12.20.18 Conference Summary

Morbidity and Mortality

Dr. Andrew Schaub, PGY-3

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Case 1:

  • Middle aged male with left upper arm swelling x1 day. Hemodynamically stable

    • Visit 1:

      • Labs unremarkable

      • CT PE negative

      • LUE with occlusive thrombus

      • Dispo: Eliquis starter pack -> Discharge

    • Visit 2:

      • Admitted on heparin gtt -> concern for exercise induced thrombosis -> Vascular surgery consult- HOD4 with catheter directed angioplasty

  • Discussion: DVT

    • Virchow’s Triage: altered blood flow (surgery w/i 4 weeks, flight >6 hr, bed rest >72 hr, chronic venous insufficiency), endothelial injury (vessel puncture, chronic/repetitive microtrauma- athletes, carpenters, roofers), hypercoagulability (sepsis, solid cancer, advanced age, estrogen, chronic inflammatory diseases)

    • Paget-Schroetter Syndrome: Axillary/subclavian thrombosis secondary to repeated upper extremity movements, usually in the setting of an anatomic variant of the thoracic outlet

      • Mainly from endothelial injury

    • When to intervene?

      • Plegmgasia Cerulea Dolens- large clot burden, limb threatening

      • Proximal veins: subclavian, iliac, IVC

      • Patients with contraindication to anticoagulation or high risk of bleeding

      • High likelihood of thoracic outlet syndrome or post-thrombotic syndrome

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Case 2:

  • Middle aged gentleman HTN, CHF (EF 15%), afib, HLD, heavy cocaine use with SOB and cough, occasionally with small amount of blood. Tachypneic/borderline hypotension but maintaining MAPs in ED. Labs with elevated BNP, elevated troponin with a mild AKI

    • ED course: went into atrial fibrillation RVR, attributed troponin to demand -> diltiazem with decrease in HR (150s -> 110s), no new anticoagulation because already anticoagulated on Xarelto

    • Afib RVR on floor with intermittent VT -> was given 20 mg diltiazem with decrease in heart failure but had VTach so switched to amiodarone

    • Hospital course: Worsening tachypnea/tachycardia -> ICU -> intubation -> PEA arrest after intubation s/p ROSC -> multisystemic organ failure -> 3 pressors/CVVH -> legionella antigen positive -> palliative extubation

  • Cardiogenic/Septic Shock (Multifactorial Shock)

    • Shock: mismatch between oxygen delivery and tissue demand stemming from hypotension and lack of adequate blood flow resulting in cellular injury/necrosis

    • 4 types:

      • Distributive: sepsis, SIRS, anaphylaxis, neurogenic shock, toxin related shock, adrenal insufficiency

      • Cardiogenic: MI, arrhythmia, mechanical abnormality

      • Hypovolemic shock: Hemorrhagic, non-hemorrhagic

      • Obstructive: PE, tension pneumothorax, pericardial tamponade (R side heart obstruction)

    • Evaluation:

      • RUSH exam, broad laboratory testing including lactate

    • Sepsis induce cardiomyopathy

      • Troponin and BNP are less useful here

      • Thought to be an inflammatory response and NO release cause a decreased sensitivity to calcium in the myocardium

    • Dobutamine

      • Use of inotrope treatment in septic shock was associated with increased 90 day mortality

      • However, did not look at combo septic and cardiogenic shock

    • Methylene blue:

      • Administration increased the MAP and SVR while decreasing the vasopressor requirement

        • Think about after multiple pressors, given steroids, relative healthy person

    • Levosimedan

      • Reduced mortality in shock, not available in the US

      • Thought to increase calcium response in the myocardium

  • DKA and atrial fibrillation are two states that can have an underlying cause- always be cautious

Pediatric Respiratory Illnesses

Dr. Leslie Dingeldein

Respiratory variations:

  • Obligatory nose breathers until 4 months

    • Smaller airways, easier to fill with pus -> leads to bronchiolitis, croup, etc

  • Periodic breathing:

    • Need to listen for a full minute for rate in patient under two years old

  • Diaphagram: Lower glycogen, fat, strong fibers -> fatigue

  • Belly breathing: Normal unless combined with chest collapse -> impending respiratory failure

  • Nasal flaring (increase airway diameter to decrease airway resistance), head bobbing, grunting

  • Infants metabolize O2 at twice the rate of adults -> desaturate faster, recover slower

Respiratory Illnesses

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  • Asthma:

    • IV? Labs?

      • RFP in patient with concomitant cardiac disease

      • IV if not tolerated PO, given IVF based on fluid status

      • Magnesium: kids get hypotensive with magnesium

    • CXR: new onset wheezing, no response to therapy, or suspect concurrent illness

    • Dexamethasone: one dose shown as effective as a 3 day prednisone treatment, 2 doses might extend it to 5 days

    • Disposition:

      • Discharge: No respiratory distress (wheezing ok) for at least 1-2 hours after last treatment, ability to give albuterol at home

      • Admit: continued distress, oxygen requirement, social concerns

      • ICU: Continuous albuterol here, respiratory support beyond nasal cannula

      • Anticipatory guidance/Parental encouragement

    • Asthma intubation

      • Indications: AMS, increasing hypercapnea

      • Allow permissive hypercapnea, slower rate, lower i/e ratio

      • prevent air trappinh

      • continue bronchodilators

  • Viral Croup:

    • History/Physical

      • Ages 6 months to 3 years, but can be up to age 8

      • Barky cough, hoarse voice/cry, difficulty breathing or history of difficulty breathing

      • Sudden onset, URI prodrome

      • Stridor: worse at night, early morning, with exercise/crying

      • Better after exposure to cool, humdified air

    • Assessment

      • Mild: diagnosis may be made on history, no stridor, occasional barky cough

      • Moderate: stridor at rest, some retractions

      • Severe: stridor at rest, significant retractions, agitation

      • Impending respiratory failure: cough less prominent, cyanosis, lethargy

    • Treatment

      • Racemic epi: stridor at rest, extreme agitation, cyanosis with or with agitation

      • Dex 0.6 mg/kg mat 10-12 mg PO or IM

        • even for mild croup- helps with resolution of symptoms, decreases return visits

    • Disposition

      • Discharge: no stridor at rest (calm, afebrile), no return of stridor, distress after 2 hours observation perdio neb racemic epi (even two back to back)

      • ICU: refractory stridor with persistent distress, hypoxia, need for heliox or intubation

  • Bacterial Tracheitis

    • Mortality 20-40%

    • Signs: minimal response to croup treatment, high fever, drooling, toxic appearance, older child (up to about age 14, but can happen in anyone), XR neck may show irregularity at level of trachea

    • Management:

      • Call anesthesia/ENT

      • Secure airway in OR ideally but be prepared to manage emergently

      • Labs (CBC may be normal, blood culture may be negative, may defer- don’t risk airway)

      • Transfer early- critical care

        • Consider careful intubation prior to transport because pseudomembranes can obstruct airway at any time

      • Fluid resuscitation/pressors (treat shock/SIRS)

      • IV antibiotics (penicillin-sulbactam, third generation cephalosporin, vancomycin)

      • Keep kid calm and in position of comfort

  • Epiglottis

    • Presentation

      • High fever, stridor, abrupt onset

      • Tripod, muffled voice

      • Stridor and hypoxia are often late signs- expect impending airway obstruction

    • Causes:

      • GAS, strep pneumo, klebsiella

      • Caustic ingestions

      • More common in unimmunized kids

    • Management

      • Keep calm, keep patient in positive of comfort

      • Be prepared to manage airway, assume it will be difficult

      • OR/anesthesia on call, ENT- manage airway

      • Delay labs and IV placement if possible to keep kid calm

      • OK to visualize posterior oropharynx without instrumentation if the patient is cooperative and calm

      • Lateral neck xray can be obtained

  • Bronchiolitis

    • Etiology: influenza, adenovirus, RSV, enterviruses, metapneumovirus

    • Typically <2 years old

    • Lower respiratory symptoms

    • Treatment (AAP guidelines):

      • Nasal suctioning

      • Albuterol trial is not recommended

        • Controversial: Causes tremors, tachycardia BUT can help in certain patients with lung exam

        • Need more evidence, especially with history of RAD and family h/o of asthma

      • Nebulized hypertonic saline not indicated in ED

      • Feeding trial

      • IV/NG hydration if poor oral intake, severe tachypnea, poor IOP

      • CXR in severely ill children with fevers

      • Supplemental oxygen, ventilatory support

      • No role for (steroids, antibiotics, chest physio, diagnostic RSV testing)

      • HFNC

        • 1.5-2 L/kg/minute with max 30 L/minute

        • Best in kids less than 8 kilos

    • Disposition:

      • Admit:

        • Tachypnea

          • RR >50-60 for infants 2-12 months

          • >40 for 1-2 years

        • Infants less than 60 days

        • Cannot eat or drink

        • Underlying illness

        • H/o prematurity

        • Social concerns, poor followup

      • ICU: apnea, bradycardia, HFNC

  • Foreign Body Aspiration

    • Keep calm and call specialists

    • Be prepared for decompensation

    • Lateral decubitus x-rays- look for air trapping, chest CT, bronchoscopy (especially kids that look good with concerning history)

    • Awake and not breathing

      • Indicates complete upper airway obstruction

      • Attempt back blows, intubate, need McGill forceps

    • Obtunded, unconscious

      • PALS/CPR

      • Advanced airway

      • Pull or push (consider right mainstemming the object)

      • Prepare for surgical or alternate airway management

    • Object consideration

      • button batteries, medications, sharp objects, nut allergies/food allergies

Pediatric airway

  • Airway soft tissue structures are proportionally larger

    • Larynx anterior, epiglottis floppy -> use a miller blade in kids under 3 years old

  • Large occiput

  • Below larynx smaller than above

  • Mature between 8-12 years

  • Preemie: 1-2-3 rule

  • Meds:

    • Midazolam, ketamine, etomidate (not in septic shock)

    • Rocuronium, succinylcholine

    • USE A BROSELOW TAPE/CARDS

EM/Trauma: Mass Casualty Management

Dr. Andrew Loudon

Disaster Preparedness

  • Hospitals must prepare and drill to handle the worse

    • Training drills with EMS, mass intake drills with hospital staff

  • These events are inevitable

  • Each hospital should plan to be self sufficient

  • Must have a comprehensive plan and all hospital response

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Mass Casualty

  • Any event that overwhelms a hospitals usual capacity to care for victims

  • Surge capacity

  • Hartford Consensus

    • Nobody should die from uncontrolled bleeding

    • T (threat suppression), H (hemorrhage control), RE (Rapid extrication to safety), A (assessment by medical providers), T (transport to facilty)

  • Mass Casualty/Multiple Casualty

    • Multiple Casualty: Patients are successfully managed by mobilizing additional resources (ie multiple level one traumas)- providing standard of care

    • Mass Casualty: Overwhelm resources- providing sufficient care

    • Problem with sufficient care:

      • Most unfamiliar with this and difficult to handle

      • Disaster situations require triage or patients and resources

      • Routine vs Crisis Response

        • The ability to recognize a crisis and respond effectively is an essential skill in disaster management

        • Size or scale alone does not define a crisis

        • Transition from routine to crisis depends on how quickly those in charge note the need for the response

        • Routine response: familiarity with the condition, full awareness, reliance on “recognition primed” decision making

        • Crisis response: standard response plan invalid, new untried organizational structure, inadequate resources, lack of experience, many unknown unknowns

Journal Club- Airway Management

Discussion lead by Dr. Matthew Stull

Article 1: Efficacy of Nasal Cannula Oxygen as a Preoxygenation Adjunct in Emergency Airway Management (Clare Hayes-Bradley et al, Annals of Emergency Medicine, August 2016)

  • Looked at EtO2 using varying preoxygenation techniques in 60 healthy patients with no signs of a difficult airway

    • Bag-valve-mask (BVM) with or without nasal cannula and nonbreather with or without nasal cannula

      • BVM without an airleak: No improvement in EtO2 but no significant difference with or without a nasal cannula

      • BVM with an airleak: Increase in EtO2 with the nasal cannula

      • Nonrebreather: Increase in EtO2 with a nasal cannula

      • No differences between BVM with airleak and nonrebreather (both with nasal cannula)

Article 2: Emergency Department Intubation Success with Succinylcholine vs Rocuronium: A National Emergency Airway Registry Study (Michael Dr. April et al, Annals of Emergency Medicine, December 2018)

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  • Looked at intubation success rate between succinylcholine and rocuronium

    • Primary outcome: First pass intubation success

    • Secondary outcomes: Adverse events (cardiac arrest, dental trauma, direct airway injury, dysrhythmias, epistaxis, esophageal intubation, hypotension, hypoxia, iatrogenic bleeding, larngoscope failure, laryngospasm, lip laceration, main-stem bronchus intubation, malignant hypothermia, medication error, pharyngeal laceration, pneumothorax, ET tube cuff failure, vomiting)

  • They used prospectively collected data from the NEAR database during the year 2016

  • Results:

    • No significant differences in first pass rates or adverse events with high dose rocuronium

  • To note:

    • The succinylcholine patients were in general younger, higher incidence of trauma, more likely to have video laryngoscopy, and intubated by more experienced providers

Article 3: Effect of Cricoid Pressure Compared with a Sham Procedure in the Rapid Sequence Induction of Anesthesia- the IRIS Randomized Clinical Trial (Aurelie Birenbaum MD et all, JAMA surgery, October 2018)

  • Testing the hypothesis that the incidence of pulmonary aspiration is not increased when cricoid pressure is not performed

  • Randomized, double-blind, noninferiority trial from 10 academic centers

  • Primary endpoint: incidence of pulmonary aspiration (at the glottis level during laryngoscopy or by tracheal aspiration after intubation)

  • They failed to demonstrate noninferiority of the sham procedure in preventing pulmonary aspiration

    • Secondary end points (pneumonia, length of stay, and mortality) not significant different

    • Statistically significant longer intubation time and worse grade view in cricoid pressure group

Article 4: Effect of Use of a Bougie vs Endotracheal Tube and Stylet on First-Attempt Intubation Success Among Patients with Difficult Airways Undergoing Emergency Intubation: a randomized clinical trial (Brian E Driver et al, JAMA, May 2016)

  • Randomized clinical trial from September 2016-September 2017 including 757 patients over the age of 18

  • Primary outcome: first-attempt intubation success in patient with at least one difficult airway characteristic (body fluids obscuring the laryngeal view, airway obstruction or edema, obesity, short neck, small mandible, large tongue, facial trauma, or the need for cervical spine immobilization)

  • Secondary outcome: first-attempt success in all patients, first-attempt intubation success without hypoxemia, first attempt duration, esophageal intubation, and hypoxemia

  • Results:

    • Among 380 patients with at least 1 difficult airway characteristic, first attempt intubation success was higher in the bougie group

    • Among all patients, first attempt intubation success in the bougie group was higher than the endotracheal tube + stylet groups

    • No difference between median duration of the first intubation attempt and hypoxemia