TRAUMA YELLOW
  • Clinical
    • Discharge Macros
    • Procedure Macros
    • Exam Macros
    • Pediatric Macros
    • Antibiogram
    • Follow Up
    • 2023 MDM
    • Heart Pathway
    • Jeromy's Macros
  • Education
    • EM Education
    • Critical Care
    • FOAM
  • Orientation
    • Dept Orientation
    • Cerner
    • Dragon
  • Links
    • Clinical Links
    • StatMacros
    • ICU Bootcamp
  • Private
    • MCS
    • GWU Contacts & Map

Grand Rounds - April 23, 2016

4/6/2016

1 Comment

 
  • Dyspnea in Pregnancy
  • M&M
  • LVADs
  • AHA Guidelines Update
Dyspnea in Pregnancy – by Murteza Shahkolahi
  • Presentation and Approach
    • There is no formalized risk stratification, validated PTP score for pregnant population (usually excluded from studies)
    • Diagnostic Algorithm
      • Standard of care: ATS/STR/ACOG
        • Do NOT Dimer
        • increases in normal preg
        • slowly declines postpartum
        • still can have false negatives
  • *D-dimer cutoffs (D-dimer threshold increase with pretest probability unlikely for pulmonary embolism to decrease unnecessary computerized tomographic pulmonary angiography http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3319270/
Picture
  • http://www.acog.org/~/media/Districts/District%20VIII/PulmonaryEmbolismPregnancy.pdf?dmc=1&ts=20140525T0200225053
    • Evolving perspective: Kline et al (not yet validated)
      • Revised D-dimer cutoffs*
        • First trimester <750
        • Second trimester <1000
        • Third  trimester <1250
      • Normal HR 100 -> 105                                                                              

  • Alternative to V/Q scan -> just get a Q scan
    • normal perfusion scan = NPV approaching 100%
    • no reduction in diagnostic accuracy
    • Rosen’s has contradictory recommendations regarding D-dimer use
  • Fetal Radiation Exposure:
    • CTPA: 25-50 cents
    • V/Q: 50-75 cents
    • 0.1 gray = $100
    • CXR: 1/10 of a penny
  • CTPA > VQ by 150x
  • Background radiation: $5 (during entire pregnancy)
  • Shielding controversial (can bounce around off shield)
  • Maternal Radiation Exposure:
    • Breast shields: 34-57% reduction (though some say machines calibrated to reduce exposure wo shield
  • Treatment
    • Heparin or LMWH (Warfarin can be teratogenic in 1st trimester
 
 
 
Morbidity and Mortality – by Chrissy Woodward
Case 1
  • 59M PMH aflutter s/p cardioversion 1m.a., presenting w DOE (planned ablation next week)
    • PMH CHF, HTN, Aflutter
    • PE: HR 125, 98% on 2L
    • Labs: Trop I 0.095, BNP 4,550
    • EKG: Aflutter 125 BPM w atrial conduction
    • CXR: cardiomegaly w early cardiac decompensation
    • Tx: Dilt 10mg IV
    • MDM: aflutter for several days, worsening DOE, admit to gold for ablation
    • Nursing note: Pt does not want to stay in hospital over 4-day weekend
    • Left AMA after multiple discussions, rpt Tn 0.089 (3h)
  • Aflutter…not same as Afib
    • baseline is all p waves (sawtooth appearance) at rate >200 BPM
    • 2:1, 3:1, or 4:1 blocks most common
  • Returned 3 days later, found down, intubated by EMS
    • CPR -> pronouncement of death
  • Discussion:
    • Pt not angry, very aware of condition, educated, responsible, had f/u scheduled
    • Could have considered cardioversion before leaving
    • Could have considered asking him to return next day to ED for f/u
    • Important to document pt capacity
 
Case 2
  • 23M no PMH presenting  with 3d acute R lower back pain
    • HPI
    • radiating to posterior R leg
    • worse sleeping/sitting, better w NSAIDs
    • 6mo chronic back pain
    • Mom at bedside worried about depression
    • PE: numbness in R toes, mild R lumbar TTP, occasional sadness, dec enervy, dec concentration, denies SI/HI/hallucinations
    • RX: valium, ibuprofen
    • Ed materials: sciatica, depression
    • DCI: Back pain possible from physical strain and poss psychological factors…pls f/u w PMD
    • F/u: 7 options listed (med and psych)
    • Attending MDM: depression, R sciatica, mom concerned wants psych eval, no SI/HI
  • Returned as Trauma Yellow: jumped in front of metro train
    • BL BKAs, revisions, psych care
  • Discussion:
    • Who warrants psych consult in absence of SI?
    • Psych SW is option for another opinion (depending on SW)
    • Can have pt get on phone w insurance while waiting in ED; if no appointment, can involve psych SW/psych residents
    • Suicide RFs: older, divorced/widowed, males, access to firearms, worthlessness, prior attempts, perfectionist -> psych overtones
    • Optional out-of-pocket appointments (can call James Griffith, GW Psych Chair)
      • GW $250/visit, cash only
    • Avg wait time for 1st apt:
      • uninsured homeless – 8 weeks
      • other - 3 weeks
    • ZocDoc – can sort by who takes Medicare/aid
    • Unity Care: Friendship Place (Homeless resources)
      • Thursdays 1-3pm, anonymous psych care, drop-in
    • Telepsychiatry: e-psychiatry.com(?) ($300 initial; $125 f/u consults)
 
Case 3
  • 21M PMH whiplash, slipped and fell from standing while intoxicated
    • HPI: initially unable tomove extramitiyes, sleep overnight, woke w HA, + pina and needles, difficulty using phone
    • PE: mild distress, TTP head globally, neuroexam intact
    • Imaging: CT head normal, CT spine: congenital spinal canal narrowing at C1-C2
    • Meds: 2L IVF, Compazine, tylenol, ketorolac
    • MDM: conscussion, w subjective weakness + paresthesias, ambulatory, HR in 80s
    • F/u: GWU-NSGY (given copy of imaging results), concussion clinic, family doc, internist
  • Returned to Georgtown: unstable CS injury (cord contusion from congenital PLUS trauma), fusion occiput to C4
  • Discussion:
    • In pt with narrowed spinal canal, should we be more aggressive in investigating minor clinical findings?
    • CT was fine, would have needed MRI for further eval
 

 
Case 4
  • 25F with epigstric pain, pleuritic
    • Meds: Carafate, Pepcid
    • MDML substernal pain rad to back, d-dimer pos, but CTA neg for PE
    • Returned w epigastric + RUQ pain rads to back x 3 days, N/V
    • PE: mild distress, TTP upper back and epigastrium
    • Labs: AG 16, TB 4.5 Alk Pho 244, transaminases 500s, lipase…(not in presentation)
    • Dx: gallstone pancreatitis
  • Course: admitted, endoscopy, failed stone extraction, lap cholesy, TPN for persistent N/V/pain
  • Discussion:
    • Should have gotten lipase on initial visit
 
Case 5
  • 58F PMh lymphedema, obesity, hypothyroid presenting w worsening DOE x 1 wk
    • HPI: previously exercising w no SOB, substernal CP 1 w.a.
    • PE: normal VS, normal exam
    • EKG: low voltage, NSR, non-specific lateral TW changes
    • Labs: BNP 641, Dimer 2.59 (sent at end of shift, per request of Gold team)
    • MDM: Pt PMH CP wks ago, not recurred, increasing DOW x wks, resovled w rest. Concern for angina pain despite EKG, planned admit to Gold.
  • Course: admitted to Gold, normal cath, got CT showing large saddle PE, xfer to Blue team, R pop vein VTE, lovenox > xarelto, additional hx long plane flight, formal echo showed no R heart strain
  • Discussion:
    • Right heart strain -> shock = 2x mortality
    • EKG
      • Sinus tachycardia is MC EKG finding in PE
      • S1Q3T3 – not common
      • right axis deviation
      • RBBB
      • RV strain
 
Case 6
  • 84M PMh CAD w pacemaker, HTN, DM, p/w CP x 1h
    • HPI: midsternal, heavy , no rads, has cardiologist
    • PE: exam normal
    • EKG:
    • Labs: WNL (including CEs and CXR)
    • Meds: ASA, NTG -> Bp dropped to 70/40, the improved w IVF
    • MDM: Suddden onset SSCP rads to BL arms, mild SOB, admit to Gold
  • Course: 2nd Trop just before moved upstairs slipped through cracks, morning Tn 29, “paced EKG hard to tell STEMI vs NSTEMI”, got urgent cath: 80% LAD stenosis, OM2 90%, DES x 3, doing well
  • Discussion:
    • systems errors, orders placed in transit get lost in cracks
    • Sgarbossa Criteria:
    • http://www.aliem.com/2013/modified-sgarbossa-criteria-ready-primetime/
    • http://lifeinthefastlane.com/ecg-library/basics/sgarbossa/
      • ORIGINAL SGARBOSSA CRITERIA
        • Concordant ST-segment elevation ≥ 1 mm in any lead (5 points)
        • Concordant ST-segment depression ≥ 1 mm in lead V1 – V3 (3 points)
        • Discordant ST-segment elevation ≥ 5 mm in any lead (2 points)
      • WHAT ARE THE NEW MODIFIED SGARBOSSA CRITERIA?
        • Concordant ST-segment elevation ≥ 1 mm in any lead
        • Concordant ST-segment depression ≥ 1 mm in lead V1 – V3
        • Discordant ST/S Ratio ≤ -0.25

 

 
 
 
 
 
 
 
LVADS – by John Greenwood (UMD Pulm Crit Care Fellowship recent grad)
johncgreenwoodEgmail.com
@JohnGreenwoodMD

  • LVADs give pts a second chance
  • Myth #1: The Manual Pump
    • LVADs used to have a backup manual pump, but no longer exist
  • Pt 1 – Joe, wanted to see grandkids graduate
    • given HeartMate II
    • alarm went off one day and he passed out
    • at hosp, alarm went off again, Joe went into VT
  • Measuring BP w LVAD
    • inflate cut on axillary artery and deflate until you register on Doppler = MAP
  • VADs are preload dependent, but afterload sensitive
    • give IVF early
  • LVAD Initial Assessment
    • A – auscultate: should hear nice consistent hum of motor
    • B – battery: usually 2 external batteries, can push battery button on controller to show charge; need to be charged
    • C – controller: iPhone sized; ask family, they’re usually well-trained
    • D –driveline: check surrounding skin for infection
    • E – EKG/echo bedside: EKG - nothing specific to VADs (often low voltage, evidence of end-stage HF, prone to tachydysrhythmias but you’ve got more time since they have VAD as backup)
  • Controls:
    • Don’t be afraid to press buttons – you won’t turn it off
    • Press home button + silence button to review alarms
  • Mechanical problems:
    • Suck Down: when LV is empty (low preload), can suck wall of LV into inlet
      • give fluids
  • What the Cardiologist wants to know:
    • Speed
    • Flow
    • Power/PI
    • Other:
      • recent changes to settings
      • pulsatility – measure of how much native heart function is contributing to flow
  • Echo:
    • LV underfilled: if inflow valve is 1:1 size of LV -> high risk of suck down
      • hypovolemia
      • tamponade
      • excessive pump speed
      • RV failure
    • LV overdistended
      • pump malfunction (rare)
      • pump thrombus
      • AR
      • severe HTN
    • RV underfilled
      • hypovolemia
      • tamponade
    • RV overdistended
      • RV failure
      • hypervolemia
      • PE
      • severe TR
  • Pump thrombosis
    • mortality 48%
    • particular problem in HeartMate II machines (quadrupled rate from 2011-2013 for unknown reason)
    • machine gets hot, strianing
    • consider LDH – thrombus could be spinning and hemolyzing
    • if suspected, call CT team right away, poss start hep drip
  • Myth #2 – If you perform CPR on pt w LVAD, they will explode
    • unkown if pumps are dislodged – but better than dead!
    • options: (e.g. if MAP <40)
      • start inotrope – epinephrine (low dose, 5mcg/min or wt-based)
      • start a pressor – levophed
      • call for ECMO, get lines started
  • Pt 2 – Frank
    • HeartWare (axial flow device – thought to cause less trauma)
    • had GI bleed – VAD pts more prone to AVM in GI tract, also possible shearing forces on platelets
    • intubated
    • endoscopy found AVM
  • Myth #3 – Never reverse AC in a VAD pt
    • get a TEG/ROTEM
    • fix platelets (give DDAVP, or dose of plts)
    • reverse INR (PCC or FFP)
  • Intubation
    • remember, they are preload dependent
    • Rocketamine! (preload sparing)
      • ketamine
      • rocuronium
  • Bottom Line:
    • ABCDE (of VAD)
    • Focus on the tank
    • Fix the coagulopathy
 
 
 
 
AHA Guideline Update – by Stas Haciski
2015 ACLS UPDATES- https://circ.ahajournals.org/content/132/18_suppl_2/S315.full.pdf+html
  • FOAM Resources:
  • http://first10em.com/2015/10/21/acls-2015/
  • http://emergencymedicinecases.com/acls-guidelines-2015-cardiac-arrest/
  • http://emergencymedicinecases.com/acls-guidelines-2015-cardiac-arrest/
  • CPR
    • Hard and fast – but not more than 120
    • …and allow rebound
    • minimize compression interruptions
      • chest compression fraction: how much of total time during resus is spent with compressions ongoing (80-85% is good; Seattle has 90+%)
 


  • Machines
    • ResQPod – regulates pressure in airway to maximize efficiency of compressions
      • conflicting studies, not formally recommended in guidelines
    • LUCAS – automate compression device
      • no difference in outcomes between manual CPR
        • many confounders
        • delayed time to defib in mechanical arms
      • guidelines state “it may be reasonable” in certain circumstances
  • Pressors
    • Epinephrine
      • Alpha 1 increased contractility
      • Downsides: increased cardiac demand
      • Studies show no benefit to neurologic function w/wo epi
        • recent study showed increased interval bw epi administrations lead to better outcomes
      • Guidelines: standard dose (1mg) Epi “may” be reasonable
      • High-dose Epi (5mg) a/w myocardial necrosis
      • Epi drip studies in pigs were promising
    • Vasopressin
      • No advantage vs standard dose Epi
      • Removed from guidelines in 2015
      • RTC in 2013 of vasopressin, Epi, and steroids showed improved neurologic outcomes
        • guidelines say “can consider”
  • When to call the code?
    • 88-92% don’t make it
    • If EtCO2 <10mmHG (intubated) after 20 mins, is ONE component to consider
    • EtCO2 jumps with ROSC, but finish round of CPR!
    • Consider whole picture:
      • ROSC on scene by EMS
      • age
      • co-morbid conditions
      • POCUS – though cardiac standstill can be survived
      • reversible cause
      • time
1 Comment
CPR Classes Tucson link
8/13/2022 11:02:07 am

Thank you!

Reply



Leave a Reply.

    Categories

     

    All
    Abx
    Article
    Cardiac
    EKG
    EKG Challenge
    GI Bleed
    Grand Rounds
    Headache
    ICU
    Orthopedic
    Pain
    Peds
    Reading
    Stroke
    Subarachnoid Hemorrhage
    Syncope
    Teaching Pearl
    Trauma
    Travel
    Zika

    Archive

     

    February 2018
    January 2018
    December 2017
    November 2017
    October 2017
    September 2017
    August 2017
    May 2017
    April 2017
    March 2017
    February 2017
    January 2017
    December 2016
    November 2016
    October 2016
    September 2016
    August 2016
    July 2016
    June 2016
    May 2016
    April 2016
    January 2016
    December 2015
    November 2015

    Picture
    Please read our Terms of Use.
Donate
This site is independently owned and operated and not affiliated with the George Washington University, George Washington University Hospital, or Medical Faculty Associates. All information on this site is the opinion of the author alone and in no way should be seen to represent the views of the George Washington University, George Washington University Hospital, or Medical Faculty Associates. The information on this page is for personal use only and should not be see as medical advice or used directly for patient care. The author provides no guarantee of the accuracy of the information provided on this page. ​

​Please refer to our Terms of Use. 
  • Clinical
    • Discharge Macros
    • Procedure Macros
    • Exam Macros
    • Pediatric Macros
    • Antibiogram
    • Follow Up
    • 2023 MDM
    • Heart Pathway
    • Jeromy's Macros
  • Education
    • EM Education
    • Critical Care
    • FOAM
  • Orientation
    • Dept Orientation
    • Cerner
    • Dragon
  • Links
    • Clinical Links
    • StatMacros
    • ICU Bootcamp
  • Private
    • MCS
    • GWU Contacts & Map