8.2.18 Conference Summary

M&M with Dr. Lauren McCafferty

Case 1: Adrenal Crisis

  • Adrenal physiology: hypothalamus -> pituitary -> adrenal glands (remember negative feedback system)
    • Primary: adrenal glands responsible
    • Secondary: pituitary gland responsible

    • Tertiary: hypothalamus responsible

  • Symptoms are non-specific  (weakness, anorexia, n/v, abdominal pain,          constipation) with high morbidity and mortality
  • Caused by insufficient levels of cortisol with inability to overcome elevated stress levels
  • Adrenal crisis presents as hypotension and shock that is refractory to fluids or pressors
  • Infection is the #1 causes of acute adrenal crisis (particularly GI infections as these classically cause n/v, thus leading to inability to tolerate meds ->  acute lack of steroids)
  • Treatment: IV hydrocortisone 100 mg STAT (give without confirmatory testing if highly suspicious for diagnosis)

Case 2: Septic shock secondary to pneumonia with severe hypoxia

  • Hospital to hospital transfers and questions for the provider to ask   his/herself:
    • Is patient stable?
    • Do benefits outweigh the risks of transfer?
  • Per EMTALA, the sending physician is responsible for the patient until they          arrive at the receiving hospital
  • 3 types of transfer
    • Basic life support: basic EMS (“Uber with a cot”)
    • Advanced life support: can intubate and administer some medications
    • Critical care transport/Mobile ICU: can administer any medication, ventilator capability, invasive monitoring, etc (truly a mobile ICU)
  •  Use of NIPPV (non-invasive positive pressure ventilation) in pneumonia
    • Harmful in patients with pneumonia alone (doubles mortality)
    • Considered safe/potentially helpful in pneumonia + CHF/COPD
    • NIV failure is associated with higher hospital mortality, longer hospital stays, and less likely to be discharged

Case 3: Acute cocaine toxicity secondary to large oral ingestion

  • Cocaine has short, but dramatic effect
    • Cocaine blocks the reuptake of catecholamines and has direct alpha and beta agonism
  • Most common presentation: agitation, HTN, tachycardia, restlessness
  • Life threatening complications
    • Arrhythmias (due to sodium channel blockade)
    • Neurotoxicity (i.e. seizures)
  • Management: start with benzodiazepines and avoid beta-blockers; consider             sodium bicarbonate for severe acidemia and to aid in arrhythmia mgmt
    • Consider lidocaine for these arrhythmias as it is a class 1-B antiarrhythmic that directly blocks the effects of cocaine on the sodium channel

Cardiac US with Dr. Marina Shpilko

  • Point of care  (POC) ultrasound is not meant to replace full ultrasonography; it is meant to answer specific questions to guide immediate management
  • Parasternal long will provide best view of LVOT (left ventricular outflow tract)
  • 4 questions to guide POC cardiac echo
  1.  LV function?: are walls moving in unison; myocardium should contract ~30%
    1. EPSS length is a quantitative measure of LVEF: anterior mitral leaflet to interventricular septum (cannot use this method if hx of mitral stenosis)
      1. Normal is <6 mm
  2. RV dilation?
    1. “D sign”: RV pressure is so high that the septum pushes into LV
    2. RV wall thickness >5 mm suggests chronic problem such as COPD or pHTN
    3. <5 mm suggests acute process such as PE
  3. Presence of pericardial effusion?
    1. Must distinguish between pleural and pericardial fluid (use aorta to distinguish this)
    2. Size of effusion matters; small pericardial effusions are <1 mm
    3. Presence of ultrasonographic tamponade?
      1. Dilated IVC
      2. RV diastolic collapse
    4. Cardiac activity (if arrest present)
      1. Stay tuned for next ultrasound lecture…
  • Aortic dissection
    • Look for a dilated aortic root >4 cm suggests acute aortic dissection -> consider CTA chest/abdomen
    • May also see a “valve within the aorta” which represents the aortic    dissection flap
  • Endocarditis
    • Appearance of vegetations vs. stenotic valve

Airway Grand Rounds with Dr. Matthew Stull

  • Indications for intubation:
    • failure to oxygenate
    • failure to ventilate
    • anticipated clinical course
    • failure to protect airway
  • Universal emergency airway algorithm
    • Unconscious, unreactive, near death? -> crash airway algorithm
      • Maintain oxygenation with BVM immediately and attempt intubation
      • If unsuccessful, paralysis and small dose of sedation and reattempt intubation
      • If again unsuccessful, consider new operator
    • Difficulty airway? -> Difficult airway algorithm
      • LEMON pneumonic
        • Look: initial impression of external airway
        • Evaluate: 3, 3, 2 (3 fingers between patient’s incisors, 3 fingers   between patient’s hyoid-mental space (strongest predictor of anterior airway), 2 fingers between mandible and thyroid membrane
        • Mallampati score (degree of visualization of true vocal cords)
        • Obstruction/Obesity (i.e. external signs of obstruction such as stridor)
        • Neck mobility (i.e. hx of cervical fusion, trauma patients requiring full spinal immobilizater
      • If forced to act, give RSI medications and best attempt
      • If not forced to act, BVM and give RSI with double set-up of backup cricothyrotomy
    • Non-difficult airway? -> RSI
    • Failed airway? -> Failed airway algorithm
      • Immediately call for assistance
      • Failure to maintain oxygenation? -> Extra-glottic device may be attempted with consideration of cricothyrotomy
      • No failure to maintain oxygenation? -> consider flexible endoscopy, video laryngoscopy, blind naso-tracheal intubation

-TAKE HOME POINTS: be proactive (not reactive), be prepared, and have confidence that we ARE the masters of the airway

SANE Demo with Mary Suchetka, RN

  • If you perform a sexual assault collection kit, and the DNA is matched, and you are called to court, we must remain medical professionals during all court processions
    • Thus, if we are asked “Do you believe the patient was raped?”, our answer   must be that “we are not present to pass judgment and simply to perform a        medical exam”
  • 96 hours to perform kit from time of incident
  • 72 hours to give prophylactic STD medications from time of incident
  • Can only swab areas that were “licked, kissed, or bit”
  • Remember to swab under fingertips, as this is a common source of assailant DNA

Power (half) Hour with Dr. Andrew Schaub

Case #1: VZV

  • Hutchinson sign: vesicles on tip/side of nose; precedes development of ophthalmic herpes zoster

  • Fluorescein stain of ophthalmic involvement will show pseudodendritic pattern (‘branches without leaves’)

  • Most common cause of meningoencephalitis

  • Treatment of pain: gabapentin, pregabalin; steroids no longer thought to be helpful

Case #2: Posterior vitreous detachment

  • Ocular ultrasound: ‘washing machine sign’ = echogenic opacities in posterior           chamber that swirl with eye movement

    • Compare to retinal detachment where you’d see an linear echogenic structure tethered posteriorly to optic nerve

Case #3: Dog Tick

  • Carries RMSF and Tularemia
  • Commonly seen in kids’ hair/back
  • Tx: doxycycline, erythromycin
    • Beware of Jarisch-Herxheimer reaction (death of spirochete leads to systemic viral-like illness)

Case #4: Horner's Syndrome

  • ptosis, miosis, anhidrosis
  • ddx: CVA, Bell’s palsy, pancoast tumor, carotid dissection, MS

    • Wallenberg Syndrome: lateral medullary CVA – ischemia to PICA or branches

Pediatric Lecture Series: Pediatric HEENT with Dr. Riley Grosso

  • Normal lateral neck x-ray 7 mm at C2 and 2 cm at C7 (1.4cm at C7 in kids); if greater than these values, consider phlegmon or retropharyngeal cellulitis/abscess
    • Position is important; must be performed while in extension and during inspiration; otherwise false positives are abundant
  • Ill appearing child with tripod positioning, DDx: croup, tracheitis, retropharyngeal abscess, FB ingestion, asthma, epiglottitis, dental abscess, Ludwig angina
    • Epiglottitis
      • Thumb print sign: seen on lateral soft tissue of neck x-ray and is ~90%        sensitive and 95% specific for epiglottitis
      • Don’t lay patient flat
      • Be sure to have surgical airway at bedside at all times; arrange for ENT and transport to OR as soon as possible
      • Ceftrixaone IV
    • Croup
      • Steeple sign on AP neck x-ray
      • All children should get 0.6 mg/kg decadron PO
      • May consider racemic epinephrine for those with stridor at rest or any respiratory distress, but must watch for 2 hours thereafter; if rebound symptoms occur, admit patient for observation
    • Bacterial/suppurative tracheitis
      • Lateral neck x-ray shows irregularity in the tracheal lumen, representing       sloughing of the trachea
    • Retropharyngeal abscess
      • Older children and adults often present secondary to penetrating trauma to  the oropharynx
      • Children < 3 yo are often due to suppurative cervical lymphadenopathy
      • Clindamycin IV & ENT consult
    • FB ingestion in child with stridor: keep calm and maintain upright positioning
    • Acute on chronic inspiratory and expiratory stridor: consider tracheomalacia and give positive pressure
  • Pre-septal (peri-orbital) vs. septal (Orbital) cellulitis: differentiate between the two by presence of pain with extraocular motion or visual changes
    • Will determine need for CT and admission with IV antibiotics vs. discharge   home with PO antibiotics
    • Ceftriaxone for septal cellulitis with ophtho consult. Consider adding Vanc based on history
  • Otitis media: no antibiotics recommended for the first 48-72 hours
    • Consider giving parents info from theNNT.com regarding harm and antibiotics in children for this disease
  • Otitis externa: Cipro-dex
  • Mastoiditis: ear is pushed forward with tenderness and erythema behind auricle
    • CT head, ENT consult, IV antibiotics, and admission with possible LP