Grand Rounds Recap 8.28.19
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MORBIDITY AND MORTALITY WITH DR. HAM
Spontaneous Bacterial Peritonitis
Mortality 31.5% at one month
Emergency medicine physicians are poor at diagnosing SBP clinically in the emergency department (Chinnock 2008).
Sensitivity 76%, specificity 34% based on history and physical examination
Indications for diagnostic paracentesis per American Association for the Study of Liver Disease:
Hepatic encephalopathy
Worsening ascites
Abdominal pain
Fever
Leukocytosis
Renal failure
Patients requiring hospital admission for any reason
Treatment
Third-generation cephalosporin
Albumin
Reduces mortality from 29% to 10%
Indications include creatinine > 1, BUN > 30, total bilirubin > 4
Dosing 1.5 g/kg
Infected Kidney Stones
Urinalysis interpretation for culture-positive UTI (Marques 2017)
Leukocyte esterase (LE) positive: 79% sensitive, 84% specific
Nitrite positive: 28% sensitive, 99% specific
Sediment (includes all debris, but specifically looking at > 10 WBC/hpf): 92% sensitive, 71% specific
LE + nitrites: 85% sensitive, 84% specific
(LE or nitrites) + sediment: 94% sensitive, 85% specific
False positive nitrites can be caused by:
Prolonged time to analysis
Dipsticks stored in open air
Red urine (including gross hematuria, reagent tests)
For infected kidney stones, cover with appropriate antibiotic therapy and talk with urology about stenting or stone removal.
Euglycemic Diabetic Ketoacidosis
Appears similar to alcoholic ketoacidosis on laboratory testing
Becoming more common with the use of SGLT-2 inhibitors
Keep a broad diagnostic work up for patients with an anion gap metabolic acidosis.
Renal panel
Blood gas
Lactate
Ketones
Special testing: salicylates, toxic alcohols, serum osmolarity
Delays in Antibiotic Administration
The definition and management of sepsis continues to evolve with time and new data.
If you are concerned a patient has shock that may be sepsis, order broad spectrum antibiotics early as this has consistently been shown to improve mortality.
Task Saturation
Task saturation occurs when the number or complexity of tasks exceeds the ability to execute them at a high level.
Behaviors that occur when providers experience task saturation (Davis 2014):
Shutting down: quitting the task or taking frequent breaks
Compartmentalization: acting busy without accomplishing much, linear task completion
Target fixation: focusing intensely on one single task at the expense of all else, allowing new tasks to accumulate
Task saturation is associated with breakdowns in teamwork, communication, and mutual accountability.
Strategies to reduce task saturation:
Plan ahead
Have a wingman to delegate tasks
Check your execution gaps, or the potential space between your strategy and its execution
R3 SMALL GROUPS: HEENT WITH DRS. LI, MAKINEN, MAND, AND SKROBUT
Grab Bag
Le Fort fractures
Le Fort I: floating palate
Le Fort II: floating maxilla
Le Fort III: floating midface
Adults have 32 teeth.
Maximum lidocaine dosing in lidocaine with epinephrine is 7 mg/kg
The thyroid cartilage lies on the inferior margin of Zone III of the neck.
Phenytoin, calcium channel blockers, and leukemia are all associated with gingival hyperplasia.
Green tea has been found to be non-inferior to Peridex mouthwash in the treatment of pericoronitis.
Corneal Foreign Bodies
Assess for intraocular foreign body.
Methods for superficial foreign body removal include irrigation, moist cotton Q tip, or the tip of a needle.
Numb the cornea prior to intervention.
Consider tetanus and prophylactic antibiotics.
Ear Foreign Bodies
Assess for perforated TM.
Methods for ear foreign body include, irrigation, alligator forceps, Katz extractor, currettes, Q tip with superglue in limited settings.
Minimize iatrogentic damage.
Hydrogen peroxide can break up impacted cerumen.
If there is a live bug, use mineral oil or viscous lidocaine to drown the bug first.
Dental Emergencies
Concussion occurs when there is tenderness to palpation of a stable tooth.
Can follow up routinely with dentist
Subluxation occurs when there is tenderness and mobility without displacement.
Splint if significantly mobile.
Soft diet
Extrusive luxation occurs when there is a partial avulsion of the tooth out of the alveolar bone.
Detnal block, reposition, splint, follow up within 24 hours
Lateral luxation occurs when there is lateral displacement of the tooth in its socket.
If there is significant alveolar bone fracture, consult dental emergently.
If there is minimal fracture but extrusion, attempt block and reposition.
If there is neither fracture or extrusion, splint and follow up within 24 hours.
Intrusive luxation occurs when the tooth is displaced into the alveolar bone.
Liquid diet, follow up in 24 hours
Avulsion
Re-implant and splint if dry time < 60 minutes.
Follow up within 24 hours, consider antibiotics and tetanus.
Prehospital storage in Hank Solution or milk
Fractures:
Ellis I: smooth with emory board, routine follow up
Ellis II: calcium hydroxide and soft diet, follow up within 24-48 hours
Ellis III: calcium hydroxide, liquid diet, follow up in 24 hours, tetanus, antibiotics
Auricular Hematoma
Anesthesia with auricular block
1cm incision vs aspiration of convex area in ear area with maximal clot
Remove clot and irrigate
Can bolster with Xeroform to prevent reaccumulation
Complications include infection and “cauliflower ear”
R4 CASE FOLLOW UP WITH DR. HARTY
Carotid Blowout Syndrome
Most cases of carotid blowout syndrome are related to head and neck cancer, often squamous cell carcinoma.
These patients have extremely high mortality at about 40% and 60% require emergency intervention.
Call for help!
ENT if available, but if you are in the community without ENT coverage, anesthesia and general surgery may be of assistance
Know your patient’s anatomy.
You will be unable to orotracheally intubate a patient who has undergone total laryngectomy.
Classification
Threatened: carotid artery is exposed through skin breakdown or direct invasion of a tumor
Impending: a sentinel bleed has occurred but is now hemostatic without surgical intervention
Acute: active bleeding is present
Treatment
Open surgical repair (falling out of favor as high incidence of complications)
Embolization for those with low risk of stroke
Stenting for those with high risk of stroke
GLOBAL HEALTH GRAND ROUNDS: IMPROVING INJURY OUTCOMES WITH DR. LAGASSE
There are 5.8 million deaths from trauma worldwide annually.
This outnumbers HIV/AIDS, TB, and malaria combined.
Greater than 90% of these occur in low-middle income countries (LMICS).
Road traffic injuries are the leading cause of death in people aged 15-29 in LMICs.
Patients with life-threatening but salvageable injuries are 6x more likely to diet in a low-income setting than in a high-income setting.
Attempts are being made to improve trauma prevention and care in LMICs with the initiation of helmet laws and alcohol regulation.
In Tanzania, the mortality rate from trauma is about 15% at national referral centers (compared to approximately 4% in the US).
Poorly enforced alcohol laws
No helmet laws
No national standards for trauma care
No pre-hospital infrastructure
MASTERING MINOR CARE: ARTHROCENTESIS AND JOINT LOADING WITH Dr. LAFOLLETTE
Indications
Diagnostic arthrocentesis
Fluid analysis
Evaluate for traumatic arthrotomy
Therapeutic arthrocentesis
Drain effusion
Inject steroids
Most commonly triamcinolone
If performing injections, know most local anesthetics can cause eventual cartilage damage and arthritis, consult with orthopedics or ensure follow up for these patients.
By injecting steroids into a joint, you will likely delay potential replacement for 3-6 months.
Little data exists about complications or safety of performing arthrocentesis through cellulitis.
Bursitis
Approximately 1/3 are septic
Half of these occur in immunocompromised patients
There are mixed opinions about aspiration, but most would recommend just covering with antibiotics and assessing clinical response.
Knee
Traumatic arthrotomy saline load test (SLT) with 76cc was 94% sensitive and 91% specific.
Another article from Konda 2013
Using CT to diagnose free air in the joint and traumatic arthrotomy was 100% sensitive and specific (although 32 patient study, this is a promising alternative to a painful intervention).
Can perform arthrocentesis at any of the four quadrants of the knee but be sure to avoid neurovascular bundles.
Elbow
Arthrocentesis: approach at the center of the triangle made by the radial head, lateral epicondyle, and lateral aspect of the tip of the olecranon
SLT: 40cc is 95% sensitive for traumatic arthrotomy
Ankle
Arthrocentesis: approach laterally (anterior to the tip of the lateral malleolus with needle directed medially) or medially (in the sulcus anterior to the medial malleolus and medial to the EHL and TA tendons)
SLT: 30cc is 95% sensitive for traumatic arthrotomy
Wrist
Arthrocentesis: between extensor pollicis longus and common extensor tendons, ulnar to the radial tubercle
SLT: 2.5cc is 99% sensitive for traumatic arthrotomy
Shoulder
Arthrocentesis: if dislocated, enter in divot laterally; if not, can use anterior (between the coracoid process and humeral head) or posterior (inferior to the acromion with needle directed toward the coracoid process) approach
SLT: 68cc is 95% sensitive for traumatic arthrotomy
