Grand Rounds Recap 12.1.21

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EMS Grand Rounds WITH Dr. Skinner

Dr. Skinner explained recent changes or updates to local EMS protocols.

  • Mechanical Ventilator Setup and Management

    • EMS indication for ventilator is > 16 years old and intubated

    • Current protocol prioritizes compressions and ACLS to intubation when manpower does not allow it

    • Initial ventilator setup based on standard settings in AC and following EtCO2

  • Ventilation During Cardiac Arrest

    • Recommended breathing rate in children and infants during CPR is 1 breath every 2-3 seconds (20-30 breaths per minute), as higher rates can cause hemodynamic compromise. This is an increase from prior recommendation of 12-20 breaths per minute and matches the latest PALS update.

    • Notably the evidence this was based on consisted of mostly bradycardic arrest, and no patients in PEA or asystole survived, so there may be differences based on patient presentation.

  • Prehospital communication: STEMI, Stroke, and Sepsis specific alerts have been added to the vocabulary used for notification calls.

  • Physician On Scene: Any physician on scene can assist EMS with resuscitation, but does not necessarily take over the scene and does not have to travel with EMS to the hospital.

  • Access in cardiac arrest: IV access is preferred for drug administration, but IO should be used if no IV can be established. Current evidence suggests better outcomes when medications are administered intravenously.

  • Hypotension/Shock protocol updated to include criteria for use of push dose epinephrine in patients 16 and older. 

  • Bradycardia protocol updated to increase atropine dose from 0.5 mg to 1 mg IV/IO and to allow versed use during pacing if blood pressure allows.

  • Narrow-complex tachycardia protocol now includes passive straight leg raise in valsalva maneuver for abortion of SVT. The definition of instability no longer includes blood pressure criteria, but relies on signs of shock or hypoperfusion.

  • Post-ROSC oxygen administration should be highest available flow until SpO2 can be attained, then target of 95% or greater. 

  • Hyperthermia/heat emergencies protocol no longer includes versed to stop shivering. If means of cooling are available on scene, they should be cooled there. 

  • Pediatric pulseless cardiac arrest protocol no longer requires dilution of amiodarone, but continues with 5mg/kg dosing and max of 300 mg. 

  • Pediatric anaphylaxis protocol now allows use of pediatric epinephrine autoinjector in patients > 10 kg. No epi dosing is recommended below that weight. 

  • Intubation protocol now requires use of EtCO2 confirmation for both ETT and SGA. 

  • Pediatric needle cricothyrotomy protol now updated to differentiate protocol in patients greater than and less than 5 years of age. Surgical cricothyrotomy recommended in patients greater than 10 years of age. 

  • Cardiac arrest in pregnancy protocol now requires transport of all patients > 24 weeks or greater. 

  • EMS providers are now allowed, but not required, to collect blood samples for law enforcement. This is in line with current Ohio law. Providers can refuse the blood draw if there is concern that it could endanger the patient's health, delay transport, require access of a port, the patient is deceased, or consent has not been obtained. EMS providers must have received training to be able to perform this. 

R3 Taming The SRU: Thrombosis in COVID-19  WITH Dr. Gressick

Thrombotic Events in COVID-19

  • Overall thrombotic events are more common in COVID patients

  • PE incidence is estimated at about 15% of patients with COVID-19

    • 25% of patients with covid pneumonia

    • 50% of patients admitted to an ICU

D-dimer in COVID:

  • Median D-dimer level in COVID is 1.1ug/mL

  • There is a statistically significant increase in D-dimer in patients with PE in COVID, when compared to those with COVID only

  • There is no established cutoff for diagnosis of PE in COVID, but current thought is that a cutoff of > 1.5 ug/mL (compared to current cutoff of 0.5 ug/mL) could be used

    • In one study this demonstrates 85% sensitivity and 88% specificity

  • Using a D-dimer cutoff of 1 ug/mL, a recent study found that 15% of patients had PE on CT scan

R4 Capstone: Wellness WITH Dr. Hunt

Tips for staying happy and avoiding burnout in residency:

  • 48 % of early practitioners indicated that they were not likely to choose medicine as a career again

  • Recent studies show EM resident burnout rates > 60%

  • Why do we suck at being happy?

    • We are perfectionists

    • We are always deferring gratification

    • We have trained to remain stoic

    • We have a strong sense of purpose

Rules for Happiness During Residency:

  • Prioritize personal relationships

    • Happier people have stronger personal relationships and are more social

    • Happiness was not correlated with exercise, financial attainment, participation in religion, physical attractiveness, or use of drugs or alcohol

    • Your personal relationships must adapt to where you are in life, in both time and hierarchy.  Coping with relationship issues can become strained due to time constraints and outside stressors. Identity dissonance also occurs between our life in and out of the hospital, and this can affect who we select as friends.

  • Have a strong support network

    • Encouraging stronger support networks within a residency and through mentorship relationships can prevent burnout. 

    • Friendships at work improve happiness and satisfaction with work. 

  • Seek and implement feedback

    • Confidence positively influences health related quality of life.

    • Seeking feedback encourages growth and increased confidence.

    • Having goals for improvement makes us more likely to recognize the progress we have made.

  • Take control of your own time

    • Getting notes done at work, prevents them from taking up time you could have to yourself.

    • Choose the opportunities that you want to pursue and learn to say no in order to prevent spreading yourself too thin

    • Offloading chores such as grocery shopping or house cleaning frees up time to do things for yourself

  • Take vacations: plan ahead and get away to unplug. A staycation does not provide the same amount of stress relief. 

  • Treat yourself: make a plan to do something nice for yourself every few weeks. 

  • Get a dog.

R1 Clinical Diagnostics: Nephritic and Nephrotic Syndrome WITH Dr. Sobocinski

See Dr Sobocinski’s full post here

Glomerular inflammation causes:

  • Loss of proteins through the basement membranes, including immunological molecules, clotting factors, and albumin

  • Passage of RBCs into the renal tubules

  • Upregulation of the RAAS leading to sodium retention and hypertension 

Nephritic syndromes are due to inflammation of the glomerular basement membrane, leading to hematuria and subnephrotic proteinuria (<3.5g/day). Symptoms include hypertension, azotemia, edema, hematuria, and impaired renal function.

  • Some are well characterized, such as HUS. Others are less well defined, such as lupus nephritis or MPGN, which exist of a spectrum of nephritic to nephrotic. 

  • PSGN/Infection related GN

    • Labs – UA showing hematuria sub-nephrotic and  proteinuria, BMP with decreased renal function​

    • Management – treat active strep infection (Penicillin), diurese for edema (IV Lasix 1 mg/kg), consider blood pressure management​ (nicardipine gtt is preferred if end organ damage present)

    • Prognosis – kids typically recover with normal renal function (>90%)​

Nephrotic syndromes are characterized by glomerular damage (likely podocyte cell defects) leading to passage of large molecules such as albumin and other proteins into the urine​. 

  • Clinically, this results in  foamy urine, new edema, and exertional dyspnea. ​

  • Effects 3/100,000 adults and 2-7/100,000 children in US per year​

  • Clinical definition:

    • Proteinuria > 3.5 g/24h

    • Hypoalbuminemia < 2.5 mg/dL

    • Edema (pitting or not)

    • Hyperlipidemia with total cholesterol > 350 mg/dL

  • Primary causes: FSGN, minimal change disease, membranous glomerular disease, MPGN (IgA nephropathy)

  • Secondary causes are broad and include: immunologic, oncologic, metabolic, drug induced, infectious, congenital, and other etiologies

  • Minimal change disease: 

    • Epidemiology: approximately 80 % of pediatric nephrotic syndromes, most common <6 years old, male predominant (2:1 ratio)​

    • Symptoms:  edema to anasarca, abdominal pain, malaise, dyspnea, occurrence of abdominal hernias

    • Laboratory evaluation​: UA, CBC, BMP, hepatic panel, CXR, consideration of other infectious or thrombotic workup​

    • Management : Diurese with Lasix 1 mg/kg IV (<40 mg total), consider albumin (0.5-1g/kg)​.  Give PSCV23 if >5 years out from last dose, might coordinate with Nephrology​

    • Prognosis: Good overall, most children will respond to steroid course

  • Complications

    • Thrombosis: Due to loss of inhibitory coagulation factors (antithrombin III, protein S) and a proposed compensatory increase in pro-coagulation factors (V, VIII, X and fibrinogen)​. Present in 25 % of adults, 3 % of children with nephrotic syndrome.

    • Renal injury (nephrotic syndrome):Typically see mild decrease in renal function with pure nephrotic syndrome​. Severe renal impairment in otherwise nephrotic picture should raise suspicion for alternate etiology (pyelonephritis, renal vein thrombosis)​. More severe renal injury is expected in nephritic syndromes.

    • Infectious: 

      • Loss of immune mediation molecules (complement, antibodies).

      • Functional hyposplenism due to loss of opsonizing proteins​

      • Extra-vascular low-flow volume as growth medium​

      • Bacteremia, peritonitis, UTI, pneumonia, empyema, cellulitis​

      • At particular risk for infections with encapsulated bacteria

    • Volume Derangement: 

      • Intravascular depletion, hypoalbuminemia​

      • Concomitant total body volume excess

    • Hypertension

      • Sodium retention, RAAS activation, increased ADH secretion​

      • Can lead to hypertensive encephalopathy (up to 5 % of children with acute glomerulonephritis)  

CPC: Urachal Remnant WITH Drs. Yates and Hughes

Dr. Yates presented a case of pediatric abdominal pain that was ultimately diagnosed as an infected Urachal Remnant. Dr. Hughes walked us through an excellent differential diagnosis and her clinical reasoning. 

Urachal Remnants

  • Fibrous cord of the allantois 

    • 1st trimester – helps facilitate removal of waste through umbilical cord 

    • 2nd trimester – bladder descends into pelvis followed by obliteration of the urachus

  • At birth the median umbilical ligament (the obliterated urachus) extends from the dome of the bladder to the umbilicus.

  • Epidemiology: 0.2-1% of pediatric patients have a urachal remnant, due to incomplete obliteration. Many of these are found incidentally, but they can rarely become infected or inflamed. 

  • Urachal remnants exist as a spectrum of anomalies:

    • Median umbilical ligament: Remnant can be normal up to about 6 months old, and it tends to resolve by one year of age.

    • Urachal cysts are the most common variant and most often present with infection.

    • Patent urachus presents in the postnatal period with straw colored fluid from an umbilical mass that can delay umbilical healing.

    • Urachal Sinus does not have communication with the bladder and can present with discharge and infection. Many of these are asymptomatic. 

    • Urachal diverticula are most often incidental findings, though when large in size they can increase the frequency of UTI.

  • Diagnosis: 

    • Ultrasound

    • Voiding cystourethrogram is more helpful for urachal diverticulums

    • CT and MRI can also be used

  • Prognosis:

    • Urachal adenocarcinoma is a potential complication that is extremely rare

    • Obliteration of the urachal remnant generally occurs spontaneously within one year, so many of these may be watched

  • Short-term management:

    • Antibiotics can be considered if there is significant pain and concern for inflammation or infection

  • Long-term management

    • Surgical excision can be considered when symptomatic. Previously, all urachal remnants were removed to prevent future adenocarcinoma, but incidence is extremely rare and NNT does not favor excision. 

    • These patients should be referred to urology for follow-up

R3 Small Groups: EM in the Sunshine State WITH Drs. Broadstock, Comiskey, Kimmel, Winslow

Lightning Strikes: Mortality is low unless cardiac arrest occurs. However, cardiopulmonary arrest carries a 75% mortality rate. In mass casualty situations, patients without pulse from lightning injury should undergo CPR and should not be "tagged black" given the possibility for recovery.

EKG may show QT prolongation, tachycardia/bradycardia, evidence of ischemia, which may present later. Complex pain syndromes, neurocognitive disorders, neuroendocrine dysfunction are all common following injury. Keraunoparalysis is predominantly lower extremity paralysis secondary to intense vasospasm that typically resolves in a few hours. Brief, resolved vision and hearing deficits are common; bilateral cataracts may develop days after injury. Unlike other high voltage injuries, burns and rhabdomyolysis are uncommon with lightning strikes. Lichtenberg figures are pathognomonic and are not true burns, thought to be extravasation of RBCs from forcefully contracting capillaries 

Transvenous Pacing: Indications are the same as those for transcutaneous pacing (heart block, symptomatic bradycardia), but transvenous pacing is better tolerated and does not require sedation. Contraindications include presence of an artificial tricuspid valve and hypothermia. Place catheter through introducer, watch EKG waveform, terminate when large ST elevations are seen, indicating contact with LV. Set output and sensing thresholds as directed, confirm with ultrasound or X-ray.

Maisonneuve Fractures involve disruption of the syndesmotic membrane with proximal fibular fracture and medial malleolar fracture that typically occur after a rotational injury. Xrays (including stress views) are the mainstay of diagnosis and patients can typically be splinted until orthopedics follow-up.

Traumatic Iritis presents with progressive symptoms of pain and vision changes following direct trauma to the eye. Exam will show consensual photophobia, cell and flare, and hypopyon. Other traumatic eye injuries, such as open globe, corneal abrasion, retinal detachment, and traumatic glaucoma should be ruled out. Treatment consists of cycloplegics, steroid eye drops, and close ophthalmology follow-up 

Malignant Otitis Externa occurs with extension of infection from the EAC to nearby structures (periosteum or bones of the skull base). Malignant OE is more common in immunosuppressed states and pseudomonas or MRSA are common pathogens. CT or MRI can be used for diagnosis. Treatment should include pseudomonal coverage. 

 Lime Phytophotodermatitis occurs after exposure of skin to lime juice (or the sap of other plants) followed by UV light exposure. Lesions can occur days after the initial lime exposure. Blister formation can occur and treatment consists of wound care and topical steroids. 

Stingray Barbs:  Mainstays of treatment include hot water immersion, irrigation, barb removal, local wound care, tetanus and antibiotic prophylaxis. X-Ray is an acceptable imaging modality for detection of retained barb.

Fish Hook removal: The push-through technique is helpful for hooks with multiple barbs. The string technique can be performed in the field most easily. The needle cover technique can be helpful with large hooks. Further details can be found on ALiEM. 

Vibrio Vulnificus: Consider coverage with a fluoroquinolone or with a tetracycline + 3rd generation cephalosporin in patients with cellulitis or NSTI who have a history of saltwater exposure.  

Taser Injuries: AAEM practice guidelines state there is no indication for  labs, EKG, cardiac monitoring, prolonged ED observation, or hospital admission in a patient who is awake, alert, asymptomatic, and had <15s exposure.  Providers should remove barbs and provide local wound care and administer tetanus toxoid as indicated.  

Naegleria fowleri is a freshwater amoeba that is most often prevalent in warm months (July-September). This causes Primary Amebic Meningoencephalitis (PAM) which presents with fever, neck pain, headache, and altered mental status. It is rare but almost universally fatal.

Rabies prophylaxis should be administered to anyone with possible exposure to bats, bites or saliva contact with raccoons, skunks, or foxes. Unvaccinated patients require treatment with rabies immunoglobulin (RIG) 20 IU/kg. As much of this dose as possible should be injected at the site of the bite, and any excess should be administered at a distant anatomic site. A 4-part rabies vaccination series (given days 0, 3, 7, and 14) should be initiated. Immunocompromised patients will also require a 5th dose on day 28. Extensive irrigation has been shown to significantly decrease the risk of infection. Previously vaccinated patients will boosters on days 0 and 3. RIG is not indicated in vaccinated patients. Tetanus prophylaxis and antibiotics should be administered if indicated. If the animal is healthy and asymptomatic, you can defer RIG/immunization if the animal can be quarantined for 10 days.

Eastern coral snakes are elapids (related to the cobra) occasionally confused with the non-venomous Kingsnake. Venom travels systemically through the lymphatic system, causing neurotoxicity. Weakness begins with CN involvement (diplopia, ptosis, difficulty swallowing) followed by descending paralysis and is due to competitive inhibition of the muscarinic acetylcholine receptors at the neuromuscular junction. Respiratory failure can occur. Immobilize the limb to minimize lymphatic spread. Venom extraction devices, wrapping the wound, tourniquets, and cutting have been shown to cause greater harm.

Leishmaniasis is a parasitic neglected tropical disease caused by the trypanosome Leishmania, transmitted by sand flies. Cutaneous leishmaniasis is most common and presents as ulcerative lesions with raised borders that can persist for months to years. Lesions are typically painless. Treatment is optional, as there is a significant amount of resistance, and should be discussed with an expert. Treatment is mandatory for mucosal and visceral (hepatosplenomegaly, pancytopenia, fever, weight loss) leishmaniasis. Regimens vary based on species and regional resistance pattern, but include amphotericin B.