Grand Rounds Recap 11.11.20
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ultrasound grand rounds WITH dr. stolz
Ultrasound of the lower extremity
Knee Ultrasound and Arthrocentesis
Suprapatellar bursa: directly communicates superiorly with the joint space
Likely location of knee effusions
Arthrocentesis techniques:
In-plane technique: probe in the transverse plane
The needle is parallel to the probe and offers excellent needle visualization
Ultrasound guided arthrocentesis: 96% success vs 79% of the time blind
More fluid obtained and increased satisfaction
Ankle ultrasound and arthrocentesis
Probe in the longitudinal plane with indicator cephalad and orthogonal plane (transverse) “one view is no view”
Important to do the “normal” side
Will see the talar dome and talar head more distal
Tibia is more proximal, tibiotalar joint is where the effusion is seen
Arthrocentesis: DP artery should identified
Probe in transverse
Anesthetize the area under visualization
Antero-medial approach to go under the tibialis anterior
Can do it out of plane as well with probe in long axis
Though makes it more likely to hit the dorsalis pedis
Achilles Ultrasound
Anisotropy: the property of being directionally dependent
Artifact of the tendons, can resolve this by rocking your probe
Waves of the probe are hitting the very reflective and well arranged fibers of the tendons
If they hit them at any angle you will lose the wave as it bounces into oblivion
Change the angle of the probe to to hit the fibers at the right angle
>1cm of the tendon indicates a partial tear, especially when comparing them to the other side
Gastrocnemius tear at the myotendinous junction:
Hypoechoic or anechoic cleft in the tendon for tendon tear
Make sure to rock the probe to evaluate for anisotropy
Posterior acoustic shadowing - from the torn tendon ends:
Especially when there is hemorrhage in the tendon as it may match the surrounding echogenicities
Kager's fat herniation - rests just anterior to the tendon in the ankle
Fat will herniate posteriorly to the tendon
Lower Extremity DVT
ED providers performing bedside DVT US
95-96% sensitivity
96-96.8% specificity
Well’s low risk on DVTs can d-dimer
If negative dimer and negative 2-point scan no need to due more workup
Saphenous vein can look like an “eye” and many different shapes
A valve is also right where it joins the femoral which can be seen on US
11% of the DVT studies find other reasons to have the pain
Cyst/mass, lymphadenopathy, hematoma, cellulitis, phlebitis
Baker’s cyst
Large anechoic area in the popliteal fossa with no color doppler flow
Speech bubble appearance - medial head of the gastroc and semimembranosus tendon
R1 Clinical Knowledge: Blood Transfusion Complications WITH Dr. ferreri
Compensation in oxygen deliver in blood loss
Can compensate up to a HCt of 10%, Hbg of 3-4
Mechanism:
Increased CO (tachycardia)
R shift of the Hgb-ox dissociation curve (allows increased O2 extraction by the tissues)
PRBC: “without” platelets and plasma- 80% is removed and preservatives are added
Treated:
Leukoreduced: decreased leukocytes in the donor blood, decreases risk of reactions
Irradiated: no t-cell
Washed: w/o plasma - patients with frequent febrile reactions or transfusion reaction
Frozen: with special blood types
When to transfuse:
<7g hgb, transfusion is just a band-aid will need to address the underlying pathology
Symptomatic anemia; <10g/dL
ACS: <8g/dL has morbidity and mortality benefits
Massive blood transfusion is guided by hemodynamic parameters
0.24% have a transfusion reactions, 1 in 1.8 million mortality
Hemolytic Transfusion reactions
1 in 76000
Error in collection of blood, pre-transfusion ABO testing, patient ID
Mechanism:
Recipient ABs react to the donor RBC with lysis
Destruction of them with activation of coagulation cascade, will present in DIC
Presentation
Febrile, hypotensive, tachycardia, bronchospasm with wheezing, DIC, AKI
Treatment
Repeat type and cross, coombs test, haptoglobin, LDH, LFTs, UA
Elevated LDH, indirect bili, + direct coombs, elevated creatine
Stop transfusion, IV hydration and supportive care.
Immunologic/allergic related transfusion reactions
Febrile Nonhemolytic
0.1-1% of transfusions
Mechanism
Recipient ab attack donor leukocytes and then performed cytokines (IL-1, 6, 8, TNF-a)
Decreased risk with leukoreduced RBC
Rarely fatal
Dx of exclusion
Rigors and fever as presentation
During or within 4 hours of transfusion
Headache, myalgias, tachycardia, dyspnea, chest pain, back pain
Infectious workup and hemolytic transfusion workup
Treatment
Stop transfusion until labs come back normal
Restart transfusion if mild or after consultation
Antipyretic pretreatment for future transfusion
Anaphylactic transfusion
1 in 20-50K transfusions
IgE mediated
Increased risk in IgA deficient, will need to be treated with washed RBCs
Will occur within seconds to minutes
Severity of symptoms vary
Urticaria/purpura, wheezing, bronchospasm, resp distress, angioedema, hypotensive, shock
Treatment:
Histamine blockade, respiratory support, epinephrine, steroids (methylpred), IVF +/- pressors as needed
Differential:
TRALI and TACO: these will not improve with epinephrine
TRALI
0.04-0.1% of transfusions
Risk factors:
Critically ill, especially volume overload
Products containing plasma
2-Hit Hypothesis of pathophysiology
1=pre-transfusion the neutrophils have been primed and are ready to have a robust response
2=transfusion is an innocuous signal that leads the neutrophils in the alveoli to degranulate
Will develop during or up to 6 hours post-transfusion
Diagnosis
Acute onset hypoxia
Bilateral infiltrate on CXR
Absence of volume overrated
No pre-existing ARDS
Treatment
Will need more volume
Supplemental oxygen as needed
Steroids are controversial
Will often resolve spontaneously in 24-48 hours
TACO
1% of all transfusions, one of the most common fatal transfusion reactions
It is the development of pulmonary edema from circulatory overload
Risks:
Rapid transfusion
Underlying cardio/renal disease
Hypoalbuminemia
Extremes of age
Low body weight
Occurs within 6-12 hours
Presentation:
Respiratory distress
Hypotension and tachycardia
Hypoxia
JVD and S3
Diagnosis:
Clinical
CXR, echo, BNP
Treatment:
Supportive and diuresis
Stop transfusion
Blood borne pathogens:
Transfusion associated sepsis - can be by any organism
Blood is routinely tested for many viruses
HIV is 1 per 6 million
Electrolyte abnormalities
Hyperkalemia
Fe overload: sickle cell or thalassemia
R4 Case follow up WITH dr. skrobut
Tamponade
10% of cancer patients will develop tamponade
Fluid accumulation and the pericardium can’t stretch anymore
Increased pressures which lead to decreased ventricular compliance (decreased SV and CO)
Hypotension and shock
Beck Triad:
Muffled heart sounds, JVD, Hypotension
Cardiac surgeon at Case Western
Skrobut Triad:
Elevated CVP
Screen for tamponade with IVC ultrasound
>2.1CM or <50% inspiratory collapse
Sensitivity 95%
Specificity 40%
Chamber collapse
RA systolic collapse is the earliest sign on echo
Specificity varies
If collapsed >⅔ of cycle is more specific
Diastolic RV collapse
Severity correlates with duration of collapse, specificity of 75-90%
Mitral valve is open during diastole
M-mode through the Mitral valve
Will look at the RV collapse when the mitral valve is open (when the valve is touching the septum)
Pulsus paradoxus
Traditionally on A-line defined as >10mmHg decrease in SPB during inspiration
In-flow velocities on ultrasound
Mitral 40% increase during inspiration
Tricupsid 25% decrease during inspiration
Treatment:
Call cardiology and start pre-load
Pericardiocentesis with the 2-person technique:
Apical 4 view with one person
Subxiphoid approach as the other person
Emergency medicine in the austere setting WITH dr. ryan knight
Disaster Management model works well:
Plan, Prepare, Practice, Perform
Problem
Africa is LARGE, can fit most of Europe, India, China, US with room to spare
US fits easily in North Africa
Major movements just moving 1 country over
Plan
Medical threat analysis - CDC, Department of State, CIA
Run down for unique threats to each environment
The features of the community (physicians per capita and where they are)
Where are the closest hospitals?
Look at these hospitals and survey these places
Standard form filled out and logged
Imaging, types of specialties, units of blood and the supply chain, need phone numbers to activate resources
Staffing in the ED and trauma at times of the day
How far is hospital from airport, how big of a helicopter can come in
How to get patients around?
Propeller planes over large distances
Sometimes you have to fly around countries due to politics
Prepare
Be creative
Always strive to make patient more comfortable and improve quality of care
What to pack?
All things being taken should serve more than 1 function
Which Abx to take? Ceftriaxone and Ertapenem
Toilet paper rule=nothing else takes its place because it does its job so well
Insulin
Ultrasound: it is everything in the Austere setting!!
Very easy to take with you
Take care of yourself
Know the diseases that you are going to encounter
Blood
Difficult to maintain blood that expires in 30 days
Walking blood bank
Everyone knows their blood type
A chart is made of who can donate to who in a given unit
Practice
Training partners in the region
Train the medics to help their teams and ours
Rehearsals are done with the full teams, especially when working with new teams
Want to move as smoothly as possible when in the real deal
Practice extraction from tough areas
Perform
Do the work and hope the upfront knowledge prevents improvisation
Use the resources at hand
Set up in a gym:
Hang things from the weight racks
Use PT table to lay people on
Understanding anatomy will help perform procedures and skills you are not overly familiar with
Veterans Days Facts:
Woodrow Wilson created Armistice Day on 11/11/1919 to celebrate world peace - it was the 1 year anniversary of the ending of WWI
At 11am on 11/11/18 the Armistice went into effect
Last shots fired at 10:57 by US navy
Set to land just prior to Armistice
2738 died on that day even though the peace agreement was signed for months
In 1954 it was changed to Veterans Day to celebrate all veterans
Memorial Day honors those that died in the military service
fastest trial WITH dr. walsh
FASTEST Trial (FVIIa for Acute hemorrhagic Stroke Administered at Earliest Time)
Exemption from informed consent for emergency studies
Investigate whether Factor VIIa given w/i 2 hours can improve outcomes in selected patients at 180 days
Patients 18-80 with spontaneous and have to be able to get it w/i 2 hours of LKN
Excluded who have already in deep coma or large areas of bleeding already destined to die
Recent heart attack, stroke, blood clots in 3 months, on a blood thinner
Mobile Stroke Unit will minimize the time to treatment
r1 clinical knowledge WITH dr. yates
Prevalence is 4-60/10000, Mortality is 3-25% (depends on risk factors)
Risk factors
Patient risks (advanced age, overlying soft tissue, immunosuppression)
Joint risk (RA, OA, prosthetic, recent surgery or injections)
Risky sexual behaviors - gonococcal
Knee is the most common but any joint can have SA
How do they get infected?
Hematogenous spread
Direct spread - injections, trauma, prosthetics
Contiguous - soft tissue infection or osteomy
Microbiology
GPC (72%) - mostly staph but also strep
15% Gram Negative
Gonococcal - mostly in younger adults
Presentation
Fever, chills
Joint
Red, warm, swollen
Decreased active and passive ROM
Differential diagnosis for acute monoarthritis:
Infection
RA
Gout
Pseudogout
Osteoarthritis
Intra-articular injury
Workup:
Imaging
Plain radiographs
Joint effusion, may be normal in the early stages
More helpful with differential
Ultrasound
Joint effusion to help guide aspirations
Especially helpful in superficial joints and children (small joints)
Lab studies
WBC: >10K sensitivity of 90%, spec of 36%
ESR/CRP
ESR is an index of non-specific inflammation
ESR: Sensitivity of 66-95% Specificity of 29-48%
CRP is acute phase reactant in the liver
CRP: Sensitivity of 77-9% Specificity of 15%
Blood Cultures
Can be helpful in ID the pathogen of the septic arthritis
⅓ of patients it is positive
Positive in 14% with a negative Synovial culture
Synovial fluid (gold standard for dx)
Positive LR of WBC is increased as the values increase
LR of 28 at >100K and 7.7 at >50
Need Gram stain and culture, cell count and diff, crystals
Lactate doesn’t help with the differential
Prosthetic joints - mostly likely to occur in the first 2 years after replacement
Gout - crystals do not exclude septic arthritis
Immunocompromised
HIV=MRSA most likely
RA=damaged joint + Immunocompromised
Overlying SSTI
No studies to determine the rate of spread with overlying infection
Discuss this with the consultant
Arthrocentesis
Shoulder
Anterior approach: externally rotate and needle goes lateral to coracoid process and medial to humeral head
Posterior : find acromion, 1 cm medial and inferior to the process
Elbow
Radial head, lateral epicondyle, lateral olecranon - into the center of the triangle with elbow at 90 degrees
Wrist
Radial tubercle of distal radius, anatomic snuffbox, extensor pollicis longus, common extensor tendon
Treatment
Abx: Gram positive and pseudomonas: vancomycin and cefepime
Ortho consult - may require surgical management
Septic Bursitis
Bursa are fluid filled between joints
Very rare diagnosis
Risks are similar to septic arthritis
Differentiate between septic arthritis and septic bursitis
Septic bursitis will have no pain with passive but will have pain with active ROM
Similar coverage Abx
Discuss aspirate with ortho colleagues
pediatric rashes WITH dr. cheetham
SJS: medications are the trigger
May not be able to identify trigger in over ⅓ of cases
Disseminated rash: dusky red, coalescent macular exanthem
Atypical target lesions
Bullous lesions
Mucosal involvement in 90%
Nikolsky sign positive
CBC/ CMP/Blood culture
At risk for hypovolemic/ septic shock
Pain control
Hydration and stop offending agent
MIRM (Mycoplasma pneumoniae-induced rash and mucositis): prodrome of cough, fever
Mucocutaneous eruption of <10%
DRESS: AEDs are most common cause
Associated with atypical antipsychotics, sulfa drugs
Organ involvement in 90%
Hepatitis
Acute Interstitial Nephritis
Cough, tachypnea, dyspnea, hypoxia due to interstitial pneumonitis or pleural effusion
Hallmark is Eosinophilia
Stop offending agent, systemic corticosteroids if pulmonary or renal involvement
2-6 weeks after beginning of the agent
SSSS
Usually children <6
Caused by exotoxin from staph infection
Prodrome of fever, irritability, poor feeding
Rash evolves over time:
Macular erythema and skin pain
Generalized skin erythema
Development of flaccid bullae
Shallow erosions with superficial desquamation
Usually arises from a focus of infection
Requires hospitalization
Supportive care
IV anti-staph - oxacillin, nafcillin
May see clindamycin for antitoxin in severely ill patients but not great evidence to support this
Neonatal HSV
Different types:
Localized to skin, eye, mouth
CNS w/ or w/o SEM
Disseminated disease involving multiple organs
Swabs in newborns: Eyes, nose, recturm, mouth
Workup: neonatal sepsis workup, CMP, HSV PCR of CSF and serum as well
Management: IV acyclovir
Erythema toxicum neonatorum
Pustules that are not bunched together, well appearing child
DDx: neonatal acne, milia, HSV, staph folliculitis, transient neonatal pustular melanosis
Workup: no workup if appearing well
Management: none
Transient neonatal pustular melanosis
Not bunched up
Neonatal acne, mili, HSV, staph folliculitis
Workup: none if well appearing
Management: none- dont pop them
Omphalitis
Some times they look very sick and sometimes they look ok
Area is very indurated and cellulitic like
”Cherry redness” spreading out is indicative vs granular tissue
Differential: physiologic d/c, sepsis, necrotising fasciitis
Workup: culture the discharge, neonatal sepsis workup
High rate of bacteremia: 50%
Management: broad spectrum abx
Diaper dermatitis - irritant dermatitis
Management: good barrier cream, out of the diaper time, letting it dry out (with cool hair dryer setting)
