4.11.19 Conference Summary

Cleveland Rising Lecture Series: “Unstably Overweight”: Resuscitation Challenges in the Morbidly Obese Patients

Dr. David Snow, Program Director, Loyola University Emergency Medicine

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  • Definition of Obesity: BMI >30

    • Extreme/Severe Obesity: BMI>40

    • Note: BMI is not a measure of body fat

  • Prevalence of Obesity

    • 1/3 of U.S. States have >30% of population considered obese

  • Higher age = Higher obesity

  • Higher education = less obesity

  • Keys to success in resuscitation of critically ill morbidly obese patients

    • Pre-oxygenation

      • Safe apnea time for non-obese patients: 6 minutes

      • Safe apnea time for obese patients: 3 minutes

      • The higher the BMI, the less amount of safe apnea time and shorter time to desaturation

        • Less FRC

        • Increased oxygen consumption

        • Chest wall mass

      • Use positive pressure ventilation (PPV)

        • BiPAP or CPAP equally effective

        • At least 10 mm Hg

    • Access

      • Consider early placement of IO lines if access is difficult

        • Mean soft tissue depth for proximal humerus: 29.6 mm

        • Mean soft tissue depth for proximal tibia: 11 mm

        • Knowledge of these numbers is important as yellow IO needle has 45 mm depth

      • If central venous access is necessary, consider using an 18-gauge spinal needle as femoral vein is often deeper under multiple cm of subq tissue

    • Safety of RSI?

      • Proper positioning of the bed and patient to optimize intubation conditions

        • Be sure to place patient in sniffing position; this may require significant towels or blankets under the upper thorax/head

      • Mallampati score worsens with higher BMIs

      • No change in laryngoscopy grade with higher BMIs, particularly with video-assisted laryngoscopy

      • BVM becomes more difficult with BMI>30 and neck circumference >37 cm

        • To improve success of BVM, use oral/nasal airways and a 2 handed technique for better BVM seal

          • 2 handed technique involves using the bilateral thenar techniques to provide better seal and easier ventilation and preoxygenation

      • RSI is safe in the morbidly obese patient, but knowledge of the anatomical difficulties beforehand is key and how to troubleshoot will improve success and decrease bad outcomes

      • Awake intubation is a consideration and video-assisted laryngoscopy is as good as fiberoptic nasal intubation

    • Medications?

      • Succinylcholine and etomidate are dosed based on ideal body weight

      • Rocuronium and ketamine are dosed based on ideal weight

      • Remember this difference in dosing for the morbidly obese patients

    • Ventilator success?

      • 6 cc/kg IBW tidal volume

      • 10 cm H2O PEEP for proper oxygenation

Cleveland Rising Lecture Series: Success in Emergency Medicine

Dr. David Snow, Program Director, Loyola University Emergency Medicine

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  • Definition of SUCCESS depends on each individual’s approach

  • “Success is peace of mind, which is a direct result of self-satisfaction in knowing you made the effort to become the best of which you are capable.” - John Wooden

  • Pathway

    • Give Your Best -> Satisfaction -> Peace of Mind -> Success

  • Burnout

    • Emergency medicine has the 5th highest burnout rate as of 2019 (48% of surveyed EM physicians reported burnout)

    • Reasons for burnout

      • Too many bureaucratic tasks

      • Too many hours at work

      • Increasing computerization of practice

      • Lack of respect from administrators/employers

  • Tips to avoiding burnout and long-term success…

    • Connect with patients on a regular basis

    • Call back your (questionable) discharges

    • Organization is important

      • Last minute preparation is not an option, as this will impede on other good habits (sleep, exercise, healthy relationships)

    • Be prepared for each and every shift

      • Consider a pre-shift routine that includes meal preparation

      • Engage the mind

    • “Strive to provide thoughtful, respectful, customer-centered care with each encounter” - Dr. David Robert Brooks

    • Don’t center your career around $$$

    • Find times on shift to feel satisfied


Approach to the Undifferentiated Crashing Pediatric Patient

Dr. Paria Wilson, Pediatric Emergency Medicine, Children’s Hospital of Pittsburgh

  • Case presentation

    • 23 mo old previously healthy, fully immunized female presents with 24 hours of NBNB emesis x2, breather harder per mom, and intermittent abdominal pain

    • Decreased PO intake, urine output normal

    • Mom tried Pepto-Bismol at home with no improvements so PCP told mom to come to the ED

    • VS: T 38.2, HR 170s, RR 50s, BP 96/52, 100% on RA

    • Initial PE: Abdomen TTP diffusely, crying with exam, moans even when sleeping, capillary refill takes ~3 seconds, tachypneic with cleat breath sounds, no rashes; otherwise normal

  • Differential dx: sepsis, UTI, FB ingestion, DKA, intussusception, influenza, strep pharyngitis, appendicitis, non-accidental trauma, viral syndrome, pneumonia, pericarditis, congenital heart disease (i.e. ToF)

  • Initial labs: POC glucose, UA

  • Ketones in urine with high specific gravity; no bacteria or WBCs

  • CBC with no leukocytosis; RFP with BUN 29 and AG 19

  • CXR: bilateral interstitial prominences with mild hyperinflation. Possible small airway disease, infectious or atypical pneumonia. No report of cardiomegaly

  • Abdomen US: negative for appendicitis or intussusception

  • ABG: pH 7.4, CO2 21, base deficit -10, lactate 5

  • Blood tox screen negative

  • Interventions: Given IV fluids 20cc/kg x2; HR to 150s with good perfusion and RR to 30s; appeared more awake and wanted to drink, more “playful and interactive”

  • Kept in the ED…

    • Repeat VS: BP 109/53, HR 164, T37.2, RR 78, SpO2 99%

    • Exam: appears tired, upset during examination, increased RR and respiratory effort, poor air movement, coarse rales throughout, suprasternal and intercostal retractions, grunting and flaring, capillary refil 3-4 seconds, strong distal pulses but with mildly cool extremities

  • Further interventions…

    • Abdomen X-ray: non obstructive gas pattern, soft tissue density in the RLQ, ? small ileo-cecal intussusception

  • Repeat VS: RR 80s, HR 170s, BP 109/74, 91% on RA

  • BiPAP placed, but patient became irritated after 30 minutes

  • Intubation performed given failed PPV

    • RSI with Ketamine and Rocuronium

    • Following intubation, pulses lost with PEA on telemetry

  • Compressions and epinephrine given with no ROSC

  • SHOCK!!!!!

    • Hypovolemic, cardiogenic, distributive, obstructive

    • This patient was initially in compensated shock, that became uncompensated AFTER fluids and intubation

    • This patient lost her sympathetic drive after RSI medications

  • Hospital course

    • Intubated in peds ED, admitted to CICU

    • Echocardiogram showed cardiomegaly with bilateral severely dilated cardiomyopathy with EF ~20%

    • Developed ventricular bigeminy

    • Medications changed to nitroprusside and milrinone drip + CaCl

    • Atrial septostomy done at bedside

    • Placed on VA ECMO while awaiting heart transplant

  • Myocarditis

    • Most commonly caused by viral etiology

    • Speculated pathophysiology: virus enters host through GI or respiratory tract -> resides in the reticuloendothelial system -> attacks heart tissue as a secondary target organ

      • Eventually, the immune response down regulates -> fibrosis of myocardium develops -> ventricles become stressed -> dilated cardiomyopathy

    • Presentations

      • Respiratory (32%) with rhinorrhea, cough and SOB

      • Cardiac (29%) with chest pain, palpitations, sudden death

      • Hypoperfusion (22%) with lethargy, lightheadedness, dizziness and syncope, and possible seizure

      • Kawasaki disease (10%)

      • GI (6%) with n/v/d and abdominal pain

        • Giving too much fluids can make this worse

    • Screening tests

      • CXR with cardiomegaly (late finding), pulmonary venous congestion, pleural effusion

        • Sensitivity 43-55%

      • EKG with axis deviation, decreased ventricular voltages, ST or T wave abnormalities, atrial enlargement, ventricular enlargement, heart block

        • Presence of QTc prolongation, Q waves, or LBBB have worse outcomes

        • Sensitivity 93%

      • Labs

        • Elevated AST has highest sensitivity for myocarditis

      • Echo and Cardiac MRI

    • Management goals

      • Consider early milrinone and CaCl

      • Arrhythmia can be managed with amiodarone, adenosine, or lidocaine

      • Preserve preload without overloading; small doses of Lasix are helpful

  • Pearls

    • Minimal SBP (age>1): 70 + age x 2

    • Tachycardia at discharge from Peds ED a cause for concern?

      • Increased risk for revisit but not a critical factor associated with impending physiologic deterioration

    • Tachycardia out of proportion for age despite appropriate hydration can be a sign of shock (compensated or uncompensated)

    • Consider bedside POCUS echocardiogram to evaluate for heart failure prior to intubation!

Abdominal Aorta Ultrasound

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Dr. Jason Tehranisa, Emregency Medicine Ultrasound Fellow

  • Indications

    • Pain (abdomen, flank, groin)

    • Hypotension

    • Abdominal bruit

    • Pulsatile mass

  • Vertebral body is anatomy landmark

  • Anatomy

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  • Scanning (curvilinear probe is best)

    • Diaphragm to iliac arteries

    • Fan down past iliac bifurcation

    • Measure in 3 spots

      • Proximal (near celiac trunk or SMA)

      • Middle (just below renal arteries)

      • Distal (near bifurcation)

    • Measure outer wall to outer wall

    • Short axis view is best for measurement

    • Long axis view can be better for partial dissection and gives an overall better view of the aorta (can see saccular aneurysms)

    • Scanning techniques and pitfalls

      • Bowel gas obscures images

        • Push with steady constant pressure

        • Change angle of probe

  • AAA

    • Lipid, cholesterol and calcification leads to dilation of all three layers of arterial wall (intima, media, and adventitia)

    • Odds ratios…

      • 5.4 if age >65

      • 14.5 if age.75

      • 12.1 if hx of smoking

    • Most common location is infrarenal without involvement of celiac trunks

    • Normal diameter is 1.8-2 cm

      • Abnormal >3 cm

      • Critical if >5 cm (higher risk of rupture) and vascular surgery consultation is appropriate

    • Presentation

      • Abdominal/flank pain most common

      • Physical exam has very poor sensitivity

    • Bedside AAA detection by EM Physicians?

      • 99% sensitivity and specificity by EM physicians

      • However, studies have significant selection bias and physician must be able to visualize the entire aorta for inclusion

        • 20-50% of the time, aorta cannot be visualized (based on data from pervious studies)

  • Take home points

    • Ultrasound is a good tool to use at the beside to asses the aorta quickly

    • Ultrasound should not replace CT in patient with suspected AAA

    • Assessments of the aorta by EM physicians is accurate when we can fully visualize the aorta

    • If you can’t visualize the aorta, you cannot rule out AAA

  • Ultrasound Trivia!!

    • Seagull sign: aorta with celiac trunk and hepatic and splenic artery

    • Mean sac diameter is most accurate measure of gestational age in <6 weeks

    • Crown rump length is most accurate measure of gestational age in 1st trimester

    • Biparietal diameter or femur length is most accurate measure of gestational age in 2nd/3rd trimesters

    • Pericardial fat pad tends to be anterior, while pericardial fluid tends to be posterior and moves with cardiac contraction

    • Optic disc elevation suggests papilledema

Toxicology Series: Hallucinogens

Dr. Yasmin Moftakhar, PGY-1

LSD

LSD

  • LSD (lysergic acid diethylamide)

    • AKA “Acid”, “Loony Toons Superman”, “Yellow Sunshine”, “Lucy in the Sky with Diamonds”

    • Mechanism: serotonin type 2 agonist

    • Colorless, odorless, water-soluble

    • Quick onset (~30 min) and lasts 8-12 hours

    • Sympathomimetic stimulation

      • In massive doses, can cause coagulopathy and cardiac arrest

    • Treatment: PO/IV benzos and supportive care; move to desensitized environment

  • Psilocybin

    • AKA Magic mushroom, Silly putty, God’s flesh

    • Mechanism: same as LSD, 100x less potent

    • Typically consumed whole, but has foul taste

    • Quick onset (~15 minutes)

    • Sympathomimetic stimulation with changes in senses

  • Peyote

    • AKA Howling Wolf, Bad Seed, Half Moon, Nubs, Buttons

    • Typically used in Native Americans religious gatherings

    • Mechanism: same as LSD and Psilocybin but less potent

    • Often brewed as a tea

    • Longer onset, but initial symptoms (~2 hours after ingestion) are often negative with nausea/vomiting/palpitations; later symptoms are often euphoria and mood enhancement

  • Amphetamines (ecstasy, MDMA)

    • AKA Essence, Pep Pills, Super Jellies, Sparkles

    • Synthetic phenylethylamine derivative

    • Colorless and tasteless

    • Quick onset (~30 min) and lasts 4 hours

    • Euphoria, increased sexual interest and decreased social anxiety

    • Can cause severe HTN leading to ischemia, arrhythmia; hyponatremia, MDMA syndrome

    • Long term effects: memory loss, difficulty learning new pieces of information, depression

    • ED management: often supportive, but can be treated with IV benzos

      • If HTN severe, can use IV nitroprusside or phentolamine

      • Be sure to check Na as severe hyponatremia can result

  • Synthetic Cathinones (“Bath Salts”)

    • AKA Flakka, Ivory Wave, Bidet Refreshers, Cosmic Blast

    • Mechanism: stimulates release and re-uptake of biogenic amines

    • Snorted, ingested, or injected

    • Quick onset (~15 minutes)

    • Not detected on any typical chemical urine or blood screens

    • Can cause severe sympathomimetic toxicity with paranoia, palpitations, seizure, rhabdo, hyperthermia

  • PCP (phenylcyclidine)

    • AKA Love Boat, Peace pill, Angel Dust

    • NMDA antagonist, but at high doses can interfere with ACh and dopamine receptors

    • Often co-ingested with other drugs

    • Quick onset, but lipophilic so at high doses, duration can last for days

    • Presents with wide array of symptoms include violence, agitation

    • Medical complications are frequent with seizures, rhabdo, and hypoglycemia/hypotension/hypothermia and traumatic injuries

    • Detected in urine for up to 8 days

    • Treatment: supportive with fluids and benzos

  • Cannabinoids

    • AKA skunk, reefer, herb

    • Mechanism: cannabinoid receptor

    • Often smoked

    • Quick onset

    • Free flowing thoughts and anxiolysis with mood enhancement and euphoria

    • Detected in UDS for 3 days in non-chronic users and up to 30 days in chronic users

  • Salvia

    • AKA magic mint, diviner’s sage

    • Original use by Oaxoca indians

    • Mechanism: opiod agonist

    • Chewed or smoked

    • Quick onset

    • Distorted perceptions

    • Treatment: supportive care

Community Lecture Series: Management of Trauma Without In-House Surgery

Dr. William Jian, PGY-3

  • 3 Level 1 Adult Trauma Centers in NE Ohio Trauma Symposium (NOTS)

    • University Hospitals Cleveland Medical Center , MetroHealth Medical Center, Akron General Hospital

  • 2 Level 1 Pediatric Trauma Centers in NE Ohio

    • UH Rainbow Babies and Children’s Hospital, Akron Children’s Hospital

  • Trauma Literature Review

    • Time to management/resuscitation is important (i.e. “Golden Hour”)

    • Transfer times to definitive care facilities are too long

      • Main reason for delay was CT imaging and these are often repeated upon transfer to tertiary center

    • Transfer to tertiary trauma center was associated with a significantly lower 30 day mortality compared to admission and treatment at non-tertiary trauma center

  • Management

    • If time is available, assemble team and equipment prior to arrival

      • Assign roles and use closed-loop communication at all times

    • Follow ABCs and ATLS upon patient arrival

      • Airway, Breathing, Circulation, Disability, Exposure

      • Intubation if necessary, tube thoracostomy placement, hemorrhage control with blood products including pRBCs/FFP/cryo/TXA, gross neurologic exam, complete exposure

    • Consider transferring early and focus on speed and efficiency

      • Focus on resuscitation (RSI, chest tube, pelvic stabilization, splint placement, hemorrhage control, vascular access, transfusions, and surgical airway)

      • Resuscitate aggressively

      • Avoid CT imaging at non-tertiary center if going to transfer

      • If CT imaging is performed at non-tertiary center, avoid incomplete imaging as repeat contrast administration

      • Don’t delay transport

      • CT and XR imaging should only be performed if these will not delay transport

    • Selecting transportation?

      • If ground transportation will take >50 min, consider air transport

      • Always consider capabilities and resources of transporting team

    • Procedures prior to transfer?

      • Tube thoracostomy is not absolutely necessary if PTX small and relatively asymptomatic, even in air transport situations as medical helicopters are not pressurized

      • ED thoracotomy should absolutely not be performed if surgeon not available at institution within 15-30 minutes of procedure (according to EAST guidelines)

      • Peri-mortem C-section can be considered prior to transfer if life-saving for mother

        • If life-saving, pack abdomen with sterile dressings and transfer as soon as possible; do not close uterus or abdomen with sutures unless absolutely necessary