6.27.19 Conference Summary

Morbidity & Mortality - Dr. Andrew Schaub, PGY3

Case #1

Young male, unrestrained passenger in MVC, car flipped over bridge, presented as a trauma activation. Hemodynamically unstable. GCS 14. Massive transfusion protocol initiated. FAST negative. Electively intubated by trauma. Found to have unstable pelvic fractures, lung contusions. Taken emergently to the OR. Found to have extensive intra-abdominal/pelvic injuries, lung injury. PEA arrested in the OR, thoracotomy attempted without effect.

https://radiopaedia.org/cases/pelvic-fracture-diagrams

https://radiopaedia.org/cases/pelvic-fracture-diagrams

Unstable pelvic fractures

  • A break at 2 or more points in the pelvic ring results in an unstable pelvis

  • Types

    • Lateral compression

    • Anterior-posterior compression - commonly seen in MVC

    • Vertical shear -classically seen from fall from height, landing on extending legs; often associated with hemodynamically significant bleeding

    • “Windswept” = unilateral AP compression + contralateral lateral compression injury

  • Management

    • Resuscitation!

    • IR embolization for all cases in which hemodynamic instability is present (look for blush/extravasation) - per EAST guidelines

    • Pelvic binders— no clear mortality benefit or reduction in blood products but still recommended for all unstable pelvic fractures per EAST and orthopedic trauma guidelines

    • Packing — not recommended as primary technique but useful adjunct especially if delay to IR embolization

    • Consider REBOA if not immediately available IR or surgery in unstable patient despite MTP


Case #2

Middle aged female presented for concern for alcohol withdrawal after several days of binge drinking after having been sober for four months. Tachycardic. Ethanol mid 200s. Found to have multiple electrolyte abnormalities (low Na, K, Mg, phos); elevated serum ketones, lactate of 6, bicarb 8 with normal pH. Received fluids, benzos, thiamine for suspected alcoholic ketoacidosis. During inpatient stay, sodium corrected rapidly and she received DDAVP.

Alcohol ketoacidosis

  • Complex pathophysiologic state that results from a combination of relative starvation, decreased gluconeogenesis as a result of alcohol’s effect on metabolism, and intravascular volume depletion and that ultimately results in a ketotic state.

  • Elevated serum ketones (beta hydroxybutyrate)

  • Acid-base derangements - high anion gap metabolic acidoisis with osmolar gap. Assess for respiratory compensation vs concurrent alkalosis or acidosis

    • Including alcohol is the serum osmolality calculation can cause false elevation (and thus, a falsely lower gap)

  • Hypotonic hyponatremia is common

  • Often have concurrent illnesses

  • Treatment: dextrose + water, electrolyte repletion as needed (may self-correct)

ROSH review

ROSH review


Case #3

60s yo female with T-cell lymphoma on chemo presented for shortness of breath. Appeared hypervolemic. Increased work of breathing. Point-of-care ultrasound showed hypokinetic LV with regional wall motion abnormalities. NSTEMI. She was diuresed and admitted for new onset heart failure. Had clean cath, diagnosed with takotsubo cardiomyopathy.

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Takotsubo Cardiomyopathy (“Broken heart syndrome”)

  • Reversible LV apical ballooning/akinesis

  • Can be caused by emotional stress, drugs, cardio-toxic meds

  • More commonly seen in post-menopausal women

  • Since it mimics ACS, it’s ischemia until proven otherwise

  • Diagnosed with a clean cath and full resolution of wall motion abnormalities and return to normal EF



Toxicology Series: Opiates - Dr. Alex Votruba, PGY1

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  • High morbidity/mortality, costly to healthcare system

  • Pharmacology

    • Modulate nociception (CNS, PNS, GI systems)

    • Primary opioid receptors: mu (supraspinal), kappa & delta (spinal)

      • Most opiates are nonselective

    • GI absorption: peak blood levels

      • Standard (30-60 min) vs sustained release 60-90 min

    • First pass metabolism - affects bioavailability

      • CYP450 metabolism —> multiple drug-drug interactions

      • Therapeutic effects are influenced by hepatic metabolism

  • Toxicology - Opiate intoxicaiton

    • Coma, miosis, respiratory depression, hypotension, hypothermia, hyporeflexia, n/v, bronchospasm, urticaria, urinary retention

    • Complications: pulmonary edema, rhabdo, compartment syndrome, renal failure, seizure, etc

  • Treatment of overdose

    • Airway + breathing! (also circulation)

    • Naloxone (Narcan)

      • Competitive antagonist of all opioid receptors

      • Dose dependent on clinical assessment: 0.1mg-2mg IV q3 min

      • Monitor for recurrent mentation/respiration depression

  • Withdrawal - NOT life-threatening

    • Peaks day 3, resolves by day 5-6

    • Clonidine, antiemetics, antidiarrheals for symptoms

  • Meds for opiate use disorder - medically supervised

    • Methadone - can cause QTc prolongation, hypotension; abuse potential

    • Naltrexone - multiple effects including hepatotoxicity

    • Buprenorphine (Suboxone) - can cause peripheral edema


Super Track Series: Skin/Soft Tissue Infection - Dr. Zean Chen, PGY1

orthobullets.com

  • Necrotizing soft tissue infections (gangrene, fasciitis, myositis, etc) - 30% mortality

    • Sx: poorly demarcated, rapid progression, exquisite tenderness, violaceous bullae, crepitus, systemic sx

    • Organisms: strep, clostridium, bacteroides, polymicrobial

    • Emergent surgical consult for debridement + broad spectrum abx (include clindamycin), resuscitate

  • Bubonic plague (Yersinia pestis) - 15% mortality with treatment, 50% without

    • Painful swollen lymph nodes, systemic symptoms

    • Tx = Aminoglycoside, tetracycline, or fluoroquinolone

Anthrax

Anthrax

  • Cutaneous anthrax - rarely fatal with treatment, 20% fatality without

    • Black, necrotic, painless ulcer; most likely from handling animals (less likely terrorism)

    • Tx = Fluoroquinolone, vanc, doxy


  • Furuncles - infection of hair follicles / Carbuncles - clusters of furuncles

    • Self limiting; cephalexin first line if extensive or no improvement


  • Impetigo (usually strep)

    • Generally patient not toxic appearing; orange yellowing crusting

    • Mupirocin, pcn, 1st gen ceph

Erysipelas.jpg

Erysipelas

  • Erysipelas (bright red, well-demarcated, superficial) vs cellulitis (poorly demarcated, deeper)

    • Both can have systemic symptoms

    • Abx: 1st gen cephalo (MSSA/strep) —> inpatient - vanc, clindamycin, linezolid, daptomycin (consider MRSA for purulence, risk factors)

  • Abscess

    • Requires drainage due to poor abx penetration (highly therapeutic); packing not very useful; antibiotics only if systemic or severe local sx;

    • POCUS - frequently changes management; sensitivity 95%, specificity 80%

  • Eyelids

    • Hordeolum (bacterial infection at/near eyelash, painful, warm compresses)

    • Chalazion (above upper lid lashes, blocked oil gland, painless, may need steroid injection/surgery)



Community EM Series: Thrombectomy in the Acute Ischemic Stroke Patient - Dr. Hussein Ghoul, PGY3

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  • Thrombectomy eligibility (general)

    • LKW within 24 hrs

    • Proximal large arterial occlusion in anterior circulation

    • +/- tPA use

    • Disabling neurologic deficit; exact NIHSS stroke variable)

  • Recent major studies

    • MR CLEAN - 6 hrs LKW, NIHSS 6 or greater

    • DEFUSE 3 Trial - 6-16 hrs LKW

    • DAWN Trial - 6-24 hrs LKW

  • Outcomes: effective in reducing disability (NNT 3-7.5), relatively safe

    • No significant mortality benefit if baseline functional status is poor

    • Benefits for posterior CVA not well studied

  • Adverse effects - Increased incidence of CVA in other territory compared to tPA