Grand Rounds - May 11, 2016

• Sickle Cell Disease
• TR Presentation - Pelvic Kits
• M & M - shoulder dislocation
• Journal Club

Sickle Cell Disease - by Adbulla

Genotypes

• most severe: HbSS and HbS+beta thal
• less severe: HbSC (but can still have vaso-occlusive crisis)

Pathophysiology

• polymerization within RBC creating sickle shape and poor compliance for cell to squeeze through capilaries
• release of inflammatory molecules from RBC creating cycle of vaso-occlusion

Clinical Manifestations

• Hemolysis - most labs measure this
• Vaso-occlusion

Vaso-occlusion

• usually symetric
• Evidence-Based Mgmt of Sickle Cell Disease (National, Heart, Lung, and Blood Institute) https://www.nhlbi.nih.gov/sites/www.nhlbi.nih.gov/files/sickle-cell-disease-report.pdf
  • gold standard of pain assessment is pt self-report (no objective signs/sx that support determination of pain level)

Pts are often still d/c'd with pain, but ideally can handle it at home with PO pain meds

History

• complications

Physical Exam

• look for hypoxia, respiratory distress
• abdominal tenderness
• splenomegally
• edema at sites of pain

Labs

• leukocytosis is normal, however >20k is likely infection
• typical reticulocyte count is 3-4x upper limit of normal
• <3% - aplastic crisis
• bili, LDH, and haptoglobin all elevated at baseline, but check for extreme elevation

Pain Treatment

• administer pain meds w/in 30 minutes from triage
• first line analgesia is opioids (morphine or dilaudid)
• • can given sub-Q if delayed IV access
  • avoid demerol/meperidine (renal abnormalities will lead to decreased seizure threshold)
  • max first dose 1.5mg Dilaudid
  • reassess in 10 mins for Dilaudid, 20 mins for Morphine
• if pain not relieves with >2 doses of morphine or hydromorphone, pt should be admitted for round-the-clock parenteral analgesics
• if pain controlled in ER, can discharged with PO pain meds
• Ketorolac - don't give if pt says doesn't work, but can if it does
• Ketamine
• • no studies, but increasing use with good reported results
  • slow IV push of subdissociative dose (0.3mg/kg?)
  • some people still have dysphoria

Hydration

• no RCTs on this
• provide IVF bolus if hypovolemic

Oxygen

• only if hypoxemic

Magnesium

• RCT showed no decrease in length of stay or reduced opioid use

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TR Project: Pelvic Kits - by Colton
Notes on doing a TR project:

• Plan, Do, Study, Act (PDSA)
• 8 wastes: Lean Six Sigma
• • inventory, talent, waiting, motion, defects, transportation, overprocessing, overproduction

Plan:

• decrease LOS of pts with pelvic complaints, enable availability of rooms with doors
• goal: decrease LOS by 10-20%
• idea: pelvic kits

Pelvic Kit

• in lunch box:
• 1 large swab
• 1 pack Q-tips
• 1 redtop
• 1 saline flush
• 1 GC PCR kit
• 1 castile wipe
• 1 speculum
• 1 large chuck
• 1 small chuck
• 2 lubes

​
Logistics

• 20 kits created
• kits located in triage/vitals room in cabinet on the right
• emailed nurse managers, residents, word of mouth

Study

• Cerner polled for GC PCR tests
• corrected 12% decrease of stay (50 minutes)

Resources for TR Projects

• IHI website

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M&M Conference - by M-E
Case:

• 84M BIB family for lt arm edema and pain x 4 days, no trauma, dementia, ESRD, HTN, has pacemaker, pain with arm straightening, sitting all day with head propped on left arm all day, noticed swelling in evening, possibly caught in railing of hospital bed at home
• VS WNL
• PE: left arm diffusely swollen, TTP over elbow, no bony tenderness, some ecchymosis, full passive ROM, not moving LUE, no abrasion
• DDx: fracture, dislocation, cellulitis, stroke, DVT UE
• Labs: at baseline given renal disease
• EKG: V-paced
• Imaging: CXR, XR left humerus, elbow, and forearm, U/S LUE
• Attending Note: pulses present, non-focal TTP LUE
• U/S LUE found DVT 6 hours after presentation
• XRs read as negative, but reeval noted anterior shoulder dislocation 9 hours after presentation
• • dedicated shoulder XRs note mild Bankhart fx of glenoid and possible distal clavicle fx?
• Double sign-out for both midlevel and attendings
• Ortho paged multiple times without response
• SW involved for potential elder abuse (unknown if APS called)
• Reduction performed upstairs later in evening 17 hours after arrival in ER
• Next day pt denied sensation in M/U/R distributions, no motor function appreciated, pulses intact
• On DCS 5 days later, sensation intact to elbow, more movement at shoulder and elbow
• After discharged, brought right back to ED - family refused to assume care
• Readmitted overnight, dc'd home with home hospice
• (Soft restraints found at home for "overnight agitation")
• Nursing note of ED Delay due to "increased ED activity"

Shoulder Dislocation:

• in elderly, usually a/w rotator cuff tear
• Bankhart fracture: inferior glenoid
• Peripheral nerve injury: axillary nerve most common
• Assessment: have pt abduction shoulder (rotatory cuff and axillary nerve testing), thumbs up, "ok" sign, cross fingers for median, radial, ulnar motor testing in hand

Chronic Shoulder Dislocations

• uncommon, but typically in older patients, usually trauma
• dislocated for "several days"
• primary complaint: loss of motion with pain (most common deltoid weakness)
• to reduce or not to reduce?
• contraindications for ED providers (nothing in Rosenalli)
• • if >20% impression defect of humeral head or > 4 weeks (from ortho literature)

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