Grand Rounds Recap 03.15.17

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R4 Case Follow Up with Dr. Boyer

Middle aged female presents with an occipital headache, abrupt in onset, nausea but no vomiting.

Vital Sings: BP 130/105; P 84; 100%; RR 18; Afebrile

On head CT  found to have a perimesencephalic bleed (non-aneurysmal SAH)

  • Perimesencephalic bleeds compose 10% of SAH

Diagnosis of SAH more generally:

  • History
    • 1st degree relative with history of aneurysmal bleed
    • Heightened activity at onset of headache
    • Syncope
    • Altered Mental Status
    • Persistent Vomiting

Quick Hits:

Within 6 hours of onset of suspected SAH, is non-contrast head CT sufficient?:

If outside that window and proceeding to LP, what is the criteria for SAH?

Can a traumatic tap go home?

What is the sensitivity of CT angio for aneurysm <3mm?

An EBM Sepsis Discussion with Dr. Baez and Dr. Summers

  • 1 million patients/year suffer from sepsis
  • 5.2% of all healthcare dollars are related to sepsis care

Sepsis 3 definitions:

  • Sepsis: life threatening organ dysfunction caused by dysregulated host response to infection
  • Severe sepsis is no longer a thing!
  • Septic shock: a subset of sepsis in which profound circulatory, cellular and metabolic abnormalities are associated with a greater risk of mortality than with sepsis alone

Lactate:

  • Byproduct of pyruvate being shunted to LDH in anaerobic metabolism (probably)
  • Nguyen et al., in Crit Care Med 2004, found a 10% lactate clearance at 6 hours in sepsis decreased mortality by 11%.
  • Jones et al., in JAMA 2010 found that lactate clearance was non-inferior to ScvO2 monitoring for mortality in sepsis
  • Marik & Bellomo in Anesthesiology, Perioperative and Crit Care Med question the etiology of lactate in sepsis, however, arguing that a catecholamine surge is responsible for lactate production. If this is the case, lactate clearance merely signifies an attenuation of the stress response, and should not be a marker of resuscitation
  • Numerous studies do show, however, that an elevated lactate is associated with increased mortality broadly

qSOFA

  • Seymour et al in their Sepsis 3 definitions discuss qSOFA as a validated scoring system of septic patients in the ICU identifying those with increased mortality risk

Fluid Resuscitation

Predicting Fluid Responsiveness

  • The current state of the literature appears to suggest that Echocardiography in trained hands is likely the most robust static assessment of fluid responsiveness available in the ED.
  • Multiple dynamic indices of fluid responsiveness exist, including:
    • Pulse pressure variation
      • >12% yields good Sn and Sp for fluid responsiveness
    • Caval index - change in IVC diameter throughout the respiratory cycle
      • >18% generally indicates fluid responsiveness
    • Passive leg raise - used on conjunction with the NICOM device
      • Well validated against the gold standard of transpulmonary thermodilution
      • Can measure increase in CO with a simulated ~500cc bolus of fluid from the legs
    • All ED indices generally rely on patient being in NSR; mechanical ventilation with no spontaneous effort; a TV greater than 8cc/kg; and normal chest wall compliance

Iatrogenic Toxicology with Dr. Gauger

Neuroleptic Malignant Syndrome

  • Idiosyncratic reaction, we can not predict when or where it will occur
  • It is, however, typically during initial phase of treatment
  • Usually young to middle aged males
  • Any antipsychotics can cause this (higher incidence with 1st generation)
  • 0.2-1.4% prevalence amongst patients on antipsychotics, and carries a 4-12% mortality
  • Clinically patients are:
    • Altered
    • Rigid (lead pipe) - generalized and symmetric
    • Hyperthermic - not responsive to antipyretics
    • Autonomic dysfunction - tachy, labile hypertension
  • High CK, leukocytosis, and normal CSF studies are common
  • Tx: discontinue all neuroleptics, consider intubation with non-depolarizing agents, CCB for hypertension, actively cool
    • Dantrolene - causes muscle relaxation by inhibiting calcium release
    • Bromocriptine - dopamine receptor agonist

Acute Dopamine Depletion Syndrome

  • Clinically identical to NMS, but occurs in Parkinson's Disease patients who do not receive their medications
  • Tx is the same as NMS, in addition to repleting their Parkinsons medications

Serotonin Syndrome

  • Neuromuscular hyperactivity - specifically clonus (spontaneous or induced)
  • Altered mental status
  • Sympathetic activation
  • Tx:
    • Supportive - fluids, antipyretics, respriatory support
    • Cyproheptadine - antiserotonergic and antihistaminergic properties

Lithium Toxicity

  • Often caused from decreased GFR, volume depletion, abnormal thyroid fx (both hyper and hypo)
  • Patients present with AMS, renal failure, and electrolyte derangements
  • Lithium toxicity is a clinical diagnosis, and Li levels do not correlate to severity (the whole body LI load is clinically more important than a single serum measurement acutely), higher levels are more concerning in acute overdose as it takes hours/days to equilibrate with the CNS
  • Management includes:
    • Whole bowel irrigation if acute
    • IV hydration
    • Electrolyte repletion
    • Hemodialysis

Phenytoin Toxicity

  • Phenytoin is 90% albumin bound, so changes in serum albumin can change free levels even in a stable dose, causing toxicity
  • At higher levels of toxicity, elimination becomes 0 order, and half life can approach 60 hrs
  • Patients present with cerebellar signs (nystagmus, ataxia, dysarthria), behavioral changes, confusion, hallucinations, hyperreflexia
  • Chronic phenytoin elevations can cause gingival hyperplasia, frontal bossing, agranulocytosis, hepatotoxicity
  • Workup includes total phenytoin level and albumin (free levels will not return in real time)
  • Tx is supportive, but activated charcoal can be considered in acute overdoses, and hemodialysis can be beneficial, but is generally not necessary.

Trauma Pearls with Dr. Axelson

VBG Correlation with ABG

Indications for the FAST exam on a trauma patient

  • FAST was designed to replace the DPL, and it's use is indicated as a triage tool for the hemodynamically unstable blunt trauma patient
  • Speficity of FAST for blood in the peritoneum/visceral organ injury is ~99%
  • Sensitivity of FAST in this setting is only 40%
    • FAST rules things IN, it rules nothing OUT

Pulses, their correlation to BP with a touch of dogma

  • Historical teaching indicates that the presence of a carotid, radial, and femoral pulse corresponds to a SBP >80 mmHg in a trauma patient, with loss of femoral pulse corresponding to a BP >70, loss of femoral and radial corresponding to SBP >60 mmHG
  • According to an article in BMJ 2000; 321(7262):673-674, this pulse estimation of SBP was innacurate in 24/28 trauma patients, almost always underestimating. 

Pediatric Emergency Medicine Sim

Case 1:

7yo F o/w healthy presents to the community with cough/fever/difficulty breathing. Seen at urgent care 3 days ago for fever and cough. CXR at the time revealed ?R sided pneumonia, so given amoxicillin and sent home. She presents today for worsening symptoms.

  • Vitals: T 38.9; P 160; R 55/83% RA; BP 88/49
  • Exam: Awake, alert, nasal congestion and decreased breath sounds in RLL noted with diffuse wheezing, 2/6 systolic ejection murmur heard. No rashes. Normal abdominal exam. Looks pale but not cyanotic.
  • Ddx:
    • Influenza, pneumonia, endocarditis, reactive airway disease, cardiogenic shock from myocarditis
  • CXR: RLL pneumonia with likely associated effusion
  • Labs: 7.27/48/16/-6; lactate 3.6; Hgb of 9 and platelets of 68; Cr 0.86; glucose 230
  • Tx: 10cc/kg bolus, early antibiotics to include Ceftriaxone for GN coverage, and Vancomycin for MRSA coverage in this ill patient, tylenol for fever, and this patient needs intubation
  • Influenza rapid swab returns +Influenza B
  • She requires 60cc/kg of fluid before BP stabilization
    • After 2nd 20cc/kg bolus, at least consider Epi as a first line pressor
  • Intubated with Ketamine and succ
    • worsening oxygenation and ventilation in PICU
    • VV ECMO, converted to VA ECMO, remains on ECMO in CICU
  • Beware of flu and superimposed pneumonia!

Case 2:

3yo M presents to the community with fever and congestion. He was born at 34wks, NICU stay, and has been doing well since discharge. No travel, no vomiting or diarrhea.

  • Vitals T 39.1; P 176; R 42 94%/RA; BP 110/66
  • Exam: Awake, ill appearing, making tears and rhinorrhea noted, tachy with no murmur, cap refill 4seconds and mottling noted, decreased air exchange on R lung base, belly breathing noted
  • Ddx: Influenza, pneumonia, reactive airway disease (not bronchiolitis over 2), myocarditis
  • VBG 7.34/42/22/-1; WBC 16, 76% segs
  • CXR with RLL lobar pneumonia
    • Po high dose amox or IV ampicillin is 1st line for immunized CAP (to age 18)
    • Unimmunized or chronic health concerns, go to ceftriaxone for broader coverage
    • With bolus, IV dose ampicillin, HR normalized and patient perked up, f/u with PMD
  • Strep pneumo most common source of CAP

Simulation Case

3 mo former 30 wker presents with cough, cyanosis with feeds, difficulty breathing.

  • Vitals: HR 150s; BP 60/30s; RR 66 89% with supplemental bagging; T 37.6
  • Labs 7.18/68/10/-14 Lactate 2.1, Sodium 133; Potassium 6.2, Glucose 49, Cr 0.3
  • V/Q mismatch is most common cause of persistently low sats
  • Shunt is another consideration
  • Hypoventilation is another consideration
  • High Flow nasal cannula: warmed, humidified O2 delivered via nasal cannula at higher flow than standard nasal cannula O2. It remains questionable whether HFNC actually transmits some degree of PEEP to the alveoli.
    • Works via washout of nasopharyngeal deadspace resulting in increased O2 fraction in the alveoli
    • Reduces inspiratory resistance and work of breathing by providing adequate flow
  •  Thus far there has been no mortality benefit demonstrated with HFNC
  • HFNC may reduce intubation rates in young children, and is overall well tolerated