7.19.18 Conference Summary

Ins and Outs: Ingestions and Esophageal Foreign Body Management- Dr. Jennifer Mitzman

Dr. Jennifer Mitzman, MD is a former resident of the UH CMC EM residency program who went on to complete a pediatric emergency medicine fellowship at Wake Forest Baptist Medical Center and is currently an assistant professor of emergency medicine at Ohio State University Medical School and an assistant professor of pediatrics at Nationwide Children's Hospital where she is also Associate Program Director for the Pediatric Emergency Medicine Fellowship.

  • Laundry pods: Consumed at higher rates, higher clinical symptoms (nausea + vomiting, coughing, CNS depression/AMS)
    • 8% admitted, 2/3rds of admission got intubated- initially
    • Changes: locks on containers, plastic was made bitter, changes in detergents
    • Teenage spike (Tide Pod Challenge)- less symptoms, less injuries = changes worked
    • Symptomatic = admit
  • Bucky Balls: Strong magnets from rare earth metals, most dangerous with serial ingestions
    • Toddlers + Teenagers (used as mock piercings)
    • Can cause bowel perforations
    • Treatment:
      • Single magnet: likely d/c home
      • Multiple: conservative management unless fails (lack of migrations, gap between magnets, clinical deterioration) -> OR
  • Coins:
    • GI: Stuck at thoracic inlet (75%), midesophagus (15%), and lower esophagus (10%)
      • More pain the lower the coin is
      • Most will pass within 6-10 hours, 20 hours max
    • Treatment:
      • Emergent (airway compromise), urgent (secretions, signs of obstruction, >24 hours without migration)
      • No glucagon- doesn't work
      • Bougienage: numb throat and push coin into the stomach with Hurst dilator. One study had success rates in 90-95% range
        • Do not do it in children with midline defect, previous GI problems/surgeries
  • Button Batteries
    • Burns, content leakage, pressure necrosis- can start 2 hours after ingestion
    • Treatment: Emergent removal, honey or carafate (10 mL every 10 minutes)
    • Gastric: younger patients, larger batteries, 2 or more batteries, nonmobile x48 hours, lithium battery, or magnetic coingestion = remove
  • Marijuana
    • Food/candy ingestions: watch for 4 hours (slower GI absorption)
    • Lethargy followed by ataxia is most common
    • Use drug test if ingestion is unknown to try to avoid unnecessary testing
    • Admit all symptomatic ingestions
  • Liquid Nicotine
    • Lethal dose 1 mg/kg, symptomatic dose 0.2 mg/kg
    • Most have GI distress, more severe ingestions are tachycardic/hypertensive/agitated followed by bradycardia, hypotension, and respiratory depression
    • Supportive care
    • Most common cause of death = arrhythmia

 

Break the Silence: Recognition of and Recovery from Second Victim Syndrome, Dr. Jennifer Mitzman

  • Second Victim: Anyone who felt personally responsible for the outcomes, second guess their care, and report feelings of guilt/fear/anger/humiliation
    • 5-18% of hospital admissions complicated by error
    • About 1 death per doctor per year from an error
  • Stages
    • Chaos and Recognition
      • Recognize that there is a problem, confusion
    • Acute Stress Reaction
      • Varying symptoms: rapid heart rate, profuse sweating, wide/dilated eyes, tense posture, shallow breathing, nausea, fatigue, confusion, hyperfocused, fear, guilt, shock, agitation, anger, withdrawal, silence, crying
    • Restoring Personal Integrity
      • Professional re-integration, often aided by a mentor or mental health assistance, facing rumor mill
      • Often a scary time for providers
    • Peer Support Model:
      • Local support (continued outreach)
      • Trained Peers and Safety/Risk Management
      • Expedited Referral (to psychiatric/crisis care)
  • Assistance Utilization Trigger: unexpected patient death, preventable harm to a patient, first patient death, notification of pending litigation, death of staff, #1 cause was unanticipated event involving a pediatric patient
  • Just Culture: People should know what happens after an error (sentinel event committee)
  • Debriefing
    • "Hot" Debrief (happens immediately after event): May increase acute stress reaction/PTSD (doubled rates in Cochrane study)
    • Pause: Brief moment of silence after patient death
    • Cold Debriefs:
      • Mass casualties: Bring in critical debriefing specialists
      • M+M
      • Sentinel event committees, QI, root cause analysis

 

EM Trauma Conference: Pneumothorax Management

PTX.jpg
  • Pneumothorax: Air between visceral and parietal pleura of lungs
    • Trauma is most common cause, rest tend to be spontaneous
    • Most are urgencies, not emergencies unless tension
  • Diagnosis: Chest pain, SOB, hypoxia, decreased/absent breath sounds
    • Develop respiratory distress, deviated trachea, increased JVP, narrow pulse pressure hypotension
    • LOOK at the neck- shock in trauma bay -> if increased JVP, prob not hemorrhage
    • Workup: CXR (upright sensitivity 80-92%, AP sensitivity 24-48%), U/S sensitivity 86-98%
      • On ventilator: High peak pressures? -> Look at plateau pressure (>30 bad) -> do inspiratory hold -> peak + plateau high = pneumothorax is high prob (still others on differential)
  • Management
    • Measure lung edge to chest wall
      • Small (< 2 cm) = 100% FiO2, repeat CXR, observe
    • Needle thoracostomy:
      • Has to have tension physiology
      • Large bore IV (AT LEAST 14 gauge) -> chest tube
      • Location: 2nd intercostal space/midclavicular line (50% of needles don't reach pleural space)- inferior mammary artery runs through there
        • Can use 5th intercostal space mid axillary line but has about same amount of subcutaneous tissue
    • Tube Thoracostomy
      • Positioning: Arm needs to be up (soft restraint or hands behind head)
      • Triangle (square?) of safety (base of axilla, lateral edge of latissimus dorsi, lateral edge of pectoris major, bottom 5th intercostal space
      • Anesthesia:
        • Ample lidocaine- pull back air, inject whole way out to numb pleura
        • Midazolam vs ketamine
      • Prep your tube
        • Clamp through eye hole vs end, clamp off distal end
        • Pneumothorax = anterior/superior, hemothorax = posterior
      • Subcutaneous tunnel: if you have the time
      • EAST guideline: +/- antibiotics, here given 1-2 doses of cefazolin

 

Cardiac Chest Pain: Dr. Sean Abraham

Wellen's Waves

Wellen's Waves

  • Is this ACS?
    • H/P: Exertional, radiation to R arm, diaphoresis, chest pain with vomiting
    • >1 mm ST elevation in 2 contiguous leads
      • V2-3: 2 mm in men, 1.5 mm in women
      • REPEAT EKG
      • STEMI equivalents:
        • LBBB- not an automatic STEMI, sgarbossa criteria- can be just one lead
          • Concordant ST elevation
          • Inappropriate discordance (>20% R-S wave height)
          • Life in the Fast Lane- great reference
        • DeWinter's T waves
          • LAD occlusion (precordial leads)
          • J point depression with upsloping ST segments, tall T waves
        • Wellen's: Not STEMI equivalent
          • Need CICU, high risk for ischemia
          • Dynamic: may have normal EKGs when having pain.
            • Type A- V2-3 biphasic T waves
            • Type V- V2-3 deep, symmetric T wave inversions
    • Is this NSTEMI/Unstable angina?
      • Troponin- lags 4-6 hours behind ischemia, usually need 2 troponins
    • Treatment
      • STEMI
        • Aspirin- NNT 42
        • Heparin
        • 2nd anti-platelet agent
        • Nitroglycerin? - careful with inferior MI, might consider drip
        • Oxygen- only use in hypoxia or significant shortness of breath
      • Unstable angina/NSTEMI
        • Aspirin
        • 2nd antiplatelet
        • Nitroglycerin?
        • Oxygen- only hypoxia or significant shortness of breath
        • Heparin
      • NNT for heparin for ACS?
        • Infinity
        • Used to facilitate catheterization
    • Discharged: Can this patient be safely discharged?
      • HEART score
        • Have to consider shared decision making with patients with scores 4-5
      • Inpatient: stress test or CT coronary angiogram

 

Non-Cardiac Chest Pain: Dr. Sean Abraham

  • PE
    • Dyspnea 90%, chest pain 70%, hypotensive 10%
    • Risk Factors: Recent surgery, trauma, immobility, cancer, paraplegia, OCP
      • Up to 50% of patients have no risk factors
    • Diagnosis:
      • Low Risk (10-15% chance)- Wells criteria to determine low risk
        • PERC rule- rules people out
        • Not PERC negative = age adjusted VTE exclusion d-dimer
      • Not low risk or elevated d-dimer = Imaging
        • CT angiogram (CT PE): Best option here
        • V/Q scan: CKD patients, true allergies to ionic dye
        • Doppler: recommended in pregnant patients
        • Echo: Doesn't diagnose but is helpful
      • Treatment:
        • Heparin: cheap. requires monitoring, safe in renal failure, fully reversible
        • LMWH: expensive, no monitoring, adjust for renal failure, partially reversible, minimally lower risk of HIT, equal bleeding risk to heparin
        • DOAC: maybe discharge if stable with good follow-up? Hestia criteria
        • Catheter-directed thrombolysis
        • tPA- if unstable
  • Pericarditis
    • Exam: Rub
    • Causes: uremia, MI, SLE, idiopathic
    • EKG: ST elevation, ST depression aVR and V1, PR depression
    • Treatment: NSAIDs, chronic recurrent = colchicine can be helpful, steroids?
  • Tamponade
    • History: SOB most common symptoms
    • Exam: Beck's Triad: Sometimes
    • Causes: pericarditis, iatrogenic, malignancy, chronic idiopathic effusion, ESRD, etc...
    • Diagnosis: EKG, U/S (paradoxical RV systolic wall motion, RV collapse)
    • Pulsus paradoxus: Drop in pulse when taking a deep breath of 10 mmHg drop in systolic pressure
  • Aortic Dissection:
    • Risk factors: Marfan's syndrome! Other connective tissue disorders, etc...
    • Diagnosis: CXR- not sensitive enough, CT angio chest/abdomen/pelvis, TEE if available, MRI, traditional angiography
    • Standford Classification
      • A: ascending aorta, emergent surgery
      • B: Descending aorta, can be conservative measures
  • Esophageal perforation
    • Rapidly fatal if missed
    • Usually inciting even -> pleuritic CP -> CV collapse
    • Diagnosis: CXR, Gastrografin swallow followed by barium if negative, CT with dilute PO contrast
Type A Aortic Dissection   

Type A Aortic Dissection