M &M - Sports Medicine: the exam - accidental hypothermia - Chronic Pain and depression - Global Health Update - Case: DKA

august morbidity and mortality conference with Dr. Gorder

Case 1: Therapeutic Paracentesis in the ED

Indications:
- Tense ascites
- Refractory ascites (90% of cases can be managed medically)
- Palliative care
Possible Complications
- Post-paracentesis Hypotension
  - Likely caused by splanchnic vasodilation / decreased abdominal pressure leading to increased cardiac output
  - BP usually nadirs at 2-3 hours following procedure
  - Average MAP falls by 7mmHg
- Paracentesis-Induced Circulatory Dysfunction
  - Usually occurs after large volume taps (>5 Liters)
  - Fluid shifts lead to decreased circulatory volume
  - Renin and sympathetic nervous system stimulation can lead to hepatorenal syndrome
  - Risk is decreased with albumin administration
Summary / Recommendations
- Generally safe to perform in the ED, though time consuming
- Patients who have >5 liters removed should be given albumin (6-8 grams per liter of fluid removed)
- General practice is to not remove more than 10 liters, though not based on literature
- Patient should be observed for 2-3 hours to monitor for post tap hypotension / circulatory dysfunction

Case 2: ED Hyperkalemia Management

Hyperkalemia: K+ > 5.5 mEq/L puts patient at risk for conduction abnormalities and arrhythmia

Expected conduction changes / EKG abnormalities
- K+ >5.5: Begin to see repolarization abnormalities
  - Peaked T waves on EKG
- K+ >6.5: Progressive paralysis of atria
  - P Wave flattening
  - PR Segment lengthening
- K+ >7.0: More severe conduction dysfunction and bradycardia
  - Prolonged QRS
  - High grade blocks
- K+ >9.0: High likelihood of cardiac arrest

***History of Hyperkalemia (ex. patients with CKD or ESRD) is not cardioprotective***

Management in the ED
- Medications
  - Calcium (Gluconate or Chloride): Decreases Myocardial Excitability
    - Indication:
      - Any EKG Changes in the setting of hyperkalemia
      - OR serum potassium > 6.0 mEq/L
    - Dose:
      - Calcium Gluconate: 1.5 - 3g over 2-5 minutes
      - Calcium Chloride: 500 - 1000mg over 2-5 minutes
    - Onset/Duration
      - Cardiac stabilization peaks at 10-15 minutes
      - Re-Dose q 5-10 Minutes
      - Titrate to EKG changes
    - Risks:
      - Tissue necrosis (Especially CaCl)
      - Hemodynamic instability
      - Potentiates cardiotoxic effects of digitalis
  - Insulin / D50: Stimulates NA/K/ATPase Pump - Transcellular shift of K+ into cells
    - Dose: 10 Units Regular Insulin IV push / 1 amp of D50
    - Onset/Duration:
      - Onset is almost immediate
      - Intracellular effects last 4-6 hours
      - Decreases serum potassium by 0.5mEq/L in first 15 minutes
      - Decreases serum potassium by 1 mEq/L in first 2 hours
    - Risks: Hypoglycemia
  - Beta Agonists
    - Dose: 10-20mg of inhaled albuterol (due to lack of IV in the US)
    - Onset/Duration:
      - 10 minutes to peak plasma concentration
      - Half-Life 3.5-5 hours
      - Decreases serum potassium of up to 0.6mEq in 30 minutes
      - Decreases serum potassium of up to 1 mEq in 1 hour
      - Re-dose q 1-2 hours
    - Risks: Tachycardia, anxiety
  - Sodium Bicarbonate
    - Dose: 50mEq IV Bolus
    - Onset/Duration:
      - Rapid effect on pH
      - May not affect K+ for 4-6 hours, if at all
    - ***EFFICACY***
      - Physiologically will only function if patient is acidotic (and patient is compensating)
      - Overall efficacy for lowering K+ is debatable.
  - Kayexalate
    - Recommend against use in the ED
    - Evidence of efficacy is poor, and onset >8 hours
    - Case reports of harm (bowel necrosis, etc)
- Frequent Reassessment
  - Re-check potassium q1 hour
  - Re-check EKG more frequently if abnormalities present

Case 3: Procedural Sedation in the ED

What defines sedation?
- "Procedural sedation is a technique of administering sedatives or dissociative agents with or without analgesics to induce a state that allows the patient to tolerate unpleasant procedures" - ACEP Policy Statement
Levels of Sedation: Exists on a continuum that must be prepared for and is unique to the patient in front of you. The deeper the sedation, the greater the risk of adverse events.
- Minimal
- Moderate
- Deep
- General Anesthesia
Most Common Adverse Events in the ED:
- Apnea
- Hypoxia
- Hypotension
- Vomiting
High Risk Subgroups shown to have a higher risk of complication
- Age > 80 years old
- Poor airway protection (ex. Poor cough)
- Underlying respiratory disease (COPD, etc)
- Hypoxia at baseline
Monitoring
- All patients require respiratory and cardiac monitoring during procedural sedation
- End Tidal CO2 Should be utilized
  - Gives more immediate feedback on respiratory rate, depth, etc
  - Pulse ox changes often delayed several minutes after development of respiratory depression.

Case 4: Refractory Shock

Determining Etiology of Shock (Cardiogenic, Obstructive, Distributive, Hypovolemic)
- Early and dynamic use of the RUSH(ed) exam (Rapid Ultrasound for Shock and Hypotension)
  - Heart (Parasternal long and apical 4 chamber view)
    - Assess squeeze and valves, which is hypodynamic may suggest cardiogenic shock
    - Hyperdynamic heart may suggest distributive or hypovolemic shock
    - Right sided strain (D sign) or enlargement may suggest PE
  - Lungs (anterior pulmonary view)
    - Lung sliding
    - Assess for B-lines which may suggest edema vs infection
  - Morrison's and Splenorenal spaces w/ view of diaphragm
    - Check for blood/fluid in abdomen or chest (hemothorax/effusion)
  - IVC
    - Assess for hypovolemia suggesting hypovolemic shock
  - Aorta
    - Assess for AAA
Management of refractory distributive shock
- Fluids: Do we give more?
  - Excessive fluid resuscitation shown to worsen mortality
    - FEAST trial showed significant increase in mortality with aggressive fluid expansion
    - Evidence of fluid overload in EGDT septic shock patients showed increase in in-hospital mortality
  - Recommend continuous evaluation of fluid responsiveness. Examples include:
    - Assess pulse pressure variation
    - Passive leg raise (with or without VTI)
    - IVC diameter/variation
    - Non-Invasive cardiac monitoring
- Pressors: Which do we use?
  - Norepinephrine: 1st choice
  - Epinephrine: 2nd choice
  - Vasopressin: VASST trial showed no benefit as solo pressor. Surviving sepsis campaign did demonstrate benefit when used in conjunction with norepinephrine in reduction of dose of norepi
  - Dopamine: Usually not recommended except in profound bradycardia
  - Push-Dose Calcium: Shown to worsen outcomes in all comers. May be of benefit in patients with hypocalcemia.
- Steroids:
  - CORTICUS trial in 2008 demonstrated improved response to levophed (speeds reversal of shock without mortality benefit) with 50mg bolus of hydrocortisone
  - Surviving Sepsis Guidelines suggest hydrocortisone in the setting of refractory hypotension despite adequate fluid resuscitation and vasopressor therapy, although admitting the evidence is weak.
- Sodium Bicarbonate
  - Surviving Sepsis Campaign recommends against routine use
  - In setting of severe acidosis pH < 7.1 and hemodynamic instability it may be considered (if patient compensating)
  - However, recent meta-analyses with sepsis and severe acidosis were inconclusive
- Methylene Blue
  - Inhibits NO production
  - Has been shown in some studies to decrease pressor requirements
  - Two large systematic reviews (Kwok et al 2006, Hosseinian et al 2016) were inconclusive/lacked high quality evidence
  - May be used as last resort
Possible Future Therapies to Watch for:
- Esmolol: Reduce heart rate to allow for greater diastolic filling and increased CO.
- High Dose Insulin and Glucose: For inotropic benefit.
- Hypothermia: Slow/dampen dysregulated inflammatory system response
- Terlipressin
- CRRT: Remove and reduce inflammatory cytokines responsible for shock
- Vitamin C and Thiamine
- VA ECMO

Sports medicine: the physical exam with Dr. Betz

Definition: "Musculoskeletal Medicine." Focuses on injuries during sports and exercise, namely their prevention, diagnosis, treatment and rehabilitation.

Fellowship Opportunities:

ACGME Approved Fellowship
140 programs available
7 are EM run

Clinical Exam Pearls for Shoulder Pain

Important Anatomy
- Joints
  - Sternoclavicular Joint (SC Joint)
  - Acromioclavicular Joint (AC Joint)
  - Glenohumeral Joint (GH Joint)
  - Cervical Spine ***Consider neck injuries***
- Important Musculature
  - Deltoid
  - Teres Major
  - Teres Minor
  - Supraspinatus
  - Infraspinatus
  - Pec Major
  - Pec Minor
  - Serratus Anterior
  - Trapezius
  - Biceps (long and short head)

Full Shoulder Exam

Cervical Spine
- Spurling Test
  1. Rotate neck laterally TOWARDS injured shoulder
  2. Extend Neck
  3. Press on head providing axial load
  - If shoulder pain is reproduced, likely cervical radiculopathy
Palpate the Bony Joints: Assess for possible Injury/Tenderness/Deformity/Displacement
- SC Joint
- GH Joint
- AC Joint
Assess Range of Motion (ROM)
- Forward Flexion: 180 Degrees
- Abduction: 180 Degree
- "Painful Arc"
  - Pain between 0-60 Degrees: Likely rotator cuff injury
  - Pain between 60-180 Degrees: Likely AC pathology
- External Rotation: 0-90 Degrees
- Internal Rotation: 0-90 Degrees
Obrien's Test: Assess for injury of the labrum
1. Patient flexes the shoulder to 90 degrees with elbow in full extension, adducted 10-15 degrees towards the midline
2. They then internally rotate the arm until the thumb is pointing down
3. The examiner then presses down on the arm.
4. The patient then externally rotates the arm so that the palm is up
5. The examiner then presses down on the arm again.
- Test is positive if pain is felt when pressing on the internally rotated arm and alleviated when the arm is externally rotated
Assess the Rotator Cuff
- Assess muscular strength
  - Supraspinatus: "Empty can position" (Both arms in 90 degree shoulder flexion with elbows fully extended, arm internally rotated.
  - Infraspinatus: Elbow bent at 90 degrees. Externally rotate shoulder
  - Subscapularis: Place hand behind back palm out. Elevate hand.
- Drop Arm Test (Assesses for suprispinatus tear)
  1. Patient holds arm abducted to 180 degrees (Straight up above head)
  2. Patient then gradually lowers/adducts arm
  - Test is positive if patient is unable to smoothly control the arm/arm drops to the patient's side between 90 and 60 degrees.
- Hawkins Test (Suggests Subacromial impingement/Rotator Cuff tendonitis)
  1. Flex shoulder to 90 degrees with elbow flexed at 90 degrees
  2. Examiner then forcefully internally rotates the shoulder joint
  - Test is positive if internal rotation reproduces pain
- Neer Test (Suggestive of Impingement)
  1. Patient is standing
  2. Fully internally rotates arm (Fully pronated)
  3. Examiner passively flexes shoulder with elbow in extension through through full 180 degrees of flexion
  - Test is positive if pain is reproduced
- Crossover Test
  1. Patient places arm in 90 degrees of flexion with elbow in extension
  2. Examiner/patient adducts arm across the midline
  - Pain in AC joint suggestive of impingement
Assess the Biceps Tendon:
- Speed Test
  1. Patient flexes shoulder to 90 degrees with elbow in full extension
  2. Patient tries to flex shoulder against resistance
  - Pain in the bicipital groove is indicative of biceps tendonitis
- Yergason Test
  1. Shoulder at side, elbow flexed to 90 degrees
  2. Patient starts with forearm in complete pronation
  3. Supinates against resistance
  - Pain with supination suggestive of biceps tendonitis
Neurovascular Exam

Rapid ED Shoulder Exam

Important Elements
- Neurovascular Exam
- Palpate Bony Joints (See Details Above)
- Limited ROM testing
  - Adduction of Shoulder
  - Internal Rotation
- Dugas Test (Quick test for shoulder dislocation)
  - Patient reaches across midline with affected arm to opposite AC joint
    - Inability to touch opposite AC joint indicative of shoulder dislocation
- Drop Arm Test (See Above)

Clinical Exam Pearls for Knee Pain

Important Anatomy
- Bones
  - Patella
  - Femur
  - Tibia
- Ligaments
  - ACL
  - PCL
  - LCL
  - MCL
- Cartilage
  - Medial Meniscus
  - Lateral meniscus
- Vessels
  - Popliteal Artery
  - Popliteal Vein
- Nerves
  - Common Peroneal
  - Sciatic
  - Saphenous

Full Knee Exam

Assess for Effusion/Warmth
- Following trauma: Indicative of internal derangement (ACL, PCL, Meniscal injury, Fracture)
Range of Motion
- Flexion and Extesion
- Assess for patellar tendon/quadriceps tear
Patellar Exam
- Assess for tenderness
- Apprehension test: Lateral movement of the patella causing pain or contraction of the quadriceps
- Assess tracking during flexion and extension
- Patellar Grind Test: Downward pressure on patella while flexing quadriceps
Palpate the Joint Line
Assess the ACL and PCL
- Lachman's
  1. Knee is placed in 15 degrees of flexion
  2. Assess for anterior tibial translation
  - Positive test is if there is a "soft endpoint" without feeling ligament abruptly halt movement
- Anterior and Posterior Drawer
  1. Patients hips flexed to 45 degrees, knees at 90 degrees
  2. Examiner braces/sits on patient's feet.
  3. Tibia is moved anteriorly and posteriorly
  - Positive test is >6mm of anterior or posterior movement
Assess the MCL and LCL
- Varus and Valgus Stress
Assess for meniscal injury
- McMurray Test
  1. Patient lies supine with knee and hip both flexed at 90 degrees
  2. Examiner applies valgus stress to the knee and external rotation of the foot
  3. Examiner then applies varus stress to the knee and internal rotation of the foot
  - Reproducible clicking, locking, or pain indicative of meniscal injury
Neurovascular Exam
ALWAYS HAVE HIGH SUSPICION FOR KNEE DISLOCATION
- 50% Reduce prior to ED presentation
- Can Occur with Low Energy Mechanisms
  - Obesity
  - Hyperextension
- Can Lead to Significant Morbidity
  - 3 out of 4 Major ligaments usually disrupted
  - 40-50% have vascular injury
- Assess with CTA if concerned. ABIs may be less reliable

Environmental Injuries: accidental hypothermia with Dr. Makinen

Cold Related Injuries

Predisposing Factors
- Alcohol #1
- Extremes of Age
  - Mental Status
  - Immobility Issues
  - Body surface area to mass ratios
Common Conditions
- Pernio
  - Presentation
    - Acute, painful, erythemetous plaques
    - Usually associated with autoimmune disease
  - Management
    - Pain Control
    - Slow Rewarming
    - Nifedipine has been shown to be helpful
- Trench Foot
  - Presentation
    - Itching, burning
    - Cold, blotchy feet
    - Common in homeless population
  - Complications
    - Secondary infection
    - Necrosis
    - Gangrene
  - Management
    - Keep feet dry
    - Replace socks and encourage changing regularly
    - Pain control
    - Supportive care
- Frost Bite
  - Pathophysiology
    - Freezing of tissue with crystal deposition
    - Microvascular thrombi
    - Ischemia/vasospasm
  - Presentation similar to burn
    - Good prognosis
      - Blebs
      - Edema
      - Erythema
    - Poor Prognosis
      - Full thickness involvement
      - Hemorrhagic blebs
      - Violaceous
      - No edema
  - Management
    - Rapid rewarming
      - Shoot for 37-39 degrees
      - Do not warm above 41 degrees
    - Tetanus
    - Avoid dry heat
    - TPA?
      - May possibly improve likelihood of limb salvage
      - Must be administered within first 24 hours
- Hypothermia
  - Symptoms
    - 34-36 C: Mild
      - Excitatory response (Tachycardia, increased respiratory rate)
      - Shivering
      - Ataxia, dysarthria
    - 30-34 C: Moderate
      - Decreased / loss of shivering
      - Bradycardia
      - Hypotensive
      - Depressed mental status
      - Arrhythmia
        NST => Bradycardia => Atrial Arrhythmia => V-Fib => Asystole
        Osbourne Waves
    - <30 C or Cardiac Arrest: Severe
      - CNS: Loss of reflexes
      - CV: Myocardial Irritability
      - Pulm: Bronchorrhea
      - Endocrine: Hyperglycemia (Insulin ceases to function)
      - Heme: DIC
  - Management
    - Passive rewarming: Blankets, Remove wet clothing (Mild Hypothermia)
    - Active rewarming: Heat packs, bear hugger, Arctic Sun, warm IV fluids (Mild to Moderate Hypothermia)
    - Invasive / Core rewarming (Severe Hypothermia)
      - Warmed air
      - Thoracic lavage: 2 degree/hr
      - Gastric lavage: 1 degree/hr
      - Bladder lavage: 1 degree/hr expected warming
      - Dialysis
      - VA ECMO
        Indications
        <30 degrees
        Cardiac Arrest
  - Hypothermic Arrest
    - Cardioversion
      - Place on monitor
      - May attempt shock, though likely refractory if hypothermic
        One attempt, retry when warm
      - Code medications
        Evidence is unclear
        Pressors may be of benefit in animal models
      - Active and Invasive rewarming

R4 Soapbox: Chronic pain and depression with Dr. Ludmer

Background:

Chronic pain: Pain lasting >3 months. May be intermittent.
- 100 Million affected nationwide
- Responsible for 200 million work days lost
- Summative cost to health care system estimated to be 635 billion dollars
- Represent a large portion of ED visits
Chronic pain and depression often go hand in hand
- 30-60% of patients with chronic pain report depression
- 50% of patients with depression will suffer diffuse or chronic pain

Pathophysiology: The biological, cognitive, and behavioral links between chronic pain and depression

Biological Connection
- Similar brain regions are activated in both physical and emotional pain
  - Sections of the brain associated with fear, worry, threat, distress
    - Anterior cingulate cortex
    - Anterior insula
  - Stimulation of these areas leads to remodeling, arborization
  - Chronic stimulation from either emotional or physical pain may predispose to worsening of the other
- Similar neurotransmitters involved in depression and pain modulation
  - Seratonin, norepinephrine low in depression
  - Norepinephrine important in descending pathway modulation of pain.
Behavioral and Cognitive Connection
- Avoidance behavior: Chronic pain can cause patients to stop doing/avoid activities they enjoy. Can then lead to seclusion, isolation, perceived helplessness, and eventually depression
- Catastrophizing: Correlated with pain and depression independently.

Management: In order to better treat chronic pain, we must also recognize and treat depression

Address Physical / Chronic Pain
- Analgesia
  - Multimodal pain control is key
  - Judicious use of opiates
  - Referral to pain specialist
- Physical Therapy
  - Often used for musculskeletal pain
  - Efficacy
    - Significant improvement in chronic pain when compared to no intervention at all
    - Variable improvement in chronic pain when compared to placebo
- Surgery
  - Some conditions, such as chronic arthritis, may benefit from surgery referral
  - Of note: Patients who catastrophize are at higher risk for post operative chronic pain
Address Depression / Emotional Pain
- Antidepressant Therapy:
  - Proven to be effective in depression
  - Also shown to help with chronic pain
    - SSRIs alone decreased pain in 31% of fibromyalgia patients
    - Large study at VA demonstrated significant reduction in pain and depression with controlled anti-depressant regimen
  - Antidepressants as analgesics
    - TCAs and SNRIs that affect norepinephrine levels have been shown to have analgesic effect apart from antidepressant effect (Releived pain in non-depressed patients)
    - Thought to increase norepinephrine activity in descending pathway
- Cognitive Behavioral Therapy
  - Showed decrease in catastrophizing
  - Studies have shown small to moderate improvement in pain

What We Can do in the ED

Screen for Depression in Chronic Pain Patients
- Depression is common among the ED patient population (Up to 23% in some studies)
- More common in chronic pain
Manage Exacerbations of Acute Pain
Rational Referral
- PCP: Many PCPs manage depression and chronic pain. Can help coordinate other services that might help
  - Psychiatry
  - Physical therapy
  - Pain specialist
  - Social Work: Can help with some of the socioeconomic factors that contribute to depression
  - Surgery: If pain is caused by issue that might be amenable to surgery (i.e. joint replacement)

GLOBAL Health update with Dr. Wright

Intro to Global Health / UC Global Health Program

UC Program grew with involvement in Haiti
Continues to grow/expand

Opportunities for Involvement

Villiage Life (Shirati, Tanzania)
- Founded in 2003
- Received UC Health funding in 2014
- Partnered with SHED (Non-profit in Shirati, Tanzania)
- Daily experience
  - Sota Clinic
  - Roche Clinic
  - Shirati Hospital
Guatemala (Western Highlands of Guatemala)
- Partnership with Mayan Health Alliance
- Experience
  - Home visits
New Partnership with Lithuania University of Health Science
Events with UCEM
- GR Lectures will be incorporated more often into grand rounds
- Global Health events
  - Upcoming event 9/12

Taming the SRU: DKA with Dr. Colmer

Case: Young female presents to the ED obtunded. She had been dropped off and left outside of ED by private vehicle.

Initial Evaluation:

Primary Survey
- Airway was patent
- Breathing seemed deep and rapid (Kussmaul Breathing)
- No obvious signs of breathing
Vitals
- HR 122
- BP 83/68
- RR Rapid
- O2 98%
- Temp (Rectal) 89.9 Degrees
- ***FINGERSTICK GLUCOSE = HIGH***
GCS
- E1
- V1
- M4

Diagnostics

Notable Laboratory Studies
- pH: 6.69
- Renal Panel
  - Glucose 1020
  - Cr. 2.4
  - Potassium 8.3
- Blood Count
  - WBC 41.2
- Urinalysis: Ketones
Imaging Negative

Assessment:

AKI
Hyperkalemia
DKA
Likely Sepsis

Learning Points:

Fluid Resuscitation in DKA
- Fluid slection
  - For most resuscitation, type of fluids likely doesn't have large impact
  - In large volume resuscitation, less acidic fluid likely beneficial
    - Large RCT assessed bicarbonate and Cl after resuscitation in DKA
      - Higher pH fluid had lower chloride and higher bicarb than normal saline
    - Retrospective analysis compared plasmalyte and NS
      - Evaluated 4-6 hours following resuscitation
      - NS had lower levels of bicarbonate and increased base deficit following resuscitation
  - May be beneficial to choose normal pH fluid in DKA
Management of Hyperkalemia
- See Morbidity and Mortality Case above
- Use of Calcium
  - Calcium Chloride and Gluconate have similar efficacy
  - Onset and duration
    - 3-5 Minutes of onset
    - Duration 30 minutes to 1 hour
    - Dose q5 -10 minutes until effect
    - Re-Dose

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M&M - Sports Medicine: the exam - accidental hypothermia - Chronic Pain and depression - Global Health Update - Case: DKA