10.25.18 Conference Summary

Morbidity and Mortality - Dr. Leah Carter


Hypernatremia

  • = serum sodium >145 meq/L

  • Sodium is predominant cation in ECF; resorbed by kidney, regulated by RAA, thirst, ADH

  • Sodium-water balance

    • TBW = extracellular + intracellular

    • Tonicity vs osmolality

      • Tonicity = behavior of cell volume in given solution; what changes volume

        • cell volume increases in hypotonic solution and decreases in hypertonic solution

      • Osmolality = concentration of solutes in solution = 2[Na] + [glucose]/18 + BUN/2.8

  • Signs/sx of hypernatremia

    • Primarily CNS effect, especially with acute onset (<48 hrs) or extreme levels

    • Acute onset can cause brain shrinkage, leading to ICH

    • More common in extremes of age

    • Peds

      • Hyperpnea, weakness, crying, insomnia, lethargy —>coma in severe cases

      • Seizures usually only occur with sodium bolus or too rapid rehydration

      • Always consider abuse

    • Adults

      • Symptoms of underlying problem often manifest first, then weakness, confusion, coma

  • Causes

    • Decreased water intake

    • Hypotonic fluid loss (water loss > salt loss): sweat, burns, GI losses, impaired renal concentrating ability

    • Excessive salt

  • Workup

    • RFP, serum osmolality

    • Urine osmolality

      • low (<300): DI (increase w/ ddavp = central)

      • high (>800): total sodium gain vs unreplaced water loss

      • intermediate: nonspecific but consider partial DI, osmotic diuresis

  • Management

    • Determine acute (<48 hrs) vs chronic (>48 hrs)

    • Determine volume status and resuscitate as needed

    • Calculate free water deficit

    • Give fluids for ongoing losses

    • Correct SLOWLY (especially chronic)

      • acute: 1mM/h

      • chronic: do not exceed 10-12 mM/day

  • Why it is important to treat? —> Prolonged hypernatremia increases mortality

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Appendicitis

  • Diagnosis

    • Scoring systems poorly validated

    • Clinical gestalt 50% accurate

    • CBC, CRP poor predictive value

    • CT sensitivity ~90% (1 in 20 will be missed)

  • Nonvisualized appendix on imaging?

    • Absence of secondary inflammatory signs has relatively good negative predictive value

Traumatic SAH

  • Is 6-hour repeat CT head indicated?

    • Meta-analysis looking at isolated tSAH with GCS 13-15 showed only 5% had progression of bleed on repeat imaging and no significant need for intervention, suggesting it’s not necessary

    • Similar for anti coagulated; <1% had delayed bleeding and vast majority didn’t require intervention

  • Who can be discharged with ICH?

    • if INR>1.4 or impaired coagulation

    • No increased risk of deterioration

  • Do these patients follow up?

    • Most do not, even if instructed and/or with post-concussive symptoms



EBM: Pediatric Fever - Dr. Sara Pope

temp.jpg
  • Fever = 38.0 (100.4 F)

    • Rectal temp is best!

    • Tactile assessment relatively high sensitivity, poor specificity

    • Bundling rarely the culprit

  • Serious bacterial infection (SBI)

    • Well-appearing infants still at risk (though overall incidence decreased significantly since pneumococcal and h.flu type B vaccines)

    • Increased risk: prematurity, prolonged ROM, maternal GBS, difficulty feeding. change in activity, color change, apneic spells

  • Afebrile in ED + well-appearing… when is it safe to not workup?

    • No antipyretic given

    • No increased risk of SBI

    • Reliable home supervision/parental comprehension

    • Reliable follow-up

  • Febrile infants (take into account prematurity)

    • 7-28 days old: confirmed fever —> full septic workup

      • UA/culture, CBC w/ diff, blood culture, resp viral testing, CXR, LP +/- CRP, LFTs

      • Antibiotics: ampicillin, cefotaxime +/- acyclovir, vanc if high MRSA suspected or very sick

    • 29-90 days old

      • UA, urine/blood cultures, CBC w/ diff, CXR and resp viral panel as indicated +/- CRP & LFTs

      • LP only if concerning signs/sx

      • **No abx unless LP first or treating known bacterial infection (otherwise, you commit to 4 wks duration to cover for meningitis/encephalitis)

      • Multiple studies/criteria developed — no consensus, all have similar miss rates

  • ACEP Clinical Policy:

    • Age 2 mos to 2yrs

      • No clinical feature effectively excludes; always consider obtaining especially if higher risk (female, uncircumcised male, nonblack, fever >24 hrs or >39C, no obvious clinical source)

      • CXR - consider if respiratory sx (except wheezing or suspected bronchiolitis)

  • Outside initial 28 days, always consider LP but reasonable to defer if likely viral infx


Pediatric Orthopedic Injuries for the ED physician - Dr. Christina Hardesty, Pediatric Orthopedic Surgeon

Sailsign (1).PNG
  • Open vs closed, always look at radiocapitellar joint in arm injuries

  • Supracondylar humerus

    • Fracture —> splint

      • Posterior fat pad: blood from fracture = pathologic

    • Flexion vs extension type (distal end relative to shaft of humerus)

    • Three position types

      • I: no displacement

      • II: displaced but posterior wall intact

      • III: two pieces completely separated, disrupted posterior wall — needs operative repair

    • Anterior humeral line should be aligned with head of capitellum

    • Never reduce in ED, only in OR w/ ortho

    • When to reduce in OR? cold hand (pulselessness alone not an indication if still perfusing)

  • Distal radius

    • Acceptable degrees of angulation - malrotation - dorsal angulation

      • age <10: 15-20 deg - 45 deg - 40 deg

      • age >10: 10 deg - 30 deg - 20 deg

    • Reduce/splint is usually appropriate unless unstable, poorly reduced, vascular compromise

  • Forearm fracture

    • Forearms remodel well

    • Monteggia fracture = ulnar fracture (or bend) + proximal radius dislocation

      • Poor outcome if not repaired

      • Classification based on direction of radial head displacement +/- fx

  • Lateral condylar fracture

    • Salter IV is common; often need pinning

  • Proximal radius fracture

    • 30 degrees and less angulation is tolerated, otherwise need OR

  • Patellar sleeve fracture

    • Small chip of bone from inferior part of patella

    • Straight leg raise test?

      • if unable —> always need operative repair

      • if able (rare)—> can splint with close follow up

  • Proximal tibia fracture

    • High risk for compartment syndrome (anterior most common)

  • Tibial tubercle fracture

    • Ogden classification (type a usually splinted, type b need surgery)

  • Femur fracture

    • Mid-shaft fracture

      • 6+ yrs old —> operative repair

      • ~3 yr old —> spica cast

      • young infant —> pavlic harness (similar to hip dysplasia)

    • Bucket handle fracture

      • Avulsed fragment of bone, due to torsional force

      • NAT until proven otherwise

    • Toddler’s fracture

      • Point tenderness very specific

      • Splint —> f/u ortho in a few days

  • Ankle fracture

    • Triplane fracture: involves epiphysis, physis, metaphysis — needs OR

    • Tillaux fracture: salter III through distal tibia, can splint if not too displaced, otherwise need OR

  • Compartment syndrome

    • 5 P’s — palpable swelling, pain w/ passive stretch (most sensitive), paresthesia/hypoesthesia, paralysis, pulseless)

    • Always limb-threatening!!

    • If concerned, always admit

  • Transient synovitis vs septic joint

    • Kocher criteria (presence of 3-4 have >90% likelihood of septic joint)

      • NWB on affected side

      • ESR>40

      • Fever >38.5

      • WBC>12k

    • Ambulatory test: if able to ambulate after pain meds (i.e. toradol), likely not septic

    • Septic joint: >50k wbc joint fluid —> need emergent surgery (time-sensitive)

Reversal of Factor Xa Inhibitors - Jessica Traeger, PharmD, Clinical Pharmacist

  • Direct Factor Xa Inhibitors

    • Rivaroxaban (Xarelto)

    • Apixaban (Eliquis)

    • Edoxaban (Savaysa)

    • Betrixaban (Bevyxxa)* for DVT ppx, prescribed 30 days after discharge

  • Xa Inhibitor reversal strategies

    • Short half lives — ‘wait and see’, supportive care

    • Inability to monitor coag effect, tests difficult to interpret

    • Anti-Xa levels exist but not FDA approved

  • Prothrombin Complex Concentrates (PCC)

    • Not FDA approved for Xa inhibitor reversal

    • Recommended dose: 50 units/kg

    • 4-factor PCC (II, VII, IX, X) most common (Kcentra); 3-factor: no VII

  • Evidence for PCC — not great and conflicting

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Coagulation Factor Xa (Recombinant), Inactivated-zhzo (AndexXa)

  • Available for reversal of life-threatening bleeding associated with rivaroxaban and apixaban

  • Binds Xa Inibitors and reverses their effects

  • Preferred reversal agent at UHCMC, restricted to neurosurg/critcare

  • ANEXXA-4 Trial:

    • Multicenter, prospective, open-label, single group study in pts with major bleeding on Xa inhibitor

    • Primary outcome: change in anti-Xa activity, rate of good hemostatic efficacy at 12 hours

    • Subjects on Xa inhibitor and had major bleeding (ICH, GIB); received bolus + 2hr infusion andexxa

    • Adequate hemostasis achieved in majority of patients

    • 18% adverse events — thrombosis, some resulting in death

  • Dosing — need to know drug, dose, time of last dose to determine dosing strategy

    • 5mg dose for most pts

    • Bolus + continuous infusion

  • Downsides: takes time to make, costly (5x more than PCC)

  • Consult hematology for use with other anticoagulant agents

Journal Club: "When Bleeding Doesn’t Stop”

NOAC Reversal with PCC - Dr. Lauren McCafferty

Eerenberg et al. Circulation, 2011

  • Prospective, randomized, double-blind, crossover study evaluating the potential of prothrombin complex concentrate (PCC) to reverse the anticoagulant effect of rivaroxaban (direct Xa inhibitor) and dabigatran (direct thrombin inhibitor)

  • Included healthy male volunteers

  • Participants received either rivaroxaban or dabigatran for 2.5 days followed by single bolus of PCC or placebo (saline); had 11 day washout period then the process repeated with the other drug

  • Blood coagulation tests assessed: 1). the anticoagulant effect of rivaroxaban and dabigatran and 2). the ability of PCC to reverse their effects

  • Findings/Conclusions: PCC rapidly and completely reversed the anticoagulant effect of rivaroxaban but had no effect on dabigatran in healthy subjects

Warfarin Reversal with FFP vs PCC - Dr. Nick Parmar

Hickey et al. Circulation, 2013

  • Retrospective cohort study comparing warfarin reversal with FFP and PCC

  • Included patients age > 18 yrs, on warfarin with INR >1.5 who received either FFP or Octaplex (PCC) in the ED for active bleeding or before emergent procedure

  • Primary outcome: serious adverse events within 7 days

  • Secondary outcome: time to INR reversal, hospital LOS, RBC transfusion in 48 hrs

  • Findings/Conclusions: for urgent warfarin reversal, PCC resulted in faster reversal, fewer adverse events, and low RBC transfusion requirement compared to FFP

PATCH Trial - Dr. Zac Rasmussen

Baharoglu et al. Lancet, 2016

  • Prospective, multi-center, open-label, randomized trial looking at whether platelet transfusion improved outcomes in patients with ICH who are on anti-platelet therapy

  • Included patients age >18 yrs with supratentorial, non-traumatic ICH with GCS 8 or greater, had symptom onset within 6 hrs, and received anti-platelet agent in last 7 days

  • Participants randomized to receive either standard care alone or standard care + platelet transfusion

  • Primary outcome: difference in functional outcome at 3 months

  • Secondary outcome: survival and poor outcome (per modified rankin scale), absolute ICH growth after 24 hrs, adverse events

  • Findings/Conclusions: Patients who received platelet transfusion had poorer outcomes, increased mortality, and increased adverse events compared to standard care. Therefore, platelets not indicated for anti-platelet reversal in patients with ICH.