4.25.19 Conference Summary

Morbidity and Mortality Conference

Dr. Leah Carter

  • Case 1

    • Visit 1 : 18 yo F presents with 2-3 days of abd pain, nausea and multiple episodes of vomiting, dysuria; on ABX for UTI (Macrobid)

      • 6 weeks pregnant

      • VSS aside from tachycardia with HR 120s

      • PE: unremarkable aside from mild suprapubic pain and L flank pain/tenderness

      • Labs: WBC 18k; UA with LE, white cells and clumps, and bacteria; beta-HCG 50k

      • Treated with zofran, IVF and DC’d home with Keflex (changed from Macrobid)

    • Visit 2 (next day): same complaints, now with fever of 102 and mild vaginal spotting

      • Labs: WBC 19k with left shift, normal lactate

      • POCUS confirmed IUP with dates 6w6d

      • Admitted to OB; tx with ceftriaxone

      • Urine culture grew E. Coli pan sensitive

      • Started on IVF and Ancef

      • Blood cultures grew E. Coli

      • CT abd/pelvis showed ?renal abscess/cyst; vancomycin and zosyn initiated

      • ID and urology consulted; ABX switched to ceftriaxone

      • DC’d with Keflex 500 mg QID for 14 days

    • Question 1: How do I diagnose pyelonephritis?

      • Ultimately, a clinical diagnosis

        • UTI + nausea/vomiting/flank pain with fever

        • PPV of clinical dx of pyelo with fever: 0.98

        • PPV of clinical dx of pyelo without fever: 0.84

      • No need for imaging unless concerned for other pathology

      • UA not absolutely necessary especially if patient has symptoms consistent with UTI (dysuria, urinary frequency/urgency)

    • Question 2: Why do we care about pyelo in pregnancy?

      • Worse outcomes for mother and infant

      • More common pregnancy (unclear why; possibly because of compression on ureters)

    • Question 3: What about blood cultures?

      • 15-20% of women with pyelonephritis are bacteremic

        • But does it matter?

        • Blood cultures are rarely different from urine culture

        • ABX changes are based on clinical picture and worsening status; not based on blood cultures

    • Question 4: How do I treat pyelonephritis?

      • 2010 IDSA Guidelines

        • Non-pregnant: fluoroquinolones if resistance <10% can be considered along with typical ABX coverage

        • Pregnant: similar but choices are more limited

          • Beta-lactams, cephalosporins, metronidazole, quinolones, and gentamicin all considerations

    • Question 5: What about asymptomatic bacturia?

      • ACOD and IDSA both agree this should be treated, particularly in pregnancy

      • Older patients only with urinary bacteria with changes in mental status but no other signs of UTI, bacteria does not likely represent a true infection and physician should look for other source

  • Case 2

    • 60 yo F with PMH of ESRD and HTN presented via EMS in cardiac arrest

      • Loaded with amiodarone, epinephrine x3 prior to arrival

      • Collapsed at home, found pulseless, received bystander CPR

      • PSH: kidney transplant

      • Meds: albuterol, losartan, simvastatin, coreg, nitroglycerin, ASA 81, nifedipine among others; no immunosuppressants or steroids

      • Code sheet:

        • EMS called at 1432

        • Arrives at 1456 with Vfib on monitor

        • Received calcium, bicarb and defibrillation

        • ROSC at 1517; A-line placed

      • Post-ROSC ABG: pH 7.11 and lactate 8; cooled immediately with ice packs

      • Labs: ESRD, no hyperK, no leukocytosis

      • CT head and CXR unremarkable post ROSC

      • Post-ROSC EKG with ST depressions in V4-V6

      • Patient had some movement after ROSC

      • MDM: received defibrillation x4 PTA and x3 in ED; cooled post ROSC; cardiology called and admitted to CICU; waited in ED for 4 hours prior to admission to CICU

      • Admitted to CICU; continued on amiodarone, repeat EKG unchanged; discussion about cath and echo, not immediately taken to cardiac cath lab (however, considered but not planned)

        • Neuro consulted on HD1 given concern for eyelid “fluttering” and shaking concerning for seizures; EEG showed suppression from sedation; versed drip initiated

        • Family discussion on HD2 and life-support was withdrawn; 6 hours later, patient pronounced

    • Question 1: Do cardiac catheterizations after ROSC help?

      • Overwhelmingly, the answer is yes (especially with a shockable rhythm)

        • Multiple specialties, including critical care and cardiology, have published data showing improved outcomes with cardiac catheterizations s/p cardiac arrest, particularly in patients presenting with initial shockable rhythm such as Vtach or Vfib

    • Question 2: Timing of PCI after ROSC?

      • Trend towards improved outcomes with early PCI (<4 hours) but not statistically significant

    • Question 3: How to prognosticate after arrest?

      • Earliest prognostication should be performed is 72 hours

      • GCS score is not helpful post arrest

      • Bilateral absent pupillary or corneal reflexes or SSEP (somatosensory evoked potential) at 36H reliably predicts a poor outcome

      • We withdraw care too early on ~2500 patients in US annually who would have had an otherwise good neurological outcome (according to neurocritical care data)

      • Mortality rate for myoclonic status epilepticus: 90-100% (but studies shows we (including neurologists) are bad at interpreting EEG data)

        • Lance Adams syndrome is a variant of myoclonic status that has better prognosis (however, rare and difficulty to diagnose)

  • Case 3

    • Visit 1:

      • 44 yo F with hx or ESRD on HD, on transplant list, presents with “kidney pain”; denies urinary pain, fevers, chills

      • VS unremarkable

      • PE: L CVA tenderness

      • Labs: with stable anemia; ESR 57

      • CT abdomen/pelvis: no acute process

      • MDM: received fluids, morphine, zofran; felt improved; DC’d home

    • Visit 2 (2 hours later)

      • Presented again with back and SOB; missed dialysis

      • Now tachycardic and with acute LE weakness and saddle anesthesia

      • PE: bilateral LE flaccidity

      • Labs: CBC and RFP at basline

      • CXR and CTPE negative for PE with small effusions

      • Transferred to main campus for NSGY consultation because of lower extremity weakness

      • MRI w/ contrast of spine showed signal change in thoracic region concerning myelitis or infarction

      • NSGY and neurology saw patient

      • Initially believed to be infarction related; given ASA and treated with permissive HTN

      • Attending neurologist felt this was true transverse myelitis and then treated with steroids;

      • Admitted to NIU; no airway issues, however no NIF performed; permissive HTN continued; received HD during inpatient stay; LP performed with consistent with pleocytosis; received solumedrol 1 g QD for 3-5 days

    • Transverse Myelitis

      • Segmental spinal cord injury from acute inflammation

      • Related to or caused by infarct, SLE, radiation yelopathy, infections, RA, MS

      • Develops over several hours then orsen overs day sto weeks

      • 1/3 improve, 1/3 worsen, 1/3 stay the same

      • Incidence 1.34-4 cases per million per year

    • Question 1: How do you diagnose transverse myelitis?

      • Most commonly found in younger women

      • 50% have a preceding infection

      • Dx: MRI +- LP with consistent symptoms

      • Rate of recurrent is 10-40%

    • Question 2: How is transverse myelitis treated?

      • Steroids +- Cyclophosphamide and plasma exchange

      • No reliably good treatment

      • ASIA patients with lower functional scores (C, D, and E) benefit more from PLEX in addition to steroids

Wellness Lecture Series: Delivering Bad News

Drs. Janel Paukovits, Andrew Veverka, and Ross McDermott

Dr. Amy Pound

  • Breaking bad news to patients and their families can be a difficult situation and providing the appropriate language and context is important

  • Always remember, while cardiac arrest is often the primary diagnosis dealt with in these situations, other diagnoses such as new/recurrent/metastatic cancer, surgery, ectopic pregnancy/miscarriage can be equally difficult for patients to deal with, and physicians must deal with these encounters with the same tact

  • Good practices:

    • Remaining human and vulnerable

  • Bad practices:

    • Disruptions during the conversation

    • Delivering bad news over the phone

  • SPIKES Mnemonic (A Standardized approach to delivering bad news)

    • Developed out of oncology literature because miscommunication regarding serious diagnoses is common and improves patient satisfaction

    • S: Set up

      • Privacy, all members present, adequate seating, tissues, police on standby, anticipate interruptions, turn off phone/pager

    • P: Perception

      • Establish patient understanding first

    • I: Invitation

      • How much does the patient want to know?

      • More or less relevant depending on situation

      • Shunning information may be necessary coping mechanism initially

    • K: Knowledge

      • Use the word “died” or “dead” or something similarly clear

      • Do NOT use jargon. Be aware of your own education level

      • Be concise without being blunt. “I’m sorry to tell you ___”

    • E: Emotions

      • Be prepared for anger, sadness, stone-face, etc.

      • Let emotions run there course before moving on

      • Recognize and validate emotions, use verbal and tactile support as appropriate

      • Have appropriate support on standby (SW, nursing, PD, etc.)

    • S: Summary/Strategy

      • What’s next? (treatment, admission, police, morgue, etc.)

      • What questions do you have?

      • Have an exit plan

  • Family-Witnessed Resuscitation

    • American Heart Association recommends family-witnessed CPR as this improves understanding and grieving by family members

    • Potential barriers

      • Fear of interference

      • Fear of litigation

      • Negative effects on families

      • Stress on providers

    • Protocol

      • Assign a staff member to meet family

      • Communicate family’s wishes

      • Prepare family members for details of resuscitation (can be chaotic, loud, frightening)

      • Tend to the family

        • Staff member should accompany the family during resuscitation

      • Involve the family (when appropriate)

        • Notify family if resuscitation efforts are deemed futile

      • Declaration of Death and Aftercare

        • Remain with the family as long as needed

        • Allow family a chance to view loved one

bad news.jpg

EM/Trauma Lecture Series: Facial Trauma and Plastic Surgery

Dr. Rachel Aliotta

  • Learn nerve blocks of the face!

    • Patients are more comfortable and quiet

    • Improves your speed

    • Single shot = wide territory

    • Maintains landmarks/anatomy

Facial Nerve Anatomy

Facial Nerve Anatomy

  • Antibiotics are not typically necessary for post-laceration care on the face as long as appropriate irrigation is performed

  • Laceration Repair Rules for Aesthetically Sensitive Areas (i.e. Face)

    • Preserve everything!

    • Deep buried sutures do all the real work

    • 5 mm small bites -> across and adjacent

    • Mirror depth both sides -> everted skin

      • At first appears “heaped up”

      • Settles and gives best scar

    • Interrupted >> Running

      • BUT, consider location and your time

  • Suture choice

    • Scalp: 3-0 vicryl buried, 3-0 chromic gut, or staples

    • Muscle or Deep SQ layers: 4-0 or 5-0 PDS or 4-0/5-0 Vicryl

    • Never use suture larger than 4-0 on visible face skin

    • Visible skin layer: 5-0, 6-0, 7-0 Prolene or Nylon; 5-0 or 6-0 FAST absorbing gut

    • Mucosa (tongue/wet lip): 4-0 chromic gut or Vicryl

    • If you decide to use non-absorbable sutures…

      • Must be removed by 5 days

      • Be kind, leave a visible tail for easier removal

  • Basic Discharge Instructions

    • Shower, but no baths, starting within 24 hours

    • Plain soap and water, rinse, pat dry with clean towel

    • No perfumes or lotions

    • Thin layer of aquaphore ointment/vaseline

      • Every AM and PM at a minimum

      • Bacitracin/Bactroban/Mupirocin for no more than 3-4 days

    • Oral antibiotics are not typically necessary

  • Lacerations lateral to the cheek, always consider damage to CN VII and Stenson’s Duct

Cranial Nerve VII

Cranial Nerve VII

Stenson’s Duct

Stenson’s Duct

  • When to perform tongue laceration repair… (usually unnecessary as tongue will heal well with minimal scarring)

    • Large flaps

    • Muscular layer deep

    • >1-2 cm

  • Ear laceration

    • MUST IRRIGATE copiously as chronic chondritis is difficult to treat

    • Superficial interrupted sutures usually suffice

    • PO antibiotics necessary

    • If ear is torn off, call plastics as microsurgery may be possible to salvage ear

    • Don’t worry about repairing cartilage as this can be repaired later

  • Auricular hematoma

    • Must drain blood and place restrictive dressing to prevent re-accumulation of blood

  • Frontal sinus fractures

    • If involving 1 table, place loose sutures and close follow-up

    • If involving 2 tables, emergent NSGY or plastic surgery eval as this requires urgent repair

  • Nasal bone fractures

    • Usually non-op, but always eval for septal hematoma as this requires emergent drainage and PO antibiotics and close follow-up

  • Complex facial lacerations (especially with hanging flaps) need to be approximated quickly to save skin and preserve blood flow

  • Infraorbital floor fractures

    • Eval for visual acuity, sinus precautions

    • Loss of vision, retrobulbar hematoma or entrapment are vision threatening complications and require emergent OMFS/plastic surgery consultations

  • ZMC (Tripod Fracture)

    • Ophtho exam

    • Pain control

    • Elevate HOB

    • Most need delayed surgery due to significant swelling

  • LeFort I, III, III fractures

    • Very very rarely require emergent surgeries due to swelling

    • Will eventually require surgery

    • Document bite anatomy

    • Pain control and activity precautions

  • Mandible fractures

    • Pain control

    • Close follow-up

    • Open fractures require PO antibiotics for at least 48 hours

    • Oral hygiene

    • Strict liquid diet