Grand Rounds Recap 6.05.19

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Airway Grand rounds WITH DR. carleton

Troubleshooting an EGD

  • Assessment

    • Waveform capnography is the gold standard

    • Lung auscultation

    • Chest rise and fall

  • Response

    • Reseat more deeply (a more common problem with the I-gel)

    • Back device out slightly (a more common problem with the King LT)

    • Gastric decompression

    • Sedation/paralysis

    • PEEP

    • Change size/type of device

When to Exchange an EGD?

  • If it is not providing adequate oxygenation or ventilating, remove immediately and bag with facemask

  • If providing adequate oxygenation and ventilation weigh the following risks

    • Aspiration risk

    • Risk of ETI

    • Progressive process

    • Risk of displacement

    • Poor lung compliance

Types of EGD

  • Dual balloon devices vs. laryngeal mask devices

  • First generation (no esophageal drain) vs. second generation (esophageal drain)

How to exchange a King LT

Removing the King

  • Decompress the stomach using an 18F feeding tube

  • Consider deferring removal until after laryngoscopy

I-Gel Exchange

King LT Complications

  • Cuff pressures elevation

  • Tongue swelling (39%)

  • Gastric distension (11%)

  • Bleeding (2%)

  • Malposition (<1%)

Optimizing Direct Laryngoscopy

  • Positioning (ear to sternal notch)

  • Pre-oxygenation (less stress, longer time to intubate)

  • Laryngoscopy technique (blade choice and placement)

  • Laryngeal manipulation (utilize bimanual laryngoscopy)

  • Bougie (for not improvable CL-III or poor IIB view)

  • Keep moving your laryngoscope blade into the vallecula until you see the epiglottic twitch if you are using direct laryngoscopy, as this is a sign it has seated with the hyoepiglottic ligament.

An excellent review for managing an EGD is here.

r4 capstone WITH DR. Liebman

Recycling

  • 35% of the garbage within the country is recycled

  • Cincinnati itself only recycles 22.5% of garbage, much lower than its goal of recycling greater than 34% of its garbage

  • Try utilizing mugs for coffee instead of disposable cups in order to limit generation of excess waste

Minimizing Error in Airway Management

Clinical pathologic case: Guillain Barre Syndrome WITH DR. chris shaw vs. dr. kari gorder

Neuropathies

  • Peripheral

    • Mononeuropathy or radiculopathy

      • Isolated locations to specific nerves (ex: carpal tunnel system)

    • Polyneuropathy

      • Tend to be more distal and symmetric

      • Length dependent and progress slowly (ex: diabetic neuropathies)

    • Hyporeflexia and various degrees of weakness tend to predominate

  • Central

    • Spinal cord lesions or brain lesions

    • May have clear spinal level

    • Sensory loss is typical of brain lesions

    • Hyperreflexia and clonus are predominant

Guillain Barre Syndrome

  • Epidemiology

    • 1:100,000 annually

    • There is a spike in prevalence in 20-24 and 70-74 year old patients

    • Campylobacter species are the most commonly associated infectious precipitant of this

  • Pathophysiology

    • Antibodies are directed against myelin, causing demyelination and nerve damage

  • Presentation

    • Paresthesias and areflexia are the most common presenting symptoms

  • When to intubate

    • Can they lift their head?

    • Can they lift their elbows?

    • Can they count to 20 while exhaling?

    • If any of these, consider intubation. Also consider when NIF <20.

  • Treatment

    • Plasma exchange has a benefit

    • IVIG has been shown to be equivalent in benefit to plasma exchange

    • Treat underlying infectious causes appropriately

R1 clinical diagnostics: LBBB with stemi WITH DR. Walsh

Read Dr Walsh’s introduction post here

Why do I care?

  • LBBB occurs in 6.7% of patients with acute MI

  • LBBB obscures usual STEMI diagnosis on EKG, so can lead to a delay in care

  • Delayed treatment worsens outcomes with LBBB

LBBB

  • Supra ventricular rhythm

  • QRS > 120 ms

  • Dominant S wave in V1

  • R-wave peak of >60ms in I, V5-V6 without Q-wave

Sgarbossa Criteria

Modified Sgarbossa Criteria

Paced Rhythms

  • RV pacemaker produces LBBB due to R>L impulse

  • In a retrospective case control study of 57 patients, the Sgarbosa criteria performed in the following ways:

    • The sensitivity of “ST-segment elevation of 1 mm concordant with the QRS complex” was unable to be calculated as no ECG fit this criterion;

    • For “ST-segment depression of 1 mm in lead V1, V2, or V3,” the sensitivity was 19% (95% CI 11–31%), specificity 81% (95% CI 72–87%), with a likelihood ratio of 1.06 (0.63–1.64);

    • For “ST-segment elevation >5mm discordant with the QRS complex,” the sensitivity was 10% (95% CI 5–21%), specificity 99% (95% CI 93–99%), with a likelihood ratio of 5.2 (1.3 – 21).

Global Health guest lecturer: trauma, the neglected tropical disease WITH Dr. stephen dunlop

Background

  • Road traffic accidents are the number one way US citizens will die abroad

  • Traffic direction such as stoplights and roundabouts are relatively uncommon in Sub-Saharan Africa

  • 90% of traffic deaths are due to road crashes in the developing world, mostly among pedestrians, bicyclists, and motorcyclists

  • While war and violence play some role in trauma in the developing world, road traffic accidents are much more prevalent in the developing world ]

  • By the year 2030, the WHO predicts road traffic accidents (along with heart disease, COPD, and depression) will be some of the top contributors to the world’s disease burden

  • Road crashes cost low and middle income countries an estimated $65 billion each year, more than they receive in developmental aid

What We Can Do