Grand Rounds Recap 05.26.2021
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Morbidity and Mortality WITH Dr. Koehler
Case 1: Flexor tenosynovitis
Kanavel’s Signs
Sausage digit
Pain to palpation along flexor tendon sheath
Held in passive flexion
Pain with passive extension
Case series showed 91-97% sensitivity and 51-69% specificity
Pain with passive extension and pain along tendon sheath have high sensitivity
Ultrasound can be used to assess for FTS
94% sensitivity
74% specificity
97% negative predictive value
Risk factors for a poor outcome include:
Age > 43
Diabetes
Peripheral vascular disease
Renal disease
Case 2: Agonal Respirations in Cardiac Arrest
Gasping/agonal respirations is a brainstem reflex
Technically the patient not brain dead if they are having agonal respirations
This be very distressing to providers and family
Gasping respirations occur in 40% OHCA
OR 3.9 of 1 year survival in patients gasping during CPR
OR 57 to survival if patients have gasping respirations and a shockable rhythm
Case 3: Hyponatremia
Serum osmolality and volume status are important considerations
Urine electrolytes can be helpful in hypovolemic patients, especially prior to fluid resuscitation
Severe hyponatremia is Na <120
Difference in US and European guidelines
European guidelines recommend hypertonic with:
Vomiting, confusion, headache
US guidelines recommend hypertonic with:
Self induced hyponatremia, post-op, intracranial pathology
Both guidelines recommend hypertonic with:
Seizures and coma
Chronicity is important
Acute hyponatremia occurs in under than 48 hours
Should be corrected quickly due to increased risk of herniation
Correct sodium by 4-6 meq/L
Hypertonic
100ml q10 min
1-2 ml/kg/hr infusion
Chronic hyponatremia occurs over 48 hours
Risk of osmotic demyelination syndrome in patients with:
Na < 105
Hypokalemia
Alcohol use disorder, malnutrition, liver disease
Correct by 4-8 meq/L per day
Max 10-12 over 24 hours
Up to 18 over 48 hours
Hypovolemic hyponatremia
Use a balanced isotonic fluid
Hypervolemic hyponatremia
Fluid restriction
Case 4: Community Acquired Pneumonia
Ohio has approximately 43% of population vaccinated for Covid-19
Moderna has a 94.1% efficacy
Pfizer has 95% efficacy
Epic can show us if patients have received their vaccination under immunizations (check rarely used section)
CAP Guidelines were updated in October 2019
“Signs and symptoms of pneumonia with radiographic confirmation”
Guidelines do not apply for patients with immunocompromised conditions
Do we obtain a sputum culture?
No - for routine outpatient treatment
Yes - if empirically treated for MRSA, pseudomonas
Do we obtain a blood culture?
No - for routine out or inpatients
Yes - for severe CAP, empiric MRSA or pseudomonas treatment
Do we obtain flu testing?
Yes- when it is flu season
Inpatient vs outpatient disposition?
PSI (pneumonia severity index) preferred over Curb-65
CAP Treatment outpatient
Healthy patient
1g of amoxicillin TID
100mg doxy BID
Macrolide if local resistance is <25%
Patient with comorbidities
Augmentin plus macrolide or doxy
Respiratory fluoroquinolone
CAP Treatment for inpatients
B-lactam plus macrolide
OR Respiratory fluoroquinolone
Risk factors for MRSA or pseudomonas
Prior isolate - cover immediately
<90 day hospitalization and exposure to abx
Wait for cultures unless severe PNA
Case 5: Volume Overload and ESRD
86% of ESRD patients on dialysis had HTN
75% of ESRD patients will develop LVH
Cardiovascular disease accounts for 40% of mortality
Emergent dialysis
Acidosis, electrolytes, intoxicants, overload volume, uremia (AEIOU)
How to temporize patients prior to dialysis?
If still producing urine, give 120mg IV lasix
Manage BP
Nitroglycerin may be the best medicine
Relaxes smooth muscles of vasculature
Venodilate, decreased preload and afterload, increases cardiac output
BiPap
Especially if there is respiratory distress
Recruits alveoli
Decreases respiratory effort
Increases intrathoracic pressure
Consider their mental status
Case 6: Antibiotics in Pancreatitis and Hypertriglyceridemia Pancreatitis
Royal College of Surgeons did a review and recommends no routine antibiotics in uncomplicated pancreatitis
Recommends antibiotics in severe increased white count or overt sepsis
AGA has similar recommendations
Hypertriglyceridemia pancreatitis
High rate of ICU, SIRS, organ failure
Treatment is different
Insulin drip, PLEX
Can cause hyponatremia
Should we get triglycerides in the ED?
No clear recommendation in literature
However, it may change disposition and results in real time
Case 7: Excellent Patient Care in the ED
An excellent resuscitation of massive upper GI bleed involving transfusions, medical management of upper GI bleed, delayed sequence intubation, Minnesota tube, and MICU admission
Patient had a good outcome
Keep it up!
ABEM Residency Visitation Program Lecture WITH Dr. Kowalenko
ABEM was the 23rd recognized medical specialty
38,544 active ABEM Diplomates
93% EM residency graduates
7% applied through the practice pathway
7.6% also hold a subspeciality certificate
Covid-19 changed oral exams, please stay tuned for updates
ABEM is introducing a new way to stay certified called MyEMCert
Presidential Assassinations: A Medical History WITH Dr. Kowalenko
Abraham Lincoln
Suffered a GSW to the head
First responder was a: 24 year old Army Surgeon named Charles Augustus Leale
Removed clot from head wound to relieve pressure
Extended 2 fingers into airway to open airway
Emergency Care included:
Head to toe inspection
Wound was probed
Recleared the clot from head wound intermittently
Lincoln was bradycardic overnight, with episodes of normal heart rate as they intermittently cleared the clot from the wound
LIkely a fatal wound even in today’s standard of care
Critique of care: probed wound with nonsterile fingers/instruments (Lister theory of antisepsis was not widely accepted until 1880s)
James Garfield
Suffered a GSW to the back on July 2nd 1881
Dr. Smith Townsend arrived in four minutes
President was vomiting, fainting, dark red blood oozing from back
Tachycardic with feeble pulse, diaphoretic
Wound “2.5 inch to right of lumbar vertebra”
Sticks his finger into the wound to assess wound
Transferred to White House at 10am but was not undressed until 530pm
Receives morphine, atropine, water, milk, limewater, and cracked ice
Vomits every half hour and complains of pain in legs and numbness to arms
At 7pm, Naval Surgeon Wales reexamines the wound with his finger
Concludes it passed through liver and rests in abdominal cavity
Over next 2 days, several physicians probe the wound
Multiple physicians are recruited including Dr. Agnew from Philadelphia
President Garfield appeared to improve throughout next 2 weeks. However, on July 23rd he:
Develops vomiting and Fever and chills
Abscess discovered 3 inches below wound
Cleaned wound with 2% carbolic acid and potassium permanganate
Dr. Agnew lances abscess and inserts drain
July 26: Agnew enlarges incision and removes 1 inch piece of bone
Still cannot find bullet
July 26 and 31: Alexander Graham Bell and Newcomb attempt to find bullet
‘Induction balance’, similar to a metal detector
4.5 inches to the right of naval
August 8: Agnew explores 12 inches of wound track into pelvis. Garfield receives ether for the first time
Starts improving, but then August 18 develops parotitis and cannot tolerate PO
Receives nutrient enemas (egg, bouillon whiskey, paregoric)
President Garfield realizes he is decompensating, requests to leave DC and wants to go to the Jersey Shore
September 13 - mucopurulent sputum, pustules on back, chest pain, hallucinations
September 19 - complained of chest pain and pronounced dead shortly afterwards
Critique of care: not exposed for hours, no documented neuro exam, repeated nonsterile introduction of fingers and instruments to wound
William McKinley
Suffered GSWs to the abdomen
Ambulance arrives shortly afterwards
Dr. George Hall arrives with two medical students
Undressed the president, one bullet falls to the floor
Dr. Hall cleansed wound with antiseptic solution
Nurse gives morphine and strychnine
Dr. Mynter, surgeon, arrives shortly afterwards
However, Dr. Mann was chosen to be the physician to operate on the president. He was an ObGyn
Buffalo General Hospital was deemed too far away, it was decided they will operate at the small Hospital with a pocket set of OR instruments
Surgeons scrubbed with soap, water, mercuric chloride solution
Shave and scrubbed McKinley’s abdomen
Given ether so they cannot use gaslights, they attempted to assemble a mirror to reflect sunlight into the field of operation
Spilled stomach contents into peritoneal cavity
Post op next morning - president was tachycardic so he receives clysis fluid of extract and digitalis, he receives nutrient enemas
Next day he has no issues defecating and urinating
Has begins to have a good recovery but then a few days later he has tachycardia again and eventually passes away 8 days post-op
Autopsy showed necrosis of stomach, pancreas, retroperitoneum extending to kidney.
Review of care: large body habitus, poor lighting, inadequate instruments, no evidence to support emergent operation (could have gone to bigger hospital), post op complications due to Mann’s lack of expertise
John F Kennedy
Suffered GSW to lower neck and head
One shot puts bullet through back of neck and penetrated trachea
Another shot strikes the right occiput. Fatal wound
Arrives to Parkland Hospital in 4 minutes
Trauma room one, assessed by general surgery resident Dr. James Carrico
Slow agonal respirations, intermittent heart beats, no palpable pulse or BP, unresponsive
Carriico creates tracheostomy site at level of wound, passes ETT through tracheal injury
Venous cutdowns, receives LR, placed on vent, administered 300mg solucortef (hx of addisons) IV, chest compressions begin
Dr. Bashout, cardiology, arrives and determines monitor showed no cardiac activity
Dr. Clark neurosurgeon arrives and pronounces him dead
Review of care: ABCs done well, secondary was poor since there were undiscovered wounds
