Grand Rounds Recap 12.2.20

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Quality Improvement WITH Dr. dave Thompson

PDSA - Plan, Do, Study, Act

  • Applying scientific method to processes

  • Small tests of change and observing what happens

Root Cause Analysis

  • To understand a problem or event to avoid recurrence in the future

  • RCA for recurring problems, concerning trends, near misses, severe incidents

Process Map:

  • Analyze the workflow

  • Make the invisible visible

  • Can the default process be improved?

Swiss cheese model

  • Engineer and redesign process

  • Eliminate waste

  • Add safeguards (plug holes in cheese)

Fishbone/Cause and Effect/Ishikawa Diagram

  • Can be helpful while performing a root cause analysis


Pareto Principle and Pareto Chart

  • 80/20

  • “Vital few, trivial many”

  • Small amount of causes lead to the bulk of the outcome

R1 Clinical knowledge: Hypertension in pregnancy WITH Dr. Kelly tillotson

 Epidemiology

  • 22% of pregnant women worldwide experience preeclampsia

  • 2nd cause of mortality

Physiology

  • Blood pressure drops during the first 20 weeks of pregnancy

  • Will return to normal afterwards

Pathophysiology

  • Not completely understood, related with placenta

Complications

  • CNS dysfunction (seizure, coma)

  • Hematologic (coagulopathy)

  • CV (pulmonary edema, CHF)

Gestational HTN

  • HTN starting after 20 weeks of gestation

  • Asymptomatic and no lab abnormalities

  • 50% progress to preeclampsia

Preeclampsia

  • HTN starting after 20 weeks of gestation with EITHER

    • Proteinuria 

      • >300 mg protein/24 h

      • Urine protein:creatinine ratio >0.3

    • End organ damage

  • Can occur up to 4 weeks postpartum

  • Severe features:

    • CNS symptoms

    • Lab abnormalities

    • End Organ Failure

      • Pulmonary edema, CHF

      • Headaches, MS change

  • ACOG definition has changed

    • Degree of proteinuria does not equal disease severity

    • No requirement for proteinuria for diagnosis

    • IUGR dropped

Eclampsia

  • Grand mal seizure without other obvious cause

  • Preeclampsia history or prodrome

HELLP Syndrome

  • Hemolysis, elevated liver enzymes, low platelets

    • Hemolysis with schistocytes

    • Transaminitis/RUQ abdominal pain

    • Platelet count <100k

    • +/- HTN, proteinuria

Chronic HTN

  • Precedes 20 week gestation

  • Remains 12 week postpartum

  • Asymptomatic and normal labs

  • 50% progression to preeclampsia and eclampsia

Mimics

  • Substance use

  • Medications

  • Hyperthyroid

  • Hyperparathyroid

  • Pheochromocytoma

  • Adrenal pathology

  • Glomerulonephritis

  • Thrombotic microangiopathies (HUS, TTP)

Therapeutics

  • Limited data, minimal RCT on pregnant patients

    • Medications cross placenta

    • Teratogenic

      • ACE inhibitors, ARBs, MRAs

      • Nitroprusside → fetal cyanide

    • Acute vs chronic HTN management

  • First line agents

    • Labetalol

      • 20mg IV, every 10 min as needed until control of BP

    • Hydralazine

      • 5mg IV, every 20 min as needed until control of BP

    • Oral nifedipine (rapid release)

      • Does not require IV

      • Repeat every 30 min

    • Systemic Review showed all were equally effective to achieve control of BP without hypotension

  • Secondary agents

    • Esmolol gtt

    • Nicardipine gtt

    • Consult MFM

  • Magnesium sulfate

    • Seizure prophylaxis and seizure abortion

    • Mechanism: smooth muscle relaxant

    • Dosing

      • 4-6 gram IV loading dose

        • Careful in CKD patients, consider half dose

      • 2 gram/hr IV for 24 hours

    • Toxicity

      • Flushing, sweating, hypothermia, hypotension

      • Flaccid paralysis → monitor reflexes

      • Respiratory depression

HTN Numbers

  • 140/90 is cut off

  • Mild: <149/99

  • Moderate <159/109

  • Severe >160/110


Therapy Goals

  • HTN/preeclampsia = manage BP

  • Preeclampsia with severe features = prevent seizure

  • Eclampsia = stop seizure

  • HELLP = fix coagulopathy

Definitive Treatment

  • Delivery of placenta

  • Timing/manner clinically dependent

R3 Taming the SRU: Airway Obstruction WITH Dr. Logan Walsh

Case: Patient was eating a sandwich. Collapsed and found to be hypoxic and difficult to ventilate.

LMA

  • Great for many patients, but leak is a concern

  • Leak pressure 26-27 mm H2O

Auscultation accuracy in intubation

  • Sens 84%, spec 97% for pneumo/hemo/hemopneumo

  • Combination of tube depth and auscultation can be helpful for assessing for right main stem. Auscultation alone has poor sensitivity


Lung Pulse Sign on Ultrasound

  • Obstruction → complete atelectasis

  • Absence of lung sliding

  • Vibrations of heart activity at the pleural line

  • Requires both cardiac activity and lack of pneumothorax

  • Useful tool to assess for right main stem, superior to auscultation alone

One Lung Ventilation

  • Overdistension of available lung can lead to pneumothorax

  • Anesthesia literature currently suggests 5cc/kg TV

Social Emergency Medicine WITH Dr. Kelli Jarrell

Social Emergency Medicine Fellowship

  • 2 years

  • Work clinically as attending

  • Obtain Masters of Public Health

  • Project, such as Test and Protect during the Covid-19 pandemic

Social Emergency Medicine

  • “ED as the social barometer of its community”

  • The good physician treats the disease, the great physician treats the patient who has the disease

  • Stanford Defines as:

    • Social Emergency Medicine (SEM) recognizes the unique position of the emergency department in the community and within the health care system.

      Emergency Departments are the safety net for the healthcare system and are a safe haven for the community.  Social Emergency Medicine uses the perspective of the ED to investigate societal patterns of health inequity, identify social needs contributing to disease, and develop solutions to decrease health disparities for vulnerable populations.

Social Determinants of Health in Cincinnati

  • 73 fatal shootings in 2019 in Cincinnati

    • 82 in first 10 months of 2020

    • 92.3% in 2020 have been black

    • Over half of the shootings occurred in 7 of the 56 neighborhoods

  • Life expectancy very different among neighborhoods

    • 62.9 vs 87.8 in neighborhoods 8 minute drive apart

  • Home ownership discrepancy

    • 69% white, 18% black

R4 Case Followup - Minnesota tube WITH Dr. Jess Koehler

Check out this TamingtheSRU post! http://www.tamingthesru.com/blog/air-care-series/balloon-tamponade-of-variceal-hemorrhage

Case: Patient found down, post-ROSC, seen in the bay. Found to be a massive GI bleed and appropriately resuscitated with medications and blood products.

Varices:

  • 80% of UGIB in cirrhosis

  • 20% mortality

Esophageal Tamponade:

  • Blakemore vs Minnesota Tube

    • Two balloon devices

  • Success rate 80-90%

  • Rebleed rate 50%

    • Bridge therapy

    • Will need definitive care

  • Indications:

    • Unstable patient with massive variceal bleed

    • Endoscopy/consultants not available

    • Vasoactive agents have failed

    • Endoscopy failed

  • Contraindications

    • History of stricture

    • Recent esophageal or gastric surgery

  • Complications

    • Esophageal rupture

    • Airway obstruction

      • Intubate them

    • Arrhythmia

Placement:

  • See tamingthesru post

  • Get a chest x-ray for confirmation of placement prior to full inflation of the gastric balloon

  • Secure device

    • Football helmet

    • ET tube holder

  • Aspirate from gastric port

R1 Clinical Knowledge: IABP, Impella, LVad WITH Dr. Justine MIlligan

Cardiogenic Shock

  • Decreased cardiac output leading to inadequate tissue perfusion

  • Clinical and hemodynamic criteria

  • SCAI shock stages: at risk, beginning, classic, deteriorating, extremis

  • Commonly caused by STEMI/NSTEMI leading to impaired contractility

Management of Cardiogenic Shock in Acute MI

  • Early revascularization

  • Careful IVF

  • Vasopressors

  • Ionotropes


Mechanical Circulatory Support as an ED Physician

  • May encounter in ED, ICU, or Air Care

  • LVAD patients present to the ED


Intraaortic Balloon Pump (IABP)

  • Increase diastolic pressure and coronary perfusion pressure

  • Decrease aortic pressure and after load

  • Inserted percutaneously

  • Positioned between left subclavian and renal arteries

  • Pulsatile via inflation and deflation based on cardiac cycle

    • Inflate during early diastole

    • Deflate during early systole

  • Console has ECG leads and aortic pressure line

  • Contraindications

    • Moderate to severe aortic regurgitation

    • Aortic aneurysm

    • Aortic dissection

    • Severe PVD

    • Uncontrolled sepsis

    • Bleeding diathesis 

Impella

  • Unloads left ventricle and reduces diastolic volume. Improves myocardial oxygen supply:demand ratio

  • Placed percutaneously or surgically

  • Goes through aortic valve and sits in LV

  • Continuously aspirates blood from LV and pushes into aorta

  • Bridge to recovery, decision, long term LVAD placement

  • Purge system

    • Helps keep blood out of motor to prevent thrombosis

  • Controller will have a placement signal waveform which looks like aortic pressure waveform (this is not a blood pressure) and a motor current waveform

  • Contraindications

    • Aortic regurgitation

    • Prosthetic aortic valve

    • Aortic dissection

    • Severe PVD

    • LA or LV thrombus

  • IMPRESS trial: Impella vs IABP

    • No difference in 6 month mortality or stroke at 30 days

    • Increased risk of major bleeding and hemolysis in Impella group

Left Ventricular Assist Device (LVAD)

  • Mechanical circulatory pump

  • Continuous flow

  • Used as a bridge to recovery, bridge to transplant or now is destination therapy

  • Components

    • Inflow cannula in LV

    • Outflow cannula in aorta

    • Motor

    • External controller with batteries

    • Percutaneous driveline

  • Patients will be anticoagulated

  • Patients are very preload and afterload sensitive

  • May need to doppler a MAP to take blood pressure in these patients

  • LVAD Problems

    • Infections

    • bleeding (GIB, ICH)

    • Pump thrombosis

    • LV suction events

    • RV failure

  • Unconscious LVAD patient

    • LVAD coordinator, CVICU

    • Assess perfusion: skin color, temperature, cap refill

    • Listen for whir of LVAD

    • Assess device alarms

    • >50 MAP for perfusion

    • Treat arrhythmias as indicated with ACLS

    • CPR appropriate if needed

R3 Taming the sru: postpartum headache and neuro-protective intubation WITH Dr. Shawn Hassani

Case: Young female with right sided weakness and recent delivery. Found to have large ICH

Postpartum headache

  • Benign

    • Tension

    • Migraine

    • Post-dural puncture

    • Cervicogenic

    • Cluster

  • Scary

    • Preeclampsia/eclampsia

    • Sinus venous thrombosis

    • Stroke (ischemic or hemorrhagic)

    • PRES

    • RCVS

    • Meningitis

    • Pituitary apoplexy

    • Traumatic ICH

Neuroprotective Intubation

  • CPP = MAP - ICP

  • Patients often have a hypertensive response to intubation

  • Hemodynamically neutral induction agent: etomidate

  • Paralytic: succinylcholine shorter acting, rocuronium reversible

  • Consider pretreatment

    • Fentanyl well studied and helps blunt the CV response

    • Watch for apnea, respiratory depression, bradycardia

R4 Capstone: System 1 and 2 thinking WITH Dr. Michael Gleimer

  • System 1

    • Automatic thinking

      • The familiar drive to work

    • Reflexive, involuntary, quick, active all the time, intuition, impressions, impulses, feelings, cannot be turned off, shared with animals

    • Main character of our lives

      • Considerable computing power and speed

      • Relies on evolutionary, cultural, historical, and personal experience

      • Constantly absorbing knowledge

      • Responsible for making millions of choices per day

      • Capable of incredibly complex tasks

      • Keeps us alive

      • Doesnt ask for much in return

    • System 1 is limited

      • By necessity based on generalizations, does not keep an open mind

      • Susceptible to systematic error

      • Has no knowledge of stats or formal logic

      • Cannot be turned off

  • System 2

    • Slower thinking

      • Complicated patient

    • Effortful, voluntary or involuntary, active in idle mode, slow, concentration, complex choices, self control

    • Ego is associated with system 2

      • Exclusive to Homo sapiens

      • Intellectual

      • Rational

      • Logical

      • Capable of complex tasks: calculus, go to moon, build health system

      • “Better” than chimps, bears, birds, bacteria

  • Cognitive ease

    • It is pleasant when things fit

    • Causes of cognitive ease:

      • Repeated experience

      • Clear display

      • Primed idea

      • Good mood

    • Consequences of cognitive ease

      • Feels familiar

      • Feeld good

      • Feels true

      • Feels effortless

    • Experimentally, happy people are more intuitive and less accurate