls? Fights? Mvcs? Significant coughing?)
Vessel imaging shows right vertebral dissection
Cerebellar infarct
True neurosurgical emergency that needs a sub-occipital decompression who needs hyperosmolar therapy. Can herniate very quickly
Case 2:
60’s year old M flown in by HEMS after in a dump truck accident. Prolonged LOC. GCS 13 for HEMS. Has some head pain. Contusions on head. Raccoon eyes. No hemotympanum. Moves all extremities equally.
Head CT shows skull fracture, pneumocephalus, SAH, ICH, lateral ventricle compression
Utilize Hounsfeld units
Patient admitted to NSICU. Follow up head CT shows evolution of his contusions, contrecoup injury
Case 3:
40s yo F presents by EMS. She was driving and having conversation with family, then veered off road and hit a tree. Cannot speak or provide more history. Family states she is otherwise healthy. Left gaze preference, right sided paralysis and neglect, mute expressive aphasia.
Medical etiology leading to trauma
Trauma activation. Pan scanned. CT head is normal
What next?
Estimated NIHSS? ‘High’
ED suspected stroke. Treated with TPA
0.9mg/kg (not to exceed 90mg) of total body weight. 10% over 1 minute as bolus, 90% over 60 minutes as drip
Admitted to NSICU. Repeat CT shows hypodensity in left hemisphere in the left MCA distribution. Early compression of left ventricle and asymmetric edema. Left sulcal effacement
Patient gets hemicraniectomy and a drain with some hemorrhagic transformation and edema
Studies show decompressive surgery increases the probability of survival without increasing the number of severely disabled survivors
MRI for stroke
Diffusion weighted image (DWI) (white on mri)
Apparent diffusion coefficient (ADC) (black on mri)
Look for a match between the two
Case 4:
20s year old F who was in a T-bone mechanism MVC. 15 minute extraction. GCS 3. Blood pressure 80/40. Intubated on scene. 2 mm nonreactive pupils. Extends upper extremities on exam.
CT shows crowded sulci, loss of gray-white, tSAH, temporal bone fracture
Avoid hypotension and hypoxia
NSGY takes patient to OR for bifrontal craniectomy , goes to NSICU for medical therapy
Repeat CT shows intraparenchymal monitor, midline shift, cerebral herniation
Patient goes into vtach during apnea test for brain death
Coma, absence of brainstem functions, apnea
Potential Ancillary tests
EEG, cerebral angiography, nuclear scan, TCD, CTA, MRI/MRA
Patient had nuclear scan and was declared brain dead
R4 Simulation and Human Trafficking WITH Drs. Gleimer, Hughes, Shaw and Guest Lecturer Dr. Jamie Hope
Case:
40 year old female was found wandering around the library. Bystanders report they witnessed a possible seizure. EMS was called and she presents to the hospital. She appeared confused and EMS was concerned about suicidal ideation because the patient mentioned “I want to die”. Vital signs were stable en route. Glucose normal for EMS.
On presentation, “Frank the cousin” appears to bedside to provide some additional history. He states that the patient is generally healthy and the patient was normal this morning. He states the patient is ‘fine’ and wants to leave with the patient now.
Vitals: P 121, BP 120/80, O2 95% on RA, RR 12
On exam, the patient is tearful and asks where ‘Frank the cousin’ is. Has some bruising on thorax and abdomen. Tender with bruises on right leg.
Chart review shows a few visits to the ED recently for minor injuries and STDs. She also recently went to a local urgent care and was started on bupropion for smoking cessation.
Labs showed mild leukocytosis, metabolic acidosis with a lactate of 4, and negative ingestion labs. EKG showed tachycardia and prolonged QTc. CXR clear.
IV was established and LR bolus given. Patient seized and was treated with ativan with resolution. Placed on NRB and appeared postical. She seizes again shortly afterwards with no return to baseline and was treated with additional ativan. She was loaded with Keppra and due to hypoxia despite NRB, the decision was made to intubate the patient with RSI succinylcholine and ketamine.
While prepping for intubation, she began to become hypotensive. Additional IV fluids were given with mild improvement of blood pressure. Patient was intubated and then hypotensive afterwards. A bedside echo showed poor LV function. Norepinephrine was started, followed by dobutamine for cardiogenic shock. Head CT was normal. Toxicology was consulted and recommended transfer to an ECMO center. If patient decompensates, Intralipid can be considered as well. Given the patient likely overdosed on XL formulation of bupropion, whole bowel irrigation was recommended too.
Wellbutrin toxicity:
No clear toxidrome
Lowers seizure threshold
Associated with cardiogenic shock
Suspect OD with tachycardia and neurologic symptoms (range from confusion/delirium, tremors, all the way to seizures)
Bupropion increased QTc is not from sodium channel blockade. Bicarb not as helpful
Disposition: observe 8 hr for short acting, 24 hr for XL.
Decontamination: charcoal if within 1 hr of suspected ingestion time, WBI if they aren’t seizing yet. Bupropion is lipophillic, can consider intralipid. Usually a last resort drug.
For seizures: avoid phenytoin given the sodium channel blockade
Human Trafficking with Dr. Jamie Hope
We have likely all seen patients who are victims of human trafficking, whether we realized it or not
Human trafficking is the fastest growing crime
Tied for second with arms dealing
$150 billion / year
Human traffickers can sell their ‘goods’ over and over again
There are large scale pimps, and also small scale (parents, step parents, significant others, etc)
Victims are not necessary physically chained
Victims cannot leave for various reasons (threats to family, threat of murder, etc).
Occurs in every zip code, including affluent areas
Apps exist to ‘order’ victims
80% victims report they were seen in a medical setting while being trafficked, but no one recognized it
Average age for a boy being sex trafficked is 11-13, for girls is 12-14
If a girl is trafficked at 14, by the time she is 16 she has been sold 4000 times
Nearly 50% victims being sex trafficked are male
Victim recognition
Signs and symptoms
Strangulation (hoarse voice, bruising behind ears/neck, tongue discoloration, petechial hemorrhages, subconjunctival hemorrhage, drooling, sore throat, headache, dizzy, tinnitus)
Torso/abd bruising
Injury to breasts, genitalia
Patterned injuries
Injuries in multiple stages of healing
abd/pelvic pain
Sexual dysfunction
Depression and anxiety
Substance abuse
At risk victims
Runaways
Coming from abusive home
Non-english speaking
Immigrants
Mental illness
Substance abuse
‘Regular kids’ get seduced and groomed
“Romeo pimps” will find kids on apps (facebook, whatsapp, snapchat, instagram, tinder, grindr, meetme, kik, etc)
Additional signs
Constantly supervised
Constantly on phone (forced to check in)
Appears younger than stated age
Does not know where they are
Can’t answer typical questions (where did/do you go to school)
Branding tattoos
scripted/memorized history and then difficulty providing additional info
Fearful, lack of control, overly submissive
Defiant and untrusting
Not allowed to speak for themselves
Behavior in medical setting
Defiant and mistrusting
Demanding
Lacking social skills
Overly submissive
Poor eye contact, won’t answer questions
Asking for food, pain medications
Labor trafficking signs/symptoms
Working excessively long or unusual hours
Excessive callouses
Unexplained injuries
Injuries that would be preventable with PPE
Not in control of money/not being paid
Untreated injuries
bruises/injuries in stages of healing
hungry/dehydrated
Concern for jail/deportation
Untreated medical conditions
Sex trafficking signs
Clothing inappropriate for weather
Overly child like or over sexual
May have hair/nails done and look well taken care of
Recurrent STI
Multiple abortions
pelvic/abd pain
Bruises/injuries in stages
oral/rectal/genital trauma
Signs of strangulation
hungry/dehydrated
Untreated med conditions
Action plan
Teach staff how to recognize victims
Questions
SAFE (safety, afraid, fam/friends, emergency plan)
Do you feel safe in your relationship/home
Do you ever feel threatened, hurt or afraid
If you were hurt would your friends/family know
Do you have a safe place
Things not to ask
Why don’t you just leave
What did you do to cause this
Victim blaming will discourage accessing care in future
Things to ask
Are you “in the life”
Do you have access to your money and ID
Have you been told you have to ‘pay a debt’
Do you have restricted access to food/water/shelter/meds/social support
Have you been coerced or forced to work or do sexual acts
Teach staff how to ask questions and how to ask
Not computer check off lists
Sit, make eye contact, be empathetic
Avoid victim blaming
If victim wants help:
Contact appropriate authorities
Fbi for human trafficking
Local law enforcement training varies
Connect to resources (have robust list)
Keep them safe until they can access resources
Human trafficking hotline
Call 1888-373-7888
Text BeFree 233733
Live chat humantraffickinghotline.org
Know your local and national resources
Mandatory reporting laws (state and federal)
Local shelters and safehouses
Hotlines and websites
Legal help/ombudsman
Some victims don’t want to leave
Leaving is the highest risk time
Do not judge
You don't know what threats they might be under
Offer resources
Invite them to return any time when they need care and if they want help
Plant the seed of hope
Addressing staff safety concerns
Human trafficking potential for violence is low
The pimp does not want to be caught
‘All the traffickers want is us to do nothing’
