7.12.18 Conference Summary

Post-ROSC Management - Dr. Matt Stull

Out of Hospital Cardiac Arrest

  • About 300,000 per year
  • >90% mortality

Physiology of death: Three phases

  • First: Electrical phase (0-4 minutes)
    • “One shock wonders”- heart is still primed
  • Second: Circulatory phase (4-10 minutes)
    • Oxygen deprived tissues- need to get oxygen to myocytes
  • Third: Metabolic (10+ minutes)
    • pH undetectable, anaerobic metabolism
  • Reverse phases: high quality CPR
  • ABCs (fix the Arrhythmia, fix the Blood pressure (diastolic >35), fix Catabolism- airway, drugs, causes)

Goal directed CPR (end tidal, arterial BP monitoring) = better outcomes

To Cool or Not to Cool? 

  • Hypothermia (2002): Target 33C, NNT = 6, improved outcomes, VT/VF
  • Targeted Temperature Management (2013): No difference between 33C and 36C
    • Included PEA and asystole
  • ICU 33 C vs 36 C
    • Easier to keep patients at 33 C than 36 C- more had fevers
  • Conclusion: AVOID FEVER- cooling might not help, but fevers definitely hurt   
    • Question still: 33C vs 36C? 

To Cath or Not to Cath?

  • STEMI on post arrest EKG = activate cath lab
  • Angiogram vs no angiogram: increased neuro intact survival after cath
  • 2014: Shockable rhythm initially without STEMI on post arrest EKG: lower mortality when taken to Cath
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 “Eu” Physiology

  • Euoxia: 80-150 mmHg, SpO2% 94-99%
  • Euglycemia: 80-150 mg/dL
  • Eucapnea: CO2 35-45 mmHg
  • Eu-pressuric: MAP 70-90 mmHg

Cannot prognosticate in ED: Need 72 hours for NEURO prognostication

  • Of people who walk out of hospital post arrest, 33% had fixed/dilated pupils and GCS 3 at the time of admission

 

Newborn Complaints - Dr. Chris Peluso

  • Pediatric Assessment Triangle: Appearance/work of breathing/circulation to skin
  • TICLSS: Tone (pick baby up), Interactiveness (awake, moving all limbs), Consolability (ask parents), Look/gaze (grimace/sunken), Speech (cry), Saliva/tears
  • Neonatal Jaundice: 
    • Causes: + hemolysis (ABO incomp, Rh, infection), -hemolysis (breast milk, breast feeding, hemorrhage, physiologic, polycythemia)
    • Conjugated = Infectious
    • Labs: CBC, LFTs, Creatinine…then Coombs, Retic, Rh
    • Critical actions
      • Risk Factors: First 24 hour jaundice (NICU stat), gestation age 35-36 wk, ABO incomp, sibling with phototherapy, cephalohematoma
      • Plot Bili/Risk: In theory, low intermediate/low risk can go home, rest admit
      • Plot Bili by risk factors: Infants at higher risk = need therapy. T bili at 25 = exchange transfusion, >5 above line
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  • Neonatal Fever
    • History Pearls (> 18H ROM, maternal STIs/GBS/Fever, LBW)
    • <36 or >/= 38 = UA/UCx. CBC, BCx, CSF with viral panel/HSV, CXR, Resp panel, Stool cx if diarrhea
    • Antibiotics:
      • 0-21 days: ampicillin, cefotaxime, acyclovir, consider vanc
      • 22-28 days: ampicillin/cefotaxime +/- acyclovir, consider vanc
  •  BRUE (Brief Resolved Unexplained Event)
    • ow risk: <1 min and 1stevent, Age >2 months, born >/= 32 wga, Age 45+ wga, no CPR by trained individual
  • Vomiting
    • Can’t miss: Midgut volvulus with malrotation (bilous)
    • What I care about: bilious, sepsis/meningitis, hypoglycemia/thermia, obtunded vomiting, acute metabolic/IEM, projectile vomiting
  • Seizures
    • Myoclonic- sit ups, any rhythmic motions
    • 50-60% mostly HIE, rest metabolic, infectious, hemorrhage, abuse/trauma
    • Status: IM midazolam, IV lorazepam x2 doses -> Phenobarbital  -> fospheny or Keppra (by 5 minutes) -> airway, versed gtt (by 20 min)

 

ED Pharm 101 - Brian Lauer, PharmD

Pharmacy Resources

  • UH Intranet (Drug info page on bottom left) -> “Drug Use Policies and Guidelines”
    • Reversal Agents for anticoagulants/antiplatelets
    • Lexicomp, CMC Pharmacy Page
  • Anti-microbial stewardship program
    • Antibiogram
  • OB hemorrhage kit (located in Rooms 3B and 1A)
    • Includes methergine, hemabate, cytotec, and Pitocin
  • Trauma RSI Medication Kit
    • Includes etomidate, succinylcholine, rocuronium, versed, and fentanyl 

 

Ultrasound: FAST exam - Dr. Jessica Rockwood

FAST (“focused assessment with sonography for trauma “) exam

  • Positive and unstable -> OR
  • Positive and stable -> CT
  • Negative and stable -> CT or repeat FAST
  • Negative and unstable -> Repeat, DPL, alternative source 

FAST exam is helpful test in an evolving algorithm:

  • “Sick”: prioritize interventions include thoracotomy, tube thoracostomy, laparotomy
  • “Could be sick”: prioritize among other patients
  • “Not sick”: reassurance, help minimize CT use 

Probe selection: 

  • Phased Array or curvilinear probe has smaller footprint but less detail
  • Linear probe has higher detail 

eFAST technique

  • Pericardial
    • subcostal/subxiphoid
      • looking for anechoic strip within the pericardial sac
        • Be aware that pericardial fat pad will not be dependent and not entirely anechoic
    • parasternal long
      • easier to obtain in larger patients or those in severe pain; must remember that this is not a 4-chamber view
        • This view will allow differentiation of pericardial effusion vs pleural effusion
  • RUQ hepatorenal/perihepatic view (“Morrison’s pouch’) 
    • important to visualize the inferior pole of kidney as fluid will accumulate here first 
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  • LUQ splenorenal/lienorenal/perisplenic
    • place probe more posterior/superior compared to RUQ
    • important to look in sub-diaphragmatic/suprasplenic space because free fluid will accumulate in this region first 
    • Be careful not to confuse stomach with free fluid; stomach fluid will have a    smoother contour and more central location
  • Pelvis
    • look in both transverse and sagittal views -> most dependent portion of pelvis in females is posterior cul-de-sac or “Pouch of Douglas”; in males it is retro-vesicular region
    • Be careful not to confuse seminal vesicles (deep to bladder) for free pelvic fluid
  • Thoracic
    • eval for fluid in the thoracic cavity and lung sliding
    • +lung sliding = no pneumothorax (highly sensitive; not as specific) 
    • “Mirror artifact”: lung tissue will look like liver tissue; indicates normal anatomy
    • "Spine sign": in lateral views, you shouldn't see vertebral bodies extend above level of diaphragm; if it does, it indicates pathology in the lung (something other than air)            
    • “Seashore sign” and M mode to eval for pneumothorax
    • “Comet tails” indicate fluid within lung tissue; decreases suspicion for pneumothorax
    • “Power slide”: use power doppler to detect low velocity motion; presence of this motion is indicates lung sliding -> no pneumothorax 

Consultant of the Month: ENT - Epistaxis - Dr. Clare Richardson and Dr. Anish Abrol

  • Etiology: most commonly primary/idiopathic causes
  • Anatomy
    • Kiesselbach’s Plexus aka Little’s area
      • Anterior/inferior septum
    • Woodruff’s Plexus
      • Posterior epistaxis
      • Elderly, uncontrolled HTN
  • New Algorithm!
    • History: trauma, amount of blood, length of bleeding, laterality, and h/o nosebleeds, anticoagulation, personal/family hx blood disorders, nasal or sinus sx in last 30 days
    • Vitals/Labs: BP, heart rate (screen for anemia), consider labs
    • Clear nose of clots- blow nose with you in the room
    • Afrin (at least 5 sprays) and pressure x10 minutes, can also soak a cotton ball in Afrin before holding pressure
    • Exam with Headlight/Flashlight + Speculum- look for source
    • Recent sinus/nose surgery- CALL ENT. Avoid packing if possible
    • Repeat Afrin and pressure- can add 4% lidocaine to Afrin on cotton ball to numb
      • Use a pickup to place the cotton ball
    • Silver nitrate- IF you directly visualize source, area is relatively small
      • DO NOT cauterize bilaterally
      • Headlight/nasal speculum, numb, warn patient they might sneeze, hold over area for 10-15 seconds. Repeat x3 PRN
    • Absorbable packing
      • Gelfoam soaked in topical thrombin or Surgicel directly to area that’s bleeding
      • Floseal- gel that you can spray in nose, use 18 gauge angiocath
    • Non-absorbable Packing (Leave 3-5 days)
      • Merocel (8 cm or 10 cm)
      • Rhinorocket (second choice): be aware of amount of air put in
      • Coat packing with thin layer of bacitracin prior to placement
      • Aim straight back- along nasal floor, no significant portion of the packing should be visible outside
      • Bilateral packing = admit on continuous pulse ox
      • Antibiotics while packing in place: Keflex, doxycycline, or clinda
    • Posterior Packing- Need ENT
      • Profuse bleeding/life threatening or packing in and bleeding profusely down back of throat
        • Epistat or 12-14 Fr foley!