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Grand Rounds - May 11, 2016

5/11/2016

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

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

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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  • Clinical
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