Grand Rounds Recap - 9/10/2014

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Neonatal Resuscitation with Dr. Kamath-Rayne

http://helpingbabiesbreathe.org/

90-95% of newborns will require no intervention prior to their first breath. 5-10% of newborns will require drying, stimulation, or suctioning to get them to breath. 3-6% will require assisted ventilation with BMV. <1% will require advanced care with intubation, meds, or chest compressions

Golden Minute: within the first minute you want to ensure the baby is breathing spontaneously or have initiated BVM ventilation. 

 Tips taken from NRP: 

  • If the baby is crying, it doesn't need suctioning. Suctioning can cause harm (vagal bradycardia, infection, trauma)
  • Meconium aspiration likely occurs en utero. NRP currently recommends vigorous suctioning but this will likely go away with the new 2015 recs expected out next year. 
  • If child is breathing, but not great, consider CPAP rather than BVM or intubation
  • Effective PPV: achieve gentle chest rise, RR 40-60/min, first few breaths may require higher pressure (~20cmH2O). 
  • Most effective sign of good ventilation is increasing HR
  • Lower FiO2 is better. If need PPV, start at room air and titrate up as needed (NICU team uses a blender to mix O2 and air)
  • Don't initiate resuscitation if gestational age is <23weeks (fused eyelids, gelatinous immature skin, undescended testes, low tone) because survival rate is 0%
  • Delay cord clamping by 60 seconds if possible. Placenta auto-transfuses up to 80cc of extra blood into the fetus which decreases rates of transfusion and IVH in premature births. 
  • If need to intubate: use volume control at 4-5ml/kg or pressure control at 20cmH20 or less

Case Follow Up with Dr. McKean

 38yo F with jaw pain after a seizure. Noted to have masseter muscle spasm on exam and underbite --> anterior bilateral jaw dislocation. (Posterior, lateral, and superior dislocations are rare and are related to trauma. Anterior may happen spontaneously with yawning). 

Barton Bandage - Source:&nbsp;http://www.free-ed.net/FREE-ED/Resources/PubServ/EMS/EMS%20Primer/emsPrimer01a.asp?iNum=302

Barton Bandage - Source: http://www.free-ed.net/FREE-ED/Resources/PubServ/EMS/EMS%20Primer/emsPrimer01a.asp?iNum=302

  • Common reduction techniques: consider anxiolysis (ie benzos) or sedation (ie propofol). Protect your hands with gloves and either gauze rolled around thumbs or tongue depressors taped to fingers. Grab the occlusal surfaces of the mandibular molars and behind the angle of the mandible. Apply downward and backward pressure. Can also be performed from head of bed (intubating position) or standing behind seated patient. 
  • Uncommon reduction techniques: gag-reflex method - gagging the patient may cause them to spontaneously reduce. Hyperextension/fatigue method- open the mouth further to fatigue the masseter muscle. 
  • Post reduction: soft diet for 48hrs. Don't open mouth >2cm for 1 week. Limit re-dislocation. Can do this by placing Barton bandage or placing in a c-collar. 

Case Follow Up with Dr. Derks

32yo F with AMS. Had just been admitted for new onset seizures one week prior and discharged on AEDs. Now with bizarre behavior "sometimes I feel like I can't get my words out" and visual hallucinations. 

During rehospitalization noted to have increasing daily seizures, increasing visual hallucinations, dysautonomia, dyskinesias, and increasingly bizarre behavior. 

Found to have Anti-NMDA receptor antibodies identified from send out test from her CSF. 

Anti-NMDA receptor encephalitis. Initially described in women with teratomas and thought to be paraneoplastic in nature, but now thought that 50% of patients do not have an identifiable tumor.

  • Can start with a prodromic phase, followed by a psychotic phase, followed by dysautonomia and dyskinesia and may progress to status epilepticus or catatonic state. Average age of onset is 18 and higher female predominance. 
  • Patients with the best outcome are those with an identifiable tumor and subsequent resection. 
  • Diagnosis may be made by receptor antibody test. CSF is 100% sensitive and plasma is 86% sensitive. 
  • Treatment: surgical tumor resection, IVIG, plasmaphoresis, high dose steroids
  • Additional information available at: http://www.emrap.org/episode/2014/june/nmda

Case Followup with Dr. Selvam

21yo G1P0 at 30wk now 3 days post-op from exploratory laparotomy and excision of adnexal mass complicated by bilateral PEs on a heparin gtt. Rapid response called after she had a syncopal episode now with increasing oxygen requirement, dyspneic, tachycardic. 

EKG shows T-wave inversions in III and V1, Q-waves in III

Patient codes in front of the rapid response team. CPR initiated, intubated, fetal bradycardia identified and peri-mortem c-section performed at the bedside. Patient then given intra-arrest thrombolytics which leads to ROSC and massive hemorrhage. Massive transfusion initiated (>100 units of total product) and after several attempts to stop uterine bleeding a bedside hysterectomy was performed. Unfortunately re-arrested several more times and ultimately expired. 

PE in Pregnancy

  • Data on treatment is very limited but options include heparin, LMWH, embolectomy, catheter directed tPA, systemic tPA.
  • Systemic tPA is relatively contra-indicated in pregnancy, but since it is such a large molecule is not thought to cross the placental barrier.
  • Risks of maternal bleeding as the same as for non-pregnant patients. 

Peri-Mortem Cesarean Section "24, 4, scalpel, and scissors".

  • If the gestational age is >24 weeks (or fundus is above the umbilicus in unknown gestational age) you have 4 minutes of resuscitative efforts to decide to cut and then 1 minute to deliver the fetus (infant survival drops rapidly after 5 minutes of maternal cardiac arrest).
  • Scalpel through the abdominal wall then find the uterus, scissors through the uterus, deliver the baby, cut cord, pack the abdomen.
Edited video showing the steps of a perimortem c-section through a simulation model. From Washington University in St. Louis School of Medicine Emergency Medicine Residency.

Pediatric EM Simulation

6yo developmentally delayed child 3 days post-op from orthopedic procedure with increasing agitation, tachycardia and tachypnea found to have sepsis presumably from surgical site. 

  • Aggressive fluids early are key in pediatric sepsis.
  • Obtaining access can be hard. Consider using your first IV access to start fluids and worry about drawing labs later. If PIVs not working, consider IO.
  • Push-pull administration of IVF via a stopcock can be a reliable way to quickly administer a known bolus of fluids through a small IV. Goal is to have first 20ml/kg bolus administered in under 15 minutes and then repeat as needed with as much as 60m/kg administered in the first hour.