Grand Rounds Recap 6.8.22

/

Spontaneous and traumatic pneumothoraces WITH Dr. harward

  • Pneumothorax: gas within the pleural space

    • Pressure due to accumulating gas causes compression of lung parenchyma

    • Large volume pneumothorax will compress and displace mediastinal structures

  • Tension pneumothorax

    • Mediastinal shift places superior and inferior vena cavae under tension

    • Intrathoracic pressure and tension on cavae decreases venous return

      • → decreases preload

      • → decreases cardiac output

      • → obstructive shock

  • Primary spontaneous pneumothorax: absence of underlying pulmonary pathology

    • Subclinical structural and functional abnormalities

    • 3-6x more common in males

    • Young, thin males

  • Secondary spontaneous pneumothorax: presence of underlying pulmonary pathology

    • 80% due to COPD

    • Tumor necrosis, ablation

    • Necrotizing infection

  • Traumatic Pneumothorax

    • Blunt or penetrating

    • Iatrogenic

    • Barotrauma

  • Small PTX

    • <3cm from apex to thoracic cupola

    • <2cm between visceral and parietal pleura at level of hilum

    • Variation depending on which guidelines you follow

  • PTX findings on AP CXR

    • Deep sulcus sign

    • Floating cardiac fat pad sign

    • Double diaphragm sign

    • Crisp cardiac silhouette

  • Other imaging modalities

    • Ultrasound:

      • Absence of lung sliding

        • Other causes of absence of lung sliding: apnea, fibrosis

      • M-mode: barcode sign suggestive of PTX

    • CT scan: most accurate but not always clinically feasible depending on stability of patient, external factors in the emergency department

  • Secondary spontaneous PTX

    • Stability if:

      • RR <24 

      • HR > 60 and <120 beats per minute

      • Normotensive

      • SpO2 >90% on room air

      • Able to speak in full sentences

    • Secondary spontaneous PTX patients are inherently more likely to be clinically unstable

      • Very likely to require admission

      • Supplemental O2 reduces failure 50%

      • Always treat the underlying lung disease

  • Tension PTX- clinical diagnosis

    • Diminished breath sounds

    • Hypotension

    • Jugular venous distention

  • Summary:

    • Defined by gas within the pleural space

    • May occur spontaneously, secondary to pulmonary pathology, or as a consequence of trauma

    • If large enough, will create tension on venae cavae and result in obstructive shock

    • CXR and US may be used in rapid diagnosis. CT is most accurate

    • Management depends on size and clinical stability of the patient

Snake bites WITH Dr. Otten

  • ~6000 reported snake bites by indigenous venomous snakes (2016) in the US

  • ~3-5 deaths in US per year

  • ~2.5 million venomous snakes worldwide

  • ~100,000 deaths worldwide

  • Venomous snakes of North America

    • Medically important New World venomous snakes fall into 2 major families:

      • Crotalidae (crotalines/pit vipers)

      • Elapidae (coral snakes)

  • Pit Vipers

    • All 48 contiguous states except Maine have at least one pit viper species (Alaska and Hawaii do not have native venomous snakes)

      • Rattlesnakes (Crotalus)

      • Pygmy rattlesnakes (Sistrurus)

      • Copperheads, water moccasin (Agkistrodon)

    • Anatomy

      • Paired thermoreceptor organs (infrared detectors)

        • Extremely sensitive to temp delta (<0.1C)

        • Locating prey, aiming strikes, adjusting venom dose

      • Elliptical pupil

      • Triangular head

      • Large, anterior, mobile fangs

      • Single row of subcaudal scales

  • Elapidae

    • Outside the Western Hemisphere

      • Cobras, mambas, kraits, many snakes of Australia

    • North America

      • Coral snakes

  • Phospholipases A2

    • Neurotoxin that can increase the lethality of venom 10 to 100 fold

    • Noncompetitively binds to presynaptic calcium channels, inhibiting acetylcholine release

      • Blocks neurotransmission at the NMJ

      • Damages muscle cell membranes

        • Can lead to myonecrosis and rhabdomyolysis

  • Metalloproteinases

    • Locally destructive effects

    • Activate tumor necrosis factor alpha

    • Hemorrhagins

      • Leakage of RBC out of vasculature

  • Pit Viper Venom

    • Thrombin-like enzymes: coagulopathy

    • Disintegrins: prevent clot formation

    • Bradykinins: hypotension, vomiting, pain

    • Hyaluronidase: allow venom to spread

    • Lysolecithin: histamine release

  • Pit Viper: clinical presentation

    • Depends on species and size of snake, health of snake, age/health of patient, amount of venom injected, number of bites and anatomic location

    • Many bites occur during intentional handling (illegitimate bites)

    • 25-35% of bites are “dry” (little or no venom is injected)

  • Epidemiology of snake bites

    • Males 17-27

    • April-December

    • Alcohol intoxication

    • Southern U.S.

    • Extremities

    • Deliberate exposure (legitimate vs illegitimate bite)

  • Local signs/symptoms

    • Severe burning pain

    • Progressive soft tissue edema

    • Ecchymosis

    • Hemorrhagic/serous vesicles

    • Bullae

  • Systemic effects

    • Nausea

    • Muscle fasciculations

    • Rhabdomyolysis

    • Systemic hemorrhage

    • Metallic/rubbery/minty taste

    • Pulmonary edema

    • Myocardial depression

    • Hypotension

  • Prehospital Care

    • Factors that reduce morbidity/mortality

      • Rapid transport

      • Intensive care

      • Antivenin 

    • Prehospital care

      • Airway support

      • Cardiac monitoring

      • IV fluids

      • Removal of jewelry/tight clothing

      • Mark area of edema

    • What NOT to do

      • Incision

      • Suction

      • Tourniquets

      • Electric shock

      • Ice

      • Alcohol

      • Folk therapies

  • Hospital care

    • Airway management

      • Bites to face/neck

    • Fluid resuscitation

    • Analgesia

    • Wound care

    • Tetanus prophylaxis

  • Antivenin

    • Definitive therapy for snake envenomation

    • Imparting passive immunity to victim against circulating snake venom antigen

      • Irreversible binding

    • Should be given as soon as possible, though may be useful in treatment of coagulopathy days after the bite

  • CroFab

    • Available for commercial use in 2000

    • Derived from sheep serum

    • C. adamanteus, C. atrox, C. scutulatus, Agkistrodon piscivorus

    • Papain digestion of IgG to yield Fab fragments

    • Ovine IgG not glycosylated

      • Less immunogenic

    • Fab fragments incapable of cross-linking immune complexes

    • Small molecular size

      • More rapidly cleared by renal system

    • Current date: 14% acute reaction, 3% serum sickness

  • Antivipmyn- Polyvalent equine anti-viper serum

    • F(ab’)2 antibodies

    • Horse derived

    • From Bothrops, Crotalus, Sistrurus, Agkistrodon species

    • May replace CroFab for some bites

  • Crofab vs Anavip

    • Anavip FDA approved 2015

    • Fab2 decreased allergic reactions

    • Equine derived

    • Stays in system longer

    • Prevents coagulopathy

    • Less expensive

  • Antivenin administration

    • Supplied in lyophilized form- requires reconstitution

    • Slow rate for 1st 10-15 minutes

  • Initial control

    • Reversal/attenuation of local effects

    • Stable/improving coagulation studies

    • No worsening systemic effects

  • Recurrence phenomenon

    • Pharmacokinetic mismatch between venom and antivenom

    • Separation of circulating venom/antivenom complex after initial effective binding

    • Late onset venom components different from those initially active

    • Development of host anti-antivenom immune response

  • Surgery?

    • Incision- No

    • Excision- only 3-4 days later of necrotic tissue

    • Fasciotomy- toxic effects mimic compartment syndrome, give more antivenin

junctional and ventricular escape rhythms WITH Dr. Jackson

  • Heart conduction basics

  • SA node 

    • RCA 55% people

    • Lcx 45% people

  • AV node

    • RCA 90% people

    • LCx 10% people

  • Bundle of His

  • Right and Left Bundle Branch

  • Definition of escape

    • Junctional (AV junctional)

      • Narrow QRS

      • Rate 40-60

      • Regular 

      • Good reliability- ability to perfuse

      • Patient usually stable

    • Ventricular

      • Wide distorted QRS

      • Rate 20-40

      • Regular

      • Poor reliability

      • Patient symptomatic and unstable

  • Causes

    • Increasing age

    • MI

    • CT surgery history and scarring

    • Aortic stenosis

    • Hypothyroidism

    • Chagas disease

    • Viral

    • BB, CCB, digoxin

    • Electrolyte disturbances, hyperkalemia

    • Amyloidosis 

  • Bradycardia in acute MI

    • Risk with inferior MI due to ischemia affecting AV node or SA node

    • Junctional or ventricular escape rhythm possible

    • Typically reversible with perfusion

  • Complete Heart Block

    • Old age most important risk factor

    • If block is at the AV node or above bundle of His

      • Junctional escape

      • Increased stability

      • Unstable with ventricular escape rhythm will require pacemaker

  • Lyme Carditis

    • Incidence of 0.3-4%

    • 1-2 months after infection

    • Does not require permanent pacemaker

    • Treatment with ceftriaxone

  • Summary

    • Escape rhythms are a safety net for the heart when conduction abnormalities occur

    • Type of escape rhythm is dependent on where the conduction abnormality occurs

    • There are several etiologies that lead to escape rhythms

    • In most cases, treatment of underlying cause will result in resolution of the dysrhythmia

QIPS: building a culture of safety WITH Dr. thompson

  • Medical errors in medicine are unfortunately not uncommon

  • “Approaches that focus on punishing individuals instead of changing systems provide strong incentives for people to report only those errors they cannot hide. Thus, a punitive approach shuts off the information that is needed to identify faulty systems and create safer ones. In a punitive system, no one learns from their mistakes'' - Dr. Lucian Leape

  • The Just Culture Doctrine

    • Honest mistakes should not be penalized unless there is malicious intent, substance use, impairment, or ongoing threat

    • Penalizing mistakes discourages speaking up about safety threats and instead encourages concealment

    • “Just Culture” asks what, not who, is responsible

    • Human imperfection is expected

    • Embraces those caught in faulty systems

    • Individual failure is managed fairly

    • Seeks to balance safety and accountability

    • A Just Culture Tool is available

  • Adverse outcome causative factors- multifactorial

    • Patient’s age and health

    • MD and RN staffing

    • Hospital capabilities

    • Medication choice

    • Sleep

    • Time of day

    • On call specialist

    • Reliable history

    • Timely results

    • Prompt presentation

  • Psychological safety

    • An environment where speaking up is encouraged with any question, idea, concern, or mistake

  • Second Victim Syndrome

    • The second victim syndrome (SVS) is defined as the healthcare providers who commit an error and are traumatized by the event manifesting psychological (shame, guilt, anxiety, grief, and depression), cognitive (compassion dissatisfaction, burnout, secondary traumatic stress), and/or physical reactions that have a personal negative impact.

  • Action: What can you do?

    • Frame the work you’re doing as a learning opportunity with inherent uncertainty

    • Model curiosity. Ask questions. Embrace messengers.

    • Acknowledge your own fallibility and imperfections (with your team)

    • Be the change you want to see   

wellness: nutrition in residency with dr. roblee

  • Eating healthy is hard

    • Grueling hours

    • Difficulty eating during working hours

    • Stressful work environment

    • Circadian rhythm disruption

  • Poor dietary habits lead to…

    • Metabolic disease

    • Irritability

    • Fatigue

    • Cognitive effects

  • Meal prep

    • Use your day off

    • Plan ahead

    • Go shopping with a list

    • Make your food for the week

    • Portion out snacks

  • Eating schedule tips

    • In a 24 hour period plan for 3 meals and 2-3 snacks

    • Eat every 3-5 hours

    • Eat your biggest meal right before you go to work

    • Don’t eat too much before you go to bed

    • Don’t go to bed hungry

  • Macros- carbohydrates

    • Avoid simple carbs and refined sugars

    • Look for complex carbs

    • Foods high in fiber (4g or more) will keep you fill

    • Examples: brown rice, lentils, ezekiel bread, quinoa, beans, chickpeas, barley, buckwheat, oats, whole grain pasta, peas, sweet potato

  • Macros- Fats

    • Omega-3 and omega-6 are both essential fatty acids

    • Omega-6 fatty acids are ubiquitous in Western diets

    • Prioritize omega-3 fatty acids (anti-inflammatory properties, promote cardiovascular health)

    • Omega-3: salmon, mackerel, flaxseed, chia seeds, walnuts, olive oil, avocado

    • Omega-6: sunflower oil, corn oil, soybean oil, sunflower seeds, pumpkin seeds, meat, dairy

  • Macros-protein

    • Keeps you full and energized

    • Protein needs vary depending on activity level

    • Generally, daily protein requirement is 1gm per kg of body weight

    • Examples: dairy, nuts, beans, tofu, fish, lean meats, eggs

  • Hydration

    • Body weight (kg) x 30 = daily fluid requirement (mL)

    • Avoid drinks with added sugar or sodium

    • Ex: Bubly, LaCroix, water

  • Meal Replacement Drinks

    • Can be a good option if you need something quick

    • Liquids will not keep you full for long- pair with snack

    • Check nutrition label- many are low in fiber or too high in protein

metabolic/endocrine disorders of the neonatal period WITH dr. ketabchi

  • DDx of the ill-appearing neonate

    • Sepsis

    • Congenital heart disease

    • Congenital adrenal hyperplasia (CAH)

    • Inborn errors of metabolism (IEM)

    • Mitochondrial disorders

  • Presenting symptoms

    • Vomiting

    • Poor feeding

    • Lethargy

  • When to suspect CAH

    • Hypoglycemia

    • Hyponatremia

    • Hyperkalemia 

  • Initial Management of CAH

    • Treat hypoglycemia

      • 2ml/kg of D25 or 5ml/kg of D10

    • Stress dose hydrocortisone bolus: 100mg/m2

      • 25mg IV if <3 yo

      • 50mg IV if 3-12 yo

      • 100mg IV if >12 yo

      • Maintenance dose: same dose as above divided QID

    • Treat hyperkalemia

    • Treat shock with NS bolus(es)

  • When to suspect mitochondrial disorder

    • H&P: FTT, lethargy, hypotonia, seizures

      • Variable age of presentation, not necessarily neonate

    • Labs:

      • Lactic acidosis (upregulated glycolysis)

      • AA may be normal or elevated

  • Initial management of mitochondrial disorders

    • Treat hypoglycemia

    • Prevent catabolism with dextrose-containing IVF

      • Even if hypoglycemia not present

    • Stroke-like episodes

      • Treat with IV arginine HCl

    • AVOID lactated ringer’s solution

    • If possible, avoid

      • Over-bolusing

      • Anesthesia/paralytics

      • Valproic acid

      • Statins

      • Metformin

      • Macrolides

      • Tetracyclines

  • Inborn Errors of Metabolism

    • H&P: poor feeding, vomiting, lethargy, coma

    • Labs: (any of the following)

      • Metabolic acidosis or respiratory alkalosis

      • Elevated ammonia

      • Hypoglycemia

      • Ketones may or may not be present

  • Initial management of IEM

    • Fluid resuscitation with normal saline

      • Avoid LR, may be a lactate metabolism defect

    • Treat hypoglycemia

      • Initial bolus: 5ml/kg D10 or 2ml/kg D25

      • Maintenance: D10 + electrolyte at 1.0-1.5 x mIVF

    • AVOID enteral nutrition until Dx

      • Protein could trigger crises

    • Bicarbonate administration- unlikely to help if organic acidemia

      • In hyperammonemia, may cause cerebral edema and decrease ammonia excretion

    • Hypoglycemia (or Maintenance)

      • Doesn’t matter → give dextrose

        • Disorder of carb metabolism

        • Fatty acid oxidation disorder

        • Amino acidemia

        • Organic acidemia

        • Mitochondrial

  • Timing of presentations

    • Utilization disorders: within first few weeks

      • After fasting

      • Ex. carb metabolism, FOAD

    • Toxic metabolites: within first few weeks

      • After protein feeding

      • Ex. acidemias

    • Storage disorders: variable, often later

      • Can have phenotype features

    • Mitochondrial disorders: variable, often later

  • Neonatal Seizure Etiology

    • CNS infection

      • When can you call it a febrile seizure? → after 6 months old. If younger, consider CNS infection or disorder

    • Metabolic disturbance, hypoglycemia

    • Cofactor deficiency

    • Stroke

    • Structural

  • Neonatal Seizure Treatment

    • General

      • Phenobarbital 20-30mg/kg initial

      • 10-20mg/kg additional

      • Max 50mg/kg in 24 hours

    • Electrolyte disturbances

      • Treat accordingly

    • Cofactor deficiency

      • Pyridoxine (B6) deficiency: 100mg IV q5-15min

      • Folic Acid deficiency: 2.5 mg IV leucovorin

  • Other thoughts

    • Ask if family has care plan

    • Know how to obtain newborn screen results

    • Know how to contact nearest specialist

      • There is an exception to every rule

  • Summary

    • Dextrose is your friend

      • Initial bolus: 5ml/kg D10 or 2ml/kg D25

      • Maintenance: D10 + electrolyte at 1.0-1.5 x mIVF

    • Avoid enteral nutrition if unclear Dx

    • Stress dose hydrocortisone

      • 25mg IV if <3yo

      • 50mg IV if 3-12 yo

      • 100mg IV if >12 yo

      • Maintenance: same dose as above, divided QID

    • Consider B6 (100mg) then Folinic Acid (2.5mg) for refractory seizures