Grand Rounds Recap 6.12.2019

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R4 Capstone lecture WITH DR. continenza

Coping with the Death of Patients

  • A survey of 122 EM physicians found that 66% had direct communication with the family after the death of a child, 64% felt guilt after this, and 47% felt impaired for the rest of their shift

  • In a survey of 207 EM physicians, 54% felt a physical response from the death of a patient such as insomnia, fatigue

Strategies to Cope

  • Formal Debrief

    • There is no current evidence that a formal debrief helps prevent PTSD in providers according to this Cochrane Review

    • 64% rarely or never debriefed in a survey of ED physicians and nurses

  • Discussion after Difficult Patient Encounters

  • The Pause

    • In a survey of 34 ICU nurses and physicians, 79% taking a “pause” in their work shift after a traumatic incident brought closure and helped to overcome feelings of grief and disappointment

Taming the sru: Calcium channel blocker toxicity WITH DR. gauger

Calcium Channel Blocker Toxicity (CCB)

  • Background

    • There are two types, dihydropyridine and nondihydropyridine Ca channel blockers

      • Dihydropyridines are predominantly peripheral vasodilators with no cardiac effects at therapeutic doses, but they have less selectivity at toxic doses

      • Non-dihydropyridines predominantly effect cardiac conduction, with little peripheral vasodilation

    • CCB are highly protein bound with high volumes of distribution, causing hypotension, bradycardia, heart block, and CNS depression

  • Interventions

r4 case follow-up: Potpourri of interesting cases WITH DR. bernardoni

Tinea Versicolor

  • Triggered by hot humid weather and skin oils by the pathogen Malassezia furfur

  • Diagnosis is with KOH prep

  • Treatment is a topical antifungal for 2 weeks

  • The dyspigmentation will last months after successful treatment, and it is not contagious

Acute Necrotizing Ulcerative Gingivitis

  • Gum pain and sloughing with purulent drainage

  • Treatment is via debridement with a dentist, peridex mouth rinses, and oral flagyl x 1 week

  • Patients may lose all of their teeth, so ensure good dental follow-up

Disseminated Herpes Zoster

  • Commonly seen in patients with immunosuppression (HIV, chronic immune suppression)

  • Neurologic complications include aseptic meningitis, transverse myelitis, and peripheral motor neuropathies from this

  • Patients require a thorough ophthalmologic exam to ensure they do not have herpes keratitis

  • Herpes zoster oticus can present with facial paralysis, tinnitus, and vertigo

  • Patients require IV acyclovir if they are immunocompromised, has ocular involvement, or tinnitus/hearing loss

  • Patients are contagious if they have blisters, so should avoid unvaccinated pregnant women, premature infants, or immunocompromised patients

Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS)

  • Rapid onset morbilliform rash >50% TBSA

  • Medications typically causing this are antiepileptics, sulfa drugs, or allopurinol

  • Patients can get pulmonary complications, nephritis, and hepatitis from DRESS

  • Treatment is withdrawl of offending agent and systemic steroids if there is significant renal or lung involvement

Chemosis

  • Chemosis is caused by edema of the conjunctiva

  • Causes include conjunctivitis (allergic, viral more common), trauma, positive pressure ventilation, prolonged dependent positioning or anasarca

  • Treatment is supportive

  • If chemosis is isolated to one quadrant of the eyes, this can be a subtle sign of scleral laceration and occult globe rupture

Acute Generalized Erythematous Pustulosis

  • This is a drug rash of sterile pustules with erythema at the base of pustules, so take a good medication history

  • The onset is typically days within starting the medication

  • Treatment is stopping the medication

Pediatric simulation WITH DR. wilen

Session 1: Breaking Bad News

  • Find a comfortable place to ensure the family is prepared for the conversation

  • Hand off pagers, phones to ensure they have your full attention

  • Sit rather than stand while breaking the news

  • Use certain terms (cancer, death)

  • Give a pause afterwards to allow the family to reflect and answer any questions

Session 2: Measles

  • Indications for admission include measles encephalitis, secondary pneumonia, unable to maintain isolation from vulnerable populations (immunocompromised, unvaccinated, pregnant relatives), or unstable vital signs

  • Measles is extremely infectious by airborne spread, so call ahead so the child can be in airborne isolation

  • Pediatric infectious disease is the typical contact you will speak with in order to decide on best method of transfer if you are at a community ED

  • Contacts who are immunized require no further treatment, contacts who are unable to be immunized require immunoglobulin, contacts who are able to be immunized must receive the vaccine

Session 3: Simulation

Undifferentiated Jaundice in the Neonate

  • Differential

    • Biliary atresia

      • Typically will present with acolic stools

    • Breastfeeding or breastmilk jaundice- typically fairly well appearing

    • Right heart failure due to congenital cardiac disorders

      • Consider judicious fluids 10cc/kg at a time if suspicion for congenital cardiac disorders

      • For evaluation, consider four point blood pressures and pulse oximetry

    • Inborn errors of metabolism

      • Typically present with profound metabolic acidosis and hypoglycemia

      • Consider sending an ammonia

    • Sepsis

      • If undifferentiated and in shock, treat aggressively and early with broad spectrum IV antibiotics

  • Management of inborn errors of metabolism