Grand Rounds Recap 12.20.23

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Morbidity and Mortality WITH Dr. Kletsel

Case 1: Flank Pain​

  • Have a high suspicion for a renal abscess in immunosuppressed patient w/ back pain, fever, vomiting & CVA tenderness on exam​

  • Urine and blood studies are typically benign​

  • CT a/p with contrast is the diagnostic test of choice​

  • IV antibiotics, plus potential drainage, are the mainstays of treatment  ​

Case 2: Bradycardia ​

  • Caution with prescribing paxlovid to elderly patients, especially those on multiple other medications, due to risk of bradycardia​

  • Use of transcutaneous pacing may be limited by inability to obtain capture and/or patient intolerance ​

  • Familiarity with the kit, and procedure itself, is key to successful placement of a transvenous pacemaker in the ED​

Case 3: Seizure​

  • Hyperactive delirium w/ severe agitation should be treated as a medical emergency regardless of the underlying cause​

  • Rapid sedation with IM medications such as ketamine is key to ensuring patients do not harm themselves or others

Case 4: AMS/Bradycardia​

  • When managing an unstable UGIB, resuscitation with blood products and airway management are the priorities​

  • Endoscopy can be both diagnostic and therapeutic, yet patient needs to be adequately resuscitated  first​

  • Consider balloon tamponade as a temporizing measure to definitive endoscopy ​

Cases 5 & 6: Chest Pain & Back Pain​

  • Aortic dissections are rare, yet associated with significant mortality & morbidity ​

  • Be diligent for patients w/ risk factors presenting w/ sudden-onset, severe chest, abdominal, or back pain​

  • Classic HTN, pulse deficits, and/or BP discrepancies may not be present​

  • CTA is the diagnostic test of choice

ClinicoPathologic Case - Hypothyroidism WITH Dr. Beyde

  • Hyperthyroidism can cause worsening of asthma severity

  • When thyrotoxicosis is treated, asthma symptoms improve

  • When there is clinical suspicion, the Burch-Wartofsky Point Scale can be used to help confirm the diagnosis 

  • Treatment of thyroid storm should include:

    • A Beta Blocker: Control symptoms of increased adrenergic tone

    • A Thionamide: Block new hormone synthesis

    • Iodine: Block the release of thyroid hormone

    • Glucocorticoids: Reduce T4-to-T3 conversion

    • Bile Acid Binders: Decrease  recycling of thyroid hormones

R4 Simulation - Brash syndrome WITH Drs. kein and Milligan

  • BRASH (bradycardia, renal failure, AV nodal blockade, shock, hyperkalemia) syndrome occurs when acute renal failure leads to hyperkalemia and the accumulation of AV nodal blockers.

  • The hyperkalemia and AV nodal blockade combine to create a profound bradycardia and shock state.

  • The syndrome can be precipitated by any cause of acute renal injury such as hypovolemia, sepsis, or an up-titration of their AV nodal blockers.

  • To successfully treat BRASH, one must address the various metabolic and hemodynamic derangements leading to the syndrome to break the cycle:

    • Treat any volume derangements. For acidotic patients, an isotonic bicarb drip can be a great resuscitative fluid to improve the acidosis and shift potassium.

    • Manage bradycardia by IV calcium and epinephrine (Beta 1 activity improves heart rate and Beta 2 activity shifts potassium). The AV nodal blockade will counteract any effects of atropine, so it is less likely to work. If properly medically managed, many of these cases can avoid the need for transcutaneous or transvenous pacing, although this can be considered for refractory shock.

    • Manage hyperkalemia by standard potassium shift and removal strategies (insulin/dextrose, albuterol, lokelma, diuresis, dialysis).

    • Don't forget to treat the underlying precipitating causes (sepsis, hold the AV nodal blockers, etc.)