Grand Rounds Recap 5.10.23

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CPC: Rheumatic Fever WITH Drs. Chhabria and Baez

Case: Young patient presenting with R knee pain x5 days, progressing now with SOB and CP

  • History notable for flu-like symptoms for past 2 weeks

  • Physical exam notable for tachycardia, tachypnea, muffled heart sounds + murmur and gallop, R knee and elbow swelling

  • Remarkable diagnostics: 

    • CXR - cardiomegaly, no PNA

    • Labs - new anemia, CRP elevation, elevated d-dimer, troponin, and BNP

    • EKG - sinus tachycardia, R axis deviation, R atrial enlargement

    • Echo - Mitral regurg, pericardial effusion

  • Differential Diagnosis by Dr. Baez:

    • Key history and physical

      • Microcytic anemia with NO EVIDENCE of hemolysis

      • Normal BMP and LFTs

      • Generalized systemic illness

      • Echo: moderate effusion, mitral valve stenosis and regurg 

    • Differential mainly includes inflammatory and infectious etiologies

  • Diagnosis: acute rheumatic fever

    • Test of choice: ASO titer

  • Case Discussion:

    • Epidemiology: most commonly 5-15yo, resource limited countries

    • Etiology - typically group A strep

    • Clinical Features: Revised Jones Criteria - at least 2 major OR 1 major and 2 minor 

      • Major criteria - arthralgias, carditis, subcutaneous nodules, erythema marginatum, Sydenham chorea

      • Minor criteria - fever > 38.5C, ESR > 60mm OR CRP > 3.0mg/dL, prolonged PR interval 

    • Diagnosis

      • Routine labs (CBC< CRP, ESR), confirm GAS infection, assess cardiac (EKG, Echo, CXR), Neurologic involvement (clinical, MRI/CT, or LP)

    • Treatment:

      • Short term: supportive, NSAIDs, Steroids

      • Long term: Antibiotics - penicillins

    • Complications: Cardiac (carditis, mitral valve pathology, myopathy) + CNS

QI/KT: Carbon Monoxide Poisoning WITH Drs. Moulds and Wright

  • Epidemiology: no active surveillance system and difficult to know incidence from poison control

    • ED visits ~ 50,000, >400 deaths

    • Can occur from car exhaust, burning stoves, paint thinner, fires

    • Most often seen in young children, highest morbidity/mortality in elderly

    • Upticking morbidity and mortality with natural disasters

  • Pathophysiology:

    • Hgb-O2 dissociation curve

    • 3 mechanisms for injury: tissue hypoxia, direct cytotoxicity, lipid peroxidation changes 

  • Clinical Presentation: non-specific

    • Viral-like symptoms, N/V, headache, fatigue, altered mental status, shock, death

    • Affects heart and brain - high metabolic demand, CO greatest effects on these organs

    • Delayed Neuropsychiatric Syndrome: caused by alteration in lipid peroxidation, initial presentation more cerebellar symptoms, delayed presentation typically involves basal ganglia, studied in both human and animal models 

  • Diagnosis

    • Detection methods: screening - breath test, pulse ox for CO; serum test most accurate 

  • Treatment: 

    • High FiO2 → decreases half-life of CO

      • No studies comparing oxygen v no oxygen (considered harmful to patients)

      • Oxygen strategies that has been studied

        • NRB initial step

        • Hyperbaric oxygen can reduce half-life

        • Half-life similar in HFNC to NRB

        • Have not looked at CPAP/BiPAP, intubation is typical indications

    • Other treatments:

      • RBC transfusion - studies have not shown benefit

      • Hydroxocobalamin - helps with cyanide toxicity

        • Cyano-kit - not been shown to be beneficial for CO, but other formulations have been shown to have some benefit

  • Studies reviewed: Articles reviewed for the pathway had mixed results on benefit or harm of hyperbaric oxygen therapy treatment, most of standard guidelines based on “expert consensus”

Pediatrics: Toxicology WITH Dr. Heckle

  •  “One pill can kill” drug classes for pediatrics - antidepressant/antipsychotics, beta-blockers, calcium channel blockers, clonidine (alpha-2-antagonists), anti-parasite/antimalarial, narcotics, sulfonylureas, anti-diarrheals, xanthines, methyl salicylates, camphor, benzocaine, lindane, MAO inhibitors, toxic alcohols

  • Basic treatment principles:

    • Protect the airway

    • Breathing

    • Circulation: 20 cc/kg, epi

    • Charcoal - within first hour of ingestion, only if patient awake and willing, not recommended if vomiting, altered, or suspected metallic or salicylate ingestion

    • Wide QRS = bicarb

    • Antidotes

      • Opioids: naloxone

      • Beta blockers, CCBs, sulfonylureas: glucose

      • Toxic alcohols: fomepizole

      • Benzos: flumazenil (often do not need to worry about benzo withdrawal)

    • Whole bowel irrigation generally not recommended

Combined EM/IM: Competencies WITH Dr. Frank

  • Competence: no agreed upon definition, but it is a construct that changes over time, based on societal context

    • Important to society to label experts

    • Test? Specific Categories? 

  • 10 “windows of competence”: membership, character, time spent, knowledge, psychometric performance, meeting societal needs, competencies, entrustment, performance in context, professional identity

  • Reflections on Competence:

    • Is it something you display or possess as a part of your identity?

    • Is competence dynamic or static?

      • As far as society is concerned, often static when letters are behind your name, but as physicians it is felt dynamic

    • New Model of Competence?

      • Must include societal need, dynamic model and continuous learning, team-based focus, must be contextual and allow for adaptation, and pay attention to professional identity