Grand Rounds Recap 10.26.22
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Crush Injuries WITH Dr. Della Porta
Epidemiology
0.074% presentations to ED’s
74% lower extremity injuries
10% upper extremity injuries
9% trunk injuries
Male > Female, Age < 35 most common
Pathophysiology
Direct compressive force leads to tissue ischemia
Subsequent reperfusion injury leads to reactive oxygen species, immune activation and cell death
History/Exam
Erythema, ecchymosis, mottling
Myalgias
Myoglobinuria
Trauma (fractures)
Sequelae
Acidosis, hyperkalemia, hypocalcemia
Renal failure
Dehydration and hypotension
Myopathy
Hematuria/myoglobinuria
Rhabdomyolysis
Serum CK peaks during the first 2-3d, will downtrend in 5-7d
Pre-Hospital Care
Administer intravenous fluids before releasing crushed extremity
Do not tourniquet the affected extremity
Amputation is an absolute last resort
Obtain a baseline EKG, treat as appropriate
Management: CRUSH It
C: Compartment checks
R: RRT/ Rhabdo
U: UOP of 300 mL/hr
S: Sour - watch acid status
H: Hyper/Hypo electrolyte
Renal Replacement Therapy
No “prophylactic” dialysis
Life-threatening electrolyte derangements of anuria
CRRT > iHD
Fluid Resuscitation
Fluids within 6 hrs
UOP 300 mL/hr
Foley placement
LR > NS
LR carries lower risk of need for urine alkalinization
Acidosis
Serum acidosis is likely due to lactate
Monitor urine pH
Use LR to target urine pH of 6.5, and clearance of lactate
Bicarb maybe as last ditch effort if you only have NS first 24 hrs
Electrolytes
EKG at first contact
1 gm Calcium gluconate
5-10 U Regular Insulin
1-2 amp D50
Electrolyte derangements
Hyperkalemia is the only electrolyte abnormality that requires rapid correction in order to reduce the risk of cardiac dysrhythmias
Empiric correction of hypocalcemia with calcium chloride or gluconate should be avoided since calcium deposition may occur in injured muscle. Later, serum calcium levels return to normal and may rebound, causing hypercalcemia due to release of calcium from injured muscle and mild secondary hyperparathyroidism secondary to AKI
Other considerations
Tetanus
Prophylax these patients just as you would any other trauma patient
Compartment checks
Acute compartment syndrome is a clinical diagnosis; delta < 30 mmHg
Antibiotics
Any open fracture require orthopedics consult and antibiotics
Prognostication
McMahon Score > 6 predicts need for dialysis
Time > 24 hours portends higher mortality
Acute renal failure present in 15%, lending mortality 20-59%
Upcoming research
Ultrasound may be able to differentiate normal muscle vs. rhabdomyolysis
QI/KT: Preeclampsia and Eclampsia Management WITH Drs. Brower and Jackson
Definitions
Chronic Hypertension in Pregnancy
Hypertension diagnosed prior to pregnancy or at 20 wks
Gestational Hypertension
New onset hypertension without proteinuria > 20 wks
Preeclampsia without severe features
New onset hypertension at > 20 weeks gestation and proteinuria or end-organ dysfunction
Hypertension: SBP > 140, DBP > 90
Spot urine protein:creatinine ratio > 0.3 (81% sensitive)
Preeclampsia with severe features
Severe range BP (>160/110), headache (not relieved with treatment), RUQ/epigastric pain, visual disturbance, SCr doubled from baseline or > 1.1, Plt < 100,000, ALT/AST > 2x upper limit of normal, pulmonary edema
Eclampsia
Seizure in any pregnant patient or up to 6 weeks postpartum
HELLP
Hemolysis, Elevated Liver enzymes, Low Platelets
Epidemiology
While maternal mortality is much lower in high-income countries, 16% of maternal deaths globally can be attributed to this spectrum of disease
This spectrum of disease is a costly complication in the US healthcare system estimated to cost over $2 billion within the first 12 months of delivery – the majority of this cost being driven by premature births
Several studies have demonstrated that rates of preeclampsia-spectrum disorders, particularly chronic hypertension of pregnancy, are increasing in the US due to increasing rates of obesity, diabetes, IVF and consequent multiple births, as well as pregnancies at higher maternal ages
Pathogenesis
Various mechanisms for pathophysiology of preeclampsia have been proposed including chronic uteroplacental ischemia, immune maladaptation, an exaggerated maternal inflammatory response to deported trophoblasts
Antiphospholipid antibody syndrome, prior history of preeclampsia, and chronic hypertension conferred the greatest risk of subsequently developing preeclampsia
Definitive treatment is delivery
Diagnostics
CBC - thrombocytopenia
BMP - renal injury
LFT - transaminitis
LDH, uric acid - hemolysis
UA - proteinuria, UPC
History
Headache 50% sensitive
Visual disturbances 80% sensitive
Epigastric pain
Medical Treatment
Outpatient antihypertensives
Labetalol
Nifedipine
Urgent Anti-Hypertensive Therapy
Labetalol
10-20 mg IV, then 20-80 mg q10-30min to maximum cumulative dose of 300 mg or 1-2 mg/min IV infusion
Tachycardia is less common with fever adverse effects
Avoid in women with asthma, preexisting myocardial disease, decompensated heart failure, and heart block/bradycardia
Onset: 1-2 min
Hydralazine
5 mg IV/IM, then 5-10 mg IV q20-40min to a maximum cumulative dose of 20 mg or 0.5-10 mg/hr infusion
Higher and/or frequent doses associated with maternal hypotension, headaches, and abnormal fetal heart rate tracings
Onset: 10-20 min
Nifedipine
10-20 mg PO, repeat in 20 min if needed then 10-20 mg q2-6hrs to maximum daily dose of 180 mg
May result in reflex tachycardia and headaches
Onset: 5-10 min
One trial (Shekhar et al 2013) demonstrated that nifedipine lowered blood pressure more quickly than IV labetalol
Aspirin Prophylaxis
Initiate low-dose ASA ppx if
If 1 High Risk Factor
History of preeclampsia (especially when accompanied by adverse outcome)
Multifetal gestation
Chronic hypertension
Type 1 or 2 diabetes mellitus
Renal disease
Autoimmune disease (i.e., SLE, APS)
If > 1 Low Risk Factor
Nulliparity
Obesity (BMI >30)
Family history of preeclampsia (mother or sister)
Low socioeconomic status
Maternal age ≥35 years
Other factures (e.g., low birth weight or small for gestational age, previous adverse pregnancy outcome, more than 10-year pregnancy interval)
Management of Eclampsia
Recognition of pregnancy in seizing patient
Ultrasound may be more expedient than urine or serum testing
Magnesium
Intravenous: 6 g loading dose over 20-30 min followed by maintenance infusion of 2 g/hr
Intramuscular: 10 g loading dose (5 g IM in each buttock) followed by 5 g every 4 hours
Renal dosing: 6 g loading dose ONLY or consider following with maintenance infusion of 1 g/hr
Therapeutic goal: 5-9 mg/dL, though no high level data to support this
Monitor patellar reflexes and respiratory rate
Continuous urine output measurement
Anticipated effects of Magnesium toxicity:
5–9 Therapeutic range
8–12 Loss of patellar reflex
9–12 Feeling of warmth/flushing
10–12 Double vision, somnolence, slurred speech
>12 Respiratory paralysis
15–17 Muscular paralysis
24–30 Cardiac arrest
If concerned for toxicity, stop magnesium infusion and administer 1g calcium gluconate over 5-10min
Delivery Recommendations
Chronic HTN in Pregnancy
Not on Medications: 38w0d–39w6d
Controlled on Medications: 37w0d–39w6d
Not Controlled on Medications: 36w0d–37w6d
Gestational Hypertension
Regardless of Medication Control: 37w0d
Preeclampsia
Without Severe Features: 37w0d
Severe Features, Stable Mom/Fetus: 34w0d
Severe Features, Unstable Mom/Fetus: Immediate Delivery
Evidence
Treatment of Chronic Hypertension in pregnancy
Initiation of antihypertensives to reduce blood pressure below 140/90 vs standard care
18% RR reduction in composite outcome (preeclampsia with severe features, medically indicated preterm birth at < 35 weeks, abruption, fetal or neonatal death)
Aspirin Prophylaxis for patients at increased risk for preeclampsia
USPSTF Systematic Review of 23 studies
Aspirin use was significantly associated with lower risk of developing preeclampsia, perinatal mortality, preterm birth, IUGR
Delivery Decisions
HYPITAT Trial - Multicenter RCT in Netherlands N=756 randomizing patients with gHTN or Pre-E to induction at 37 weeks vs expectant management
Occurrence of poor maternal outcome was significantly lower for women allocated to induction of labor than for those allocated to expectant monitoring
Allocation to induction of labor corresponded to a relative risk reduction of 29% and a number needed to treat of 8 to avoid a poor maternal outcome
This reduction was mainly attributable to differences in the rates of progression to severe hypertension
Subgroup analysis as depicted here demonstrated that all subgroups except women with gestational age 36-37 weeks or cervical dilatation >2 cm trend toward a better maternal outcome with induction of labor as compared to expectant management
Significant crossover into induction group
Early Preterm (<34 Weeks) Cochrane Review
Meta-analysis is based on 4 trials with a total of 425 women with severe preeclampsia comparing early elective delivery after administration of antenatal steroids vs expectant inpatient monitoring until 34 weeks gestation or until delivery was warranted by deterioration in maternal or fetal condition
Expectant management until 34 weeks gestation may be associated with decreased neonatal morbidity
Unable to draw any reliable conclusions regarding the effect on maternal outcomes or perinatal mortality
Increased risk of neonatal IVH or hypoxemic ischemic encephalopathy
(RR 1.82, 95% CI 1.06-3.14)
Increased risk of infant respiratory distress syndrome
(RR 2.30, 95% CI 1.39-3.81)
Early Preterm (<34 Weeks): MEXPRE
Multicenter RCT randomizing Singleton or twin pregnancies at 28w0d-33w6d gestation with severe gestational hypertension or severe preeclampsia to Steroids with prompt delivery in 48 hours vs. expectant management
Outcome showed no neonatal benefit with expectant management of severe hypertensive disorders from 28-34 weeks
Preeclampsia
Magpie Trial - Women with Pre-eclampsia randomized to MgSO4 prophylaxis or placebo
58% relative risk reduction for eclampsia, NNT 91
45% relative risk reduction for maternal mortality (p = 0.11)
Regarding secondary outcomes, there were no significant differences in any measures of maternal morbidity, perinatal mortality, or neonatal morbidity
The only clear difference in outcome related to pregnancy, labor, or delivery was a 27% lower relative risk of placental abruption in the magnesium group as compared to the placebo
Eclampsia
Cochrane Review 2010 of 7 trials examining treatment of eclamptic patients with magnesium vs. diazepam evaluating maternal mortality and recurrence of seizure
Pooled relative risk analysis favored magnesium over diazepam for both maternal mortality and recurrence of seizure
Cochrane Review 2010 examining treatment of eclamptic patients with magnesium vs. phenytoin evaluating maternal mortality and recurrence of seizure
Pooled relative risk analysis favored magnesium over phenytoin for recurrence of seizure, but no difference in maternal death
Dogmalysis: Pharmacotherapy WITH Dr. Nagle
Dogma: Tetracaine should not be given long term to patients with corneal abrasions or ulcers
Tetracaine has been shown in vitro to destroy epithelial cells on the cornea, and should not be provided for home use to patients with corneal abrasions
Rabbit corneas used in studies are more sensitive to changes in pH
Most did not include humans outside of case reports
Double blind RCT comparing tetracaine to normal saline showed its use is safe for home use for short duration (~24 hours)
Should be provided to reliable patients
Contact lens users may have higher rates of complication
Dogma: Lidocaine with epinephrine should not be injected in a digit, nose nor penis
Studies demonstrating harm were published before 1948, before standardization of drug compounding
Avoid in known vasculopaths, but is generally safe to use in these areas
Lidocaine with epinephrine may be helpful during penile nerve block during priapism drainage to facilitate detumescence
Dogma: Patients should refrain from drinking alcohol when taking metronidazole
Metronidazole has no impact on aldehyde dehydrogenase levels or activity
Most studies describing the disulfiram reaction were performed in nordic countries
Some of these reactions were thought to be drug reactions, and not an interaction between the medication and alcohol metabolism
Dogma: Antibiotic ointment shall be used to promote wound healing
Antibiotic ointment does not outperform petroleum jelly with rates of wound healing and rates of infection
Antibiotic ointments (neomycin and bacitracin) can cause allergic dermatitis, 8-11% in the US population
Dogma: Beware cephalosporins in patients with penicillin allergies
1% of patients with a penicillin allergy will have a reaction to cephalosporins
10% of the population reports that they have an allergy to penicillins, true prevalence is approximately 1/10 of this reported population by antigen testing
80% of these true allergic patients will lose sensitivity within 10 years
Dogma: Tramadol is an effective, low risk option for pain control
Multiple cochrane reviews question tramadol’s efficacy in neuropathic pain, osteoarthritis pain, cancer pain.
High risk for side effects
Opiate: somnolence, bradypnea, risk of dependence
SNRI: seizure, hyponatremia, paresthesias
Paranoia, hallucinations, anxiety, confusion
Hypoglycemia
In hospitalized patients, T1DM patients are 50% more likely to have a hypoglycemic episode if treated with tramadol
Metabolism is unpredictable and is dependent on native hepatic metabolism
10% are fast metabolizers, may see therapeutic effects earlier
Dogma: Beware ketamine use in TBI patients as it may increase ICP
Evidence is poor, systematic reviews do not show elevation in ICP or decrease CPP
Similarly, does not increase intraocular pressure
Dogma: In bariatric surgery patients, you shall avoid NSAIDs or risk GI bleed
Foundation: NSAIDs impair platelet adhesion, increase vasoconstriction of GI vasculature
Evidence in admitted, post-op GI patients who received toradol (in addition to post-operative pain management) did not demonstrate increased bleeding risk
Single dose probably does not confer harm, but research needed in the ED population
Dogma: A packed nose must go home with antibiotics
Prospective studies randomizing patients to receive augmentin for anterior nasal packing did not demonstrate differences in rates of infection
Antibiotics in posterior packing has also not been shown to improve rates of infection, though these patients are likely not going home due to risk of vagal stimulation
QIPS: Cost of Emergency Care WITH Dr. Thompson
Healthcare costs have risen steadily over the last 60 years
These costs have increased disproportionately in the private sector
91% of americans have some form of health insurance
35% have public insurance (medicare, medicaid, VA)
In the US, the cost of procedures is much higher than other counties in the world, but our overall healthcare outcomes are disproportionately lower than other developed nations
Medical debt is the largest cause of personal bankruptcy
Emergency room visits is the largest historical source of medical debt
In 1965, medicare and medicaid were introduced by Lyndon B. Johnson
In 1970s, the rise of for-profit hospitals has escalated the price of healthcare
Healthcare costs were increased by hospitals and providers to offset “discounts” provided by insurance agencies to maintain net profit
Every hospital is required to publish a “charge master” with the charges attributed to facilities, services, procedures, etc.
For patients with insurance, the insurance company will pre-negotiate a price with the hospital for most diagnoses
Negotiated charge to insurance company is often less than the summative charges of items included in care
The No Surprises Act – Federal Law in effect Jan 1, 2022
No surprise billing for emergency services.
When you receive out-of-network ancillary care at an in-network facility, it must be treated as an “in-network” service.
Health care providers and facilities must use clear, understandable language to obtain patient approval before providing and billing for out of network care.
The regulations don’t prevent patients from receiving care from their preferred providers.
The U.S. Department of Health and Human Services (HHS) began implementing the first regulations January 1, 2022.
Private Equity in Healthcare
Firms that invest in businesses with goal of making more money
Accusations: prioritizing profit, metrics, efficiency over quality
>40% of EDs are overseen by staffing companies
Nearly all of them are owned by PE
Some of the largest profits are in EM
Concern: companies making policies over physicians
30 states have laws against "corporate practice of medicine"
How do we combat the rising cost of healthcare?
Apply clinical decision rules to eliminate unnecessary or low value investigations
Avoid pre-ordering; order the minimum amount of necessary testing
Communication with patients and family, shared decision making, goals of care discussions
