POTD: Aorticenteric Fistula (AEF)

Aorticenteric Fistula (AEF):

There are two different types of AEF:

• Primary: Occurs when a chronic, untreated aortic aneurysm damages or destroys the aortic and bowel tissue.

• Secondary: Occurs due to inflammation of previous aortic graft surgery that is near a section of bowel. This type is much more common than primary AEF.

AEF must be considered in any patient with GI bleeding and history of abdominal aortic surgery. Although AEF is not the most common cause of GI bleeding in these patients, it is life threatening.

The most common location is along the third or fourth portion of the duodenum. A large abdominal aortic aneurysm can erode primarily into the duodenum at these locations, resulting in fistula formation.

Fun fact: Postoperative AEF is most often associated with a graft infection. 

Aortoenteric fistula can present with a sentinel or herald bleed that is minor, or with a sudden catastrophic bleed with hematemesis, melena, or hematochezia (so don’t rely on just upper or lower GI bleed).

If the patient is hemodynamically unstable, emergent laparotomy and blood transfusion are needed. If the patient’s condition is stable, upper GI endoscopy or CT angio of abdomen/pelvis (but you may just want to get the whole aorta). This is a good example of why it’s good to have both surgery and GI consults for your GI bleeds.

In a patient I had with this diagnosis, they had severe AKI he and we attempted to get a CTA but MRA was recommended/insisted by the radiologist (the patient was very stable). The radiologists were refusing to take this patient to CT due to the Cr. In the end, we learned that in order to get an accurate MRA, the patient needs to stay extremely still and pretty much not breath (…not practical). So after all the effort to get this patient to MRI, they ended up getting the CTA anyway, just hours later. Luckily this patient still did well but it was stressful sending them so far away to MRI land. Learn from my mistakes.

In the image below, this classic triad (GI bleed, abdominal pain and palpable mass) occurs in 6-12% of AEFs. Good for MCQs, bad for real life.

 Sources:

Text: peer review, https://www.uptodate.com/contents/aortoenteric-fistula-recognition-and-management

Photo: Rosh review

POTD: Trauma Tuesdays. Le Forte Fractures

Inservice is over but let’s keep the review of Le Forte Fractures going strong!

Interesting historical fact: Named after French Surgeon Rene Le Forte. He described fracture classifications are based on experiments conducted in 1900 by dropping bricks on cadavers and observing the pattern of fractures.

I included the words for description of the fractures but pictures are truly best.

·       Le Fort I: the gist: palate. across both maxillae above the dentition.

o   More wordy: The fracture extends through the piriform aperture superior to the maxillary alveolar ridge, then propagating through the anterior, medial, and posterolateral maxillary sinus walls.

·       Le Fort II: the gist: nose + palate. starts in the maxilla laterally but extends more superiorly into the orbital floor.

o   More wordy: The fracture involves the posterolateral maxillary sinus wall and anterior maxillary wall, extending through the inferior orbital rim into the orbital floor, medial orbital wall, and the region of the nasofrontal suture.

·       Le Fort III: The gist: craniofacial separation. completely separates the facial bones from the skull. Transverses zygomatic arches laterally. Buzz word: CSF rhinorrhea.

o   More wordy: The fractures extend through the nasal bridge, medial orbital wall, posterior orbital floor, and lateral orbital wall near the frontozygomatic suture. The zygomatic arch is always fractured as well.

In general: All of these patients are going to have severe swelling, possible airway obstruction. All will need OMFS consult, IV abx, surgical management and admission.

Sources:

LIFL: https://litfl.com/le-fort-facial-fractures-eponymictionary/

ENT trauma handbook published 2017 written by the American Academy of Otolyngology- Head and Neck surgery

Photo: https://emedicine.medscape.com/article/434875-overview

POTD: Wellness. You Do You.

As we residents, ED attendings, medical students know, finding time for wellness can be a challenge, especially in the face of contiguous shifts, conferences, and multiple inversions of our sleep schedule. It can feel like the weight of Atlas’ world is resting on your shoulders. My intention with this POTD is to reflect on the lessons I have learned navigating self-care in residency, in the hopes that it will prove helpful to someone.  

After perusing articles by wellness gurus and our own PD, Dr. Arlene Chung, I realized that what I do for wellness is different that what many people do. At first, I thought that the difference between my experience and experts meant that I wouldn’t have anything to contribute, but then I realized that wellness is personal, and maybe my experience will prove helpful for someone who reads this POTD. The following are my tips for wellness: 

GENERAL:

First and foremost, approach all advice regarding wellness with curiosity and skepticism, including my own. It might be right for you.  It might not. My intention is not to write you a to-do-list, but to help you examine some areas of your life that may have potential for exercising self-care.  Experiment and see what’s right for you.  

FOOD:

Some residents don’t eat on shift. If this is a choice, either as an intentional approach to intermittent fasting, or because you don’t need to, then that's great. However, it needs to be a choice. Experiment, and learn who you are and follow what’s best for you. If you need to eat regularly, then prepare for this need. 

I bring hydration and food from home and eat before coming to shift. There is not always time to go out and grab something and I enjoy bringing food from home. Waking up early to prep food for myself is a form of self-care. I feel prepared, and loved by myself, when I can grab a frozen Tupperware meal from the fridge. The same is true when I can enjoy a nutella sandwich. I also enjoy prepping a meal/snack for my loved one.  We can go a few days without seeing each other on a long stretch, and knowing that we have that connection through a prepared food is like a lifeline to connect us when we can’t physically be together.

Also, I get hangry. Nutella keeps the Bruce Banner version of Allie in the ED, so no one has to get their rapid strep test from the 8 month pregnant Hulk version of Dr. Kornblatt.  

MEDITATION:

When I come home, I often will feel my brain racing and have thoughts of patient tasks zipping in and out, causing me to stress and have dreams about patient care. So before bed, I actively try and clear my mind to think of nothing at all. Sometimes if I’m having a rough time with this, I use a body scanning meditation technique so that I can focus. I recommend the free first ten guided medications on the app “Headspace.” (I am not paid to endorse Headspace, or a meditation expert at all). The more you practice, the easier it gets and I find in stressful situations, I can clear my mind so that I focus on the task at hand.

SCHEDULE ACTIVITIES IN ADVANCE:

If you see you have a weekend off, schedule something in advance. In my experience, if you wait until that weekend itself, you’ll just sit at home and not do anything. If you do need that time at home to recharge, then plan that, ahead of time. Planning for a weekend under the covers can make it feel intentional, and relieves any guilt associated. 

FINAL TAKE HOME THOUGHTS ON WELLNESS:

We often think of our accomplishments in numbers: test scores, numbers of procedures/requirements completed, class rank, etc. Sometimes this is helpful—comparison to our peers let’s us know if we are falling behind, or in a position to act as a leader and help our colleagues succeed. Not so with wellness. 

Wellness is not comparable, it is not a competition on who is the most well. Experiment and find what’s right for you. If you try to compare or adopt the habits of others, you are destined for disappointment.

So, go be well, whatever it means to you.

Your friendly TR this month,

Allie