Grand Rounds Recap 12.21.22

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ent emergencies w/ dr. Freiermuth

Insect in the ear canal

  • use viscous lidocaine to kill the insect

  • additional instruments available in the ENT tray (i.e. alligator forceps)

Otitis externa

  • use antibiotic drops 

  • if the canal is swollen shut, the drops won’t go anywhere. Consider placing an ear wick. Place a drop of antibiotic drop on the wick and place it (this will not be comfortable for the patient, but adequate placement is essential)

  • consider the possibility of malignant otitis externa

  • consider using a combo antibiotic/steroid gtt

Acute Otitis Media

  • TM will be bulging 

  • risk factors: children who attend daycare are at higher risk, unvaccinated, smoke exposure

  • antibiotics (amoxicillin) vs watchful waiting: no difference in pain relief, no change in long term 

  • assess for mastoiditis (erythema, tenderness)

Auricular Hematoma

  • decompress if within 48 hours of trauma

  • perform auricular block, incise and evacuate the hematoma

  • apply bolster and suture it in place 

Nasal foreign body

  • Mother’s kiss (aka parent’s kiss): have parent place their mouth around the patient’s mouth, occlude the unaffected naris, and blow to dislodge the object

    • If this is unsuccessful, consider dermabond on a q tip or Katz extractor

Epistaxis

  • Direct pressure for 15 minutes over the nasal ala and lean forward. You can create a nose clip with tape and two tongue depressors. 

  • Blow your nose to dislodge the clots

  • Afrin

  • Rhino Rocket or Rapid Rhino-consider antibiotic ppx with Keflex

  • Almost always anterior

  • If posterior, this is likely coming from the sphenopalatine artery

Septal Hematoma

-requires drainage (long term cosmetic and functional negative outcomes)

Post Tonsillectomy

  • The tonsillar beds will have healing granulation tissue that may be alarming to patients, they will also likely have halitosis which is expected

Peritonsillar Abscess

  • consider needle aspiration vs incision and drainage

  • be aware of the feared complication of carotid artery injury

  • consider use of ultrasound utilizing the endocavitary probe to approximate the location and size of the abscess

  • consider dose of steroids 

Ludwig Angina

  • polymicrobial infection, typically as a local spread from odontogenic source

  • consider airway compromise, consider intubation for airway protection early

CPC: Central Cord syndrome w/ Drs. Sobocinski and gensic

Differential Diagnosis for bilateral upper extremity pain and weakness:

Central Nervous System

Consider etiologies such as epidural abscess, hematoma, or mass; spinal cord infarct (aortic dissection, vertebral artery dissection); multiple sclerosis; viral myelitis (i.e. poliomyelitis) often when prodromal viral symptoms are present; ALS (specifically, Flail-Arm Syndrome affecting the cervical spine and causing BL arm weakness)

Person in a barrel syndrome: syndrome characterized by bilateral upper extremity weakness with preserved cranial nerve and lower extremity function. Can be caused by damage to the bilateral cerebral hemispheres, the cervical spinal cord, or bilateral brachial plexuses, often seen in prolonged hypotension/low flow state to watershed areas, such as in patients who have suffered cardiac arrest.

Peripheral Nervous System

  • Guillain-Barre

  • Vasculitic neuropathy

  • Systemic vasculitis (primary vs secondary)

  • Nonsystemic vasculitic neuropathy

  • Toxic neuropathy (i.e. EtOH, amiodarone, lithium, metronidazole, chemotherapies)

  • Compressive neuropathy (gradually progressive, intermittent or positional paresthesias preceding weakness)

  • Botulism

  • Tick paralysis (toxin in their saliva that prevents ACh release)-presents with generalized myalgias and weakness

  • Organophosphate toxicity (presents with cholinergic toxidrome)

  • Inherited myopathies

  • Acquired myopathy

    • Viral myositis 

    • Hypothyroid myopathy

    • Drug-induced myopathy (i.e. statins, fenofibrate)

  • Inflammatory myopathies

    • Dermatomyositis: often associated with proximal weakness 

    • Polymyositis: often associated with proximal weakness 

    • Inclusion body myositis: typically presents with distal > proximal weakness 

Traumatic BL UE Weakness

  • Traumatic BL cervical root avulsion

  • Traumatic BL brachial plexopathy

  • Central cord syndrome

  • Cruciate paralysis 

    • rare syndrome resulting from a lesion at the cervicomedullary junction, most commonly due to trauma, that leads to paralysis in the upper extremities but spares the lower extremities

Diagnosis: Central Cord Syndrome

Management:

  • Maintain MAP 85-90

  • Data surrounding benefit of steroid administration is controversial, discuss with spine consultants 

  • Discuss surgical intervention with spine consultants

  • Recovery peaks at 3-6 months

  • Operative intervention may provide improve functional outcomes and decreased hospital length of stay

  • 90% will regain strength at 3 years regardless of operative intervention 

R1 Clinical Diagnostics: Paraneoplastic syndromes w/ Dr. beyde

 Lambert Eaton

  • Disorder of the neuromuscular junction characterized by decreased ACh release despite a normal production and normal postsynaptic ACh receptors

  • Caused by antibodies to presynaptic voltage-gated calcium channels (VGCCs) that facilitate ACh release

  • Characterized by slowly progressive symmetric muscle weakness (i.e. difficulty rising from a chair), autonomic symptoms (dry mouth, erectile dysfunction), ptosis and diplopia (although less common than in MG), and hyporeflexia. Respiratory failure is rare (or can be a late finding)

  • Much less common than myasthenia gravis

  • Most often associated with small cell lung cancer

  • Weakness improves with repetition. Can perform post exercise facilitation (ask patient to maximally contract for 15 seconds, and then recheck strength and reflexes). This can help differentiate between myasthenia gravis

  • Treatment options:

    • Supportive care

    • 3,4-DAP (or pyridostigmine if not available)

    • IVIG

    • Azathioprine

    • Guanidine

    • Rituximab

    • Plasma exchange

Hypercalcemia of Malignancy

  • most common cause of hypercalcemia in the inpatient setting and is a marker of poor prognosis

  • occurs due to 3 main mechanisms

    • tumor secretion of parathyroid hormone-related protein (PTHrP) [most common]

    • osteolytic metastases

    • tumor production of 1,25-dihydroxyvitamin D (calcitriol)

  • most common associated cancers: breast, renal, lung, squamous cell cancers, multiple myeloma

  • Presentation (“stones, bones, abdominal groans, psychiatric overtones”):

    • Neuro: anxiety, depression, lethargy, confusion, coma

    • GI: constipation, anorexia, nausea

    • Renal: nephrolithiasis, diabetes insipidus, renal failure

    • Cardiac: short QT, AV block, Osborn waves

    • MSK: muscle weakness

  • Diagnostics:

    • repeat testing to confirm value

    • correct for albumin (available on MDCalc) or obtain an ionized calcium

    • compare level to prior lab values (determine if acute or chronic)

    • obtain EKG

    • calcium >/=13 is unusual for hyperparathyroidism. At these levels, malignancy should be considered as an etiology

  • Management: 

    • Mild (<12): PO hydration, avoid aggravating factors (thiazide diuretics, volume depletion, high calcium diet), consider discharge with follow-up to address underlying cause

    • Moderate (12-14): treat as mild if chronic and asymptomatic. Otherwise, follow algorithm for severe. Disposition is dependent on chronicity

    • Severe (>14): 1-2L IVF, calcitonin 4U/kg sq, zoledronic acid 4mg IV, hemodialysis. Patients require admission and telemetry. 

SIADH

  • Inappropriate secretion of ADH, leading to volume retention

  • Most commonly associated with small cell lung cancer, but can also been seen with neuroendocrine tumors

  • Patients will have low serum osmolality and increased urine osmolality (>300 mOsm/kg), and patients often appear clinically euvolemic

  • Historical factors in hyponatremia: Consider renal dysfunction or use of thiazide diuretic

  • Treatment: 

    • Symptomatic (seizure, coma, lethargy): 3% HTS (2cc/kg bolus up to 100 mL), can give up to two additional doses at 10 minute intervals

    • Asymptomatic: fluid restriction, salt tabs, urea

  • Beware overcorrection, as this can lead to rapid correction osmotic demyelination. Correct no more than 8 mEq/L in any 24h period

  • Many guidelines recommend admission for levels <125 mEq/L or if symptomatic

Needle cricothyrotomy w/ Dr. Kimmel

Needle Cricothyroidotomy w/ Dr. Kimmel

  • Indications: can’t oxygenate, can’t ventilate, can’t intubate in a patient <12 years old

  • Contraindications: inability to identify landmarks, significant trauma or structural abnormality

  • Equipment: 

    • Use 18G angiocath for patients <5kg

    • Use 14G angiocath for patients >5kg

    • Use BVM at 15 L/min with adapter for patients <5 y/o

    • Use TTJV at 1L/min/year of life for patients >5 y/o. Attach a 3 way stopcock to angiocath and oxygen tubing. Provide breaths by occluding the open port of the stopcock and release to allow for exhalation

  • Procedure: identify landmarks and stabilize the larynx with your nondominant hand. Angle your needle tip caudally at a 30-40 degree angle and aspirate back as you advance using a syringe filled with saline or local anesthetic. Aspiration of air (as indicated by bubbling in the syringe) indicates positioning in the airway. Advance the catheter and hub at the skin. Remove the needle and confirm placement again by aspiration. Stabilize the catheter with your nondominant hand. Attach oxygenation device to angiocath (choose device according to age as described above). 

Neonatal resuscitation w/ Dr. Winslow

Initial steps: turn on warmer, wall suction to 90, flow meter to 10, O2 to 21, PEEP to 5, PIP to 25, Pop-off pressure to 40, EKG to monitor HR, O2 sat to R arm (preductal)

Expected SpO2:

60-65% at 1 min

65-70% at 2 min

70-75% at 3 min

75-80% at 4 min

80-85% at 5 min

85-95% at 10 min

1. Initial Steps: Head down, warm (goal 36.5 to 37.5), supine, suction (bulb or NT only if resp distress as can cause bradycardia, no suction at perineum or routine tracheal suction, mouth then nose, dry, stimulate, sniffing position

  • Call for extra help

  • Radiant warming for all (Plastic bag + Hat + Thermal mattress if <32 weeks) (put baby sideways so easy access to both head [airway] and feet [umbilical line])

  • Cut cord immediately if resuscitation needed

2. At 30 seconds start positive pressure breaths if still breathing poor or HR <100 (best assessed with EKG leads, but you can also listen to or palpate the umbilical cord) (40-60 RR)

  • Room air better unless persistent hypoxia and then slowly increase O2

  • Use flow-inflating bag (Mapleson) for BVM (no CPAP/blow-by) or T-piece Resuscitator (Neopuff; finger occluding PEEP cap to give breath, set PIP and PEEP, can be used to give CPAP). For the flow-inflating bag, use the white wheel to adjust CPAP, easier to feel lung compliance.

  • Flowmeter 10 L/min, PIP 20-25 cm H2O, PEEP 5 cm H2O, Pop-off 40 cm H2O (can occlude mask on palm to check all settings)

  • MR SOPA if bagging is failing (no chest rise): Adjust mask; Reposition head; Suction mouth then nose with suction tubing; Open mouth and lift jaw; Pressure increase to PIP 40 cm H2O, Advanced airway (size 1 LMA)

  • CPAP at 5 cm H2O if labored but adequate or 100% O2 does not correct expected O2 sat (turn PIP to 0 on T-piece Resuscitator)

3. Intubate if 30 seconds of breathing is not working (<25 weeks 2.5 ETT, 25-30 weeks 3.0 ETT, 30-40 weeks 3.5 ETT) (depth 3x ETT size) (vent RR 40-60, PEEP 5, PS 8, PIP 20-25, Pressure control 15) (ETCO2) (or LMA size 1 down to 2 kg) (should take <20 sec) (Size 00 if under 25 weeks, otherwise Size 0) 

4. Start CPR if 30 seconds of ventilation via ETT not helping (HR <60)

  • 3:1 with 120 comp/breaths total per min

  • Two thumb technique

  • Go to 100% FiO2

  • Still use ECG to assess Heart Rate (check every 1 minute) (also finger and thumb to umbilical stump with middle finger tapping HR)

  • Do not extubate regardless

5. RARELY NEEDED: If HR still <60 with everything above then give epinephrine 0.01-0.03 mg/kg (1:10,000) (aka 0.1 ml/kg) Q3-5 min IV push (pull from Bristojet via 3-way stop-cock with 3 mL syringe) (emergent umbilical vein catheter below or IO [pink, >32 weeks, distal femur 1 cm above knee gap in midline] or saphenous vein in leg) (check HR after 1 min)

  • 30 week gestation is 1 kg / 24 week is 500 g / Full term is 3 kg

 6. Consider 10 ml/kg NS (not LR) or O- pRBC if still poor perfusion/pallor/weak pulse (no fast bolus, can repeat, only if placental rupture or known blood loss)

7. Other last ditch efforts: Glucose (check it via heel stick, use D10 at 2-4 mL/kg) and pneumothorax (can transilluminate the chest wall; unilateral breath sounds may be mainstem intubation)

  • Generally do NOT give naloxone even if mother has history of IVDU (may cause pulmonary edema, seizures, cardiac arrest)

  • No evidence for bicarb

tracheostomy complications w/ drs. gillespie and adan

Why do we care about this topic 

  • Common ED presentation  

  • Often, if not always seen on ICU rotations  

  • Manipulating tracheostomies incorrectly can cause patient harm  

  • Need to know when appropriate to consult a specialist, and when to conserve that resource  

  • Important to be able to distinguish when a seemingly small issue is not actually a small issue, such as a herald or sentinel bleed (TIF) 

  • Know the anatomy as different than a cricothyroidotomy – often placed at the 2nd or 3rd tracheal rings, more inferiorly  

  • There is an especially important caveat to all artificial airway/non-native airway patients: total laryngectomy or not  

    • Total laryngectomy patients do not have an available, intervenable airway from above to act upon if in respiratory distress and unable to utilize the stoma pathway  

  • Know the parts of a tracheostomy tube  

    • Pilot balloon 

    • Flange/face plate  

    • Cuff 

    • Inner cannula 

    • Obturator  

  • Geometries – basic  

    • Standard 

    • Proximal XLT, for example 

    • Distal XLT, for example  

    • Nomenclature for numbering – manufacturer dependent, can be inner diameter of tracheostomy tube  

    • Fenestrated or non-fenestrated (implications for airflow and phonation possibility  

    • Low pressure, high volume vs high pressure, low volume  

      • Ensure you know by manufacturer whether inflate with H2O or air  

  • Other devices to know 

    • Caps: occludes tracheostomy tube, usually used for weaning toward decannulation

    • Speaking valve / Passy-Muir  

      • One-way valve that allows for inspiration but closes on expiration to redirect airflow cranially over the vocal cords to allow phonation

    • T Tubes  

      • Soft, pliable stents; have superior/cranial and inferior/caudal limb intra-tracheally and external limb that may or may not be capped 

      • Know difficult to remove if absolutely necessary  

      • Know challenges related to from-above airway management given superior extension/limb  

      • Can bag through these using ETT adapter  

  • Basic complications – differ in etiology and anatomy by timeline relative to placement of the tracheostomy  

    • Bleeding  

      • Early vs late 

      • “Early” definition varies – generally, within 7-10d of surgical procedure  

      • Early – suction trauma, surgical bed, tracheitis  

      • Late – often suction trauma, tracheitis, dreaded tracheoinominate fistula  

        • Herald/sentinel bleed can be somewhat subtle (usually 100-250cc) prior to true TIF bleed 

        • TIF most often occur 3-6 weeks after trach placement and occur in about ~1% of trachs

        • Management of TIF:

          • activate MTP

          • call for help

          • over-inflate cuff

          • utley maneuver: place a finger through the stoma to apply direct pressure on the artery against the posterior sternum to compress the site of bleeding

          • supports CABs

          • manage airway (intubate from above if appropriate)

    • Decannulation  

      • Early (7-10 days)– proceed with extreme caution to replace tracheostomy tube given high risk for false passage in recent postoperative period. Recommend consultation, and only if absolutely necessary, Seldinger technique with fiberoptic endoscope for direct visualization  

    • Obstruction  

      • Pass suction catheter, remove inner cannula, deflate cuff, oxygenate from above  

  • Evaluation of any patient with a tracheostomy – the “3 W’s”  

    • Why, when, what  

      • Why: why did they have it placed? What was the initial indication? Helps to troubleshoot what you could run into if malfunctioning  

      • When: implications for late vs early / recently placed trach 

      • What: what do they have for the manufacturer, model? Do you have back-ups in place? Whether cuffed or uncuffed? Have there been any problems or complications in the past?  

      • Algorithm for evaluation: from paper cited below 

        • McGrath BA, Bates L, Atkinson D, Moore JA; National Tracheostomy Safety Project. Multidisciplinary guidelines for the management of tracheostomy and laryngectomy airway emergencies. Anaesthesia. 2012;67(9):1025-1041. doi:10.1111/j.1365-2044.2012.07217.x 

  • Random tips and tricks  

    • Can use pediatric mask or LMA as a seal over stoma to bag