Journal Club

Review of the Basics of Cognitive Error in Emergency Medicine and Updates: Still No Easy
Answers by Hartigan et al, 2020.

• Despite research, Cognitive Error remains a source of frustration
• Rapid decision making in the ED relies on a combination of intuition and analytic reasoning, both based on experience and training.
• Reviews studies on Cognitive Error interventions and assesses applicability in ED. Not much statistical data to support that these interventions translate into productive changes in clinical practice, but studies are limited and further research is needed.

Contrast-Associated Acute Kidney Injury by Mehran et al, 2019.

• Proposes change of nomenclature from “Contrast-Induced” AKI to “Contrast-Associated” AKI
• Historical significance of Contrast-Associated Acute Kidney Injury may be overstated
• Reviewed historical interventions for preventing CAAKI
• Recommend fluids and follow-up for patients at high risk of renal injury (those with known renal dysfunction)

Deaths in ED and 72 Hour Returns

• Excellent work last month, Team.
• Reviewed palliative care in ED, post-traumatic growth, and toolkits for dealing with trauma.
• https://www.psychologytoday.com/us/basics/post-traumatic-growth
• https://healthcaretoolbox.org/self-care-for-providers.html

Morbidity and Mortality Case

• Unexpected decompensation in ED with subsequent PEA arrest
• Reviewed traditional ACLS algorithm as well as updated literature discussing potential for treating PEA based on its morphology (i.e., wide complex vs narrow complex)

Ethical Considerations in Pre-Hospital Care with Dr. Selk

• Autonomy, beneficence, nonmaleficence, justice
• Capacity: ability to understand medical situation and make an informed decision about care after being advised of the risks and benefits of a particular course of action
• Competence: a legal determination.  If you are concerned that a patient is not competent, then you can refer for 
• Refusal of EMS care:  Patient must articulate reasoning for refusing and articulate ramifications regarding their decision.  This conversation should be documented and witnessed as well. 
• Death on Scene: non-traumatic cardiac arrest, unresponsive/apneic/pulseless/F&D pupils/ALS EKG with asystole in at least two leads.  Lividity, rigor mortis, presence of venous  pooling, destruction of body incompatible with life
• Law enforcement information gathering activities should not interfere with patient care.  Law enforcement video or audio recording should only be used with permission from all parties

Management of Variceal Bleeds with Dr. D. Thomas and Dr. D. Grace

• ABCs:  HOB up, preoxygenate, RSI with cardiostable sedative and high dose paralytic, have video and 2 suctions available.  Place tamponade tube PRN and call GI.
• Tamponade tube depends on the institution.  No matter what, inflate gastric tube and apply proximal traction. Start by placing 50cc air into balloon and shoot a CXR to confirm placement in stomach.  Once placement is confirmed, fully inflate balloon.  Gastric balloons can potentially migrate into the esophagus and will compress the trachea, causing high peak pressures.  If you see increased peak pressures, repeat CXR to check placement. 
  • Blakemore tube:  Gastric balloon (250mL) + esophageal balloon + gastric suction
  • Minnesota tube: Gastric balloon (500mL) + esophageal balloon + gastric suction + esophageal suction
  • Linton tube: Gastric balloon (750mL) 

Mushroom Toxicity with Dr. Webb

• Orellenine:  symptom onset 36hrs-17days, severe renal failure, frequently no other symptoms with insidious onset
• Amatoxin:  gradual onset over several days.  Initially emesis and diarrhea → elevated LFTs → GI bleeding, hepatic encephalopathy, renal failure → death.  Can treat early ingestion with charcoal and gastric decontamination.  Silbinin, NAC, benzathine penicillin have been proposed as potential treatments. 
• Ibotenic acid and mucimol:  Increases GABA And serotonin. Onset minutes but up to 3 hours → visual distortions and hallucinations.  Can see N/V, ataxia, and hypotension.  Very rarely cause coma, convulsions, and death.  Symptoms typically resolve within 24 hours. 
• Monomethylhydrazine:  Inhibits pyridoxine function in CNX. Most common presentation is N/V/D.  Can rarely cause jaundice, liver failure, and seizure. Treatment is typically symptomatic, but should give pyridoxine if patient develops seizures
• Muscarine: Sweating, salivation, lacrimation, miosis, bradycardia, wheezing.  Treatment typically symptomatic, but if severe, can use atropine. 
• Coprine: causes disulfiram-like reaction.  Don’t mix with alcohol.
• Chlorophyllum: most common mushroom poisoning in the US.  N/V/D.  Supportive treatment.  

Peds GI Emergencies with Dr. Stevenson

• Obstruction– atresia (esophageal, jejunoileal, anorectal), meconium ileus, webs/stenoses/duplication.  Typically present within early weeks of life.  Can see double bubble sign with duodenal atresia.  Call surgery. 
• Malrotation– First week or so of life, bilious emesis.  Call surgery. 
• Pyloric stenosis– First month of life.  Child appears hungry and fussy, but non-toxic.  Olive-shaped mass.  Diagnostic test of choice is ultrasound.  Call surgery. 
• Incarceration– hernia or torsion.  Associated with prematurity.  Reduce and call surgery.
• Intussusception– paroxysmal abd pain, vomiting, lethargy.  Can have positive hemoccult.   

Implicit Bias in ED with the Office of Diversity and Inclusion

• Implicit bias is an unconscious cognitive shortcut between previous experiences and current data input
• IAT as a tool to evaluate your implicit bias
• Snap judgements, elitist behaviors, negative stereotypes, positive stereotypes, cloning, wishful thinking
• Can impact our ability to effectively interact with patients and colleagues
• Can unintentionally reinforce historical social inequalities 
• How to mitigate individual biases:  develop the capacity to self-reflect, get feedback, practice “constructive uncertainty,” engage “others,” and explore awkwardness

discomfort.  

Anorectal Disorders with Dr. Harmon

Rectal prolapse–typically painless presentation, requires reduction. If edematous, can use sugar to improve swelling prior to reduction. 

Anal fissures–painful rectal pain with small bright red blood with BMs. Symptomatic management. 

Hemorrhoids–external can be painful, internal can be painless. Symptomatic management.  Referral to CRS.

Abscesses–Beware the anorectal abscess. Requires DRE looking for any disproportionate tenderness or fluctuance.  If exam concerning for deeper abscess, obtain CT. Treatment of choice is I&D.  If simple perianal, can do bedside I&D.  Any other abscess should be operatively managed.    

Cirrhosis with Dr. Cook:

Path: Progresssive hepatic fibrosis and subsequent liver dysfunction 2/2 hep C and/or alcohol.

Clinical presentation: Encephalopathy, asterixis, hepatorenal syndrome, jaundice, ascites, varices (+/- bleed), +/- SBP, HCC

Work up: Basic labs, +/- sepsis evaluation, +/- CT head, ammonia level if no history 

Treatment: Airway management and BP management PRN, beta blockers, lactulose, +/- antibiotics if concern for SBP or GI bleed.

Gallbladder Pathology with Dr. Carter:

Most gallbladder pathology related to stone–cholesterol vs pigment–formation.  Ultrasound continues to be imaging of choice.

Cholelithiasis: relenting RUQ pain after eating without systemic signs.  Should see normal labs.   Typically managed outpatient.  Can refer for outpatient HIDA. 

Cholecystitis (cal vs acalc):  Elevated WBC, +/- elevated AST/ALT, less likely to have bili elevation, + Murphy’s Sign.  Requires surgical consult. 

Ascending Cholangitis: SICK. WBC, AST/ALT and bili elevation, alk phos elevation. Charcoat’s Triad and Reynold’s Pentad aren’t present in most patients.  Focus on resuscitation, antibiotics, and surgery consult. 

Start with ultrasound (evaluating for GB wall thickening, sonographic Murphy’s, pericholecystic fluid). If ultrasound is non-diagnostic, alternative imaging includes CT w contrast (Fast) or MRI (does not require contrast, safer in pregnancy)

Room 9 Follow-up with Dr. Davenport:

Elderly female presents to resus bay with concern for fall vs ?anaphylactic reaction, per EMS.  Intubated prior to arrival for airway protection.  Given epi, benadryl, steroids PTA.

Arrives HDS.

Initial physical exam with concern for profound facial edema and upper body subcutaneous emphysema. 

Access obtained, labs drawn, CXR not super helpful given subQ air and habitus.  FAST limited 2/2 subQ emphysema. 

BP progressively starts dropping and Radiology calls with concern for tension pneumothorax.  Chest tube subsequently placed with clinical improvement. Panscan obtained with multiple rib fractures, lung contusions, pneumomediastinum, chest tube in place with small residual pneumothorax. 

Family arrives and states patient had significant fall.  No history of anaphylaxis or angioedema. EMS concern for anaphylaxis was likely related to traumatic facial swelling.  This report led to some early diagnostic anchoring, which could have caused a harm event.

Patient was admitted to trauma service, had improvement over hospital course, eventually discharged to SAR.

Learning Points:

* Epi elevates BP, which can make a hypotensive patient look falsely HDS.

* Resus bay CXRs can be difficult to read in resus bay 2/2 body habitus, as well as small screen and bright lights.

* Pneumomediastinum: typically treated with symptomatic support and observation unless injury to great vessels.

* Pulm contusions: hypoxia and hypercarbia–>respiratory acidosis.  High risk for developing ARDS. 

* Cognitive bias: beware anchoring and overconfidence.  These can be natural digressions into energy-sparing cognitive shortcuts in our high acuity in our work environment.  It is easy to develop cognitive biases.  Recognition, mindfulness, and discussion can help prevent cognitive bias.

IR PE Management with Dr. Glaenzer:

Tool for IR-directed treatment of major pulmonary embolism via aspiration of clot.  Presents an alternative to traditional EKOS (directed lytic therapy)

PE–>RV dilatation–>Increased RV wall tension–>Myocardial Tension and Inflammation–>Increased myocardial demand–>Decreased RV output–>Decreased LA preload–>Hypotension–>Death

Inari can be considered in patients with both intermediate and high mortality PE

Upper GI Bleed with Dr. Shah:

Causes:  PUD, H pylori, anticoagulation, hepatic pathology

Physical exam:   DRE, look for signs of cirrhosis (Ascites, jaundice, angioma, hepatosplenomegaly), abdominal scars? (consider aortic enteric fistula), cardiac murmurs? (consider anticoagulation status)

Workup:  CBC, CMP, PT/PTT/INR, type and cross, lactic, trop (in elderly), ammonia (if AMS)

Scoring systems:  Glasgow Blatchford Score (most useful in ED), Clinical Rockall SCore, AIMS65

MGMT:  Blood for Hbg<7.  Platelets for active bleeding and plt<50k.  PCC for INR>2 and life-threatening bleeds on warfarin.  TXA for severe upper GI bleed.  Pantoprazole 80mg IV bolus. Octreotide 25-50mcg IV bolus.  Antibiotics–typically Ceftriaxone 1g IV if concern for variceal bleed. Blakemore tube as last line for unstable patients. Endoscopy>IR>Surgery.