Grand Rounds Recap 6.6.18

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Airway Grand Rounds WITH DR. CARLETON

The Difficult Pediatric Airway

  • Anatomic differences -- including a small airway caliber, changes in airway and chest compliance, and more anterior airways -- make pediatric airways inherently more difficult than adult airways
  • Physiological differences include higher oxygen consumption and CO2 generation, a lower FRC, and a greater amount of dead space
  • A difficult pediatric airway is even more rare, yet can be more predictable based on physical exam and presentation. Additionally, children are more easily rescued by BVM or extraglottic devices
  • The incidence of the pediatric difficult airway is very rare--somewhere between 0.25% to 0.42% depending on the study--and almost all of these were predicted to be difficult up front
  • Of the difficult airways, the majority of these (>90%) were difficult due to a narrow mouth opening or mandibular hypoplasia, often due to genetic conditions. Other causes of pediatric difficult airways can include infections and foreign bodies. 
  • There are many other adjuncts to help with the difficult pediatric airway (e.g., pediatric GlideScope, Pedi AirTraq, supraglottic devices, optical stylets).

Case 1

The patient is a 2 year old female who presents from a house fire. She has 40% burn and is covered in soot, with obvious soot and edema in the airway. She is stridulous, coughing and struggling to breathe. Her oxygen saturation is 91% on a reservoir mask and tachypneic to 36. She is 12 kg, 86 cm long (the 'yellow' category on Broslow tape). 

For patients with inhalation injuries, you must intervene as quickly as possible. If decompensation occurs, use a BVM to pre-oxygenate until you can intubate. Consider down-sizing your tube for anticipated laryngeal edema, and use a stylet. Prepare for surgical airway if needed. Use the standard difficult airway algorithm, and don't be afraid to call for help if needed. 

If you are forced to act, give yourself the best attempt at first pass success by using RSI. If this fails, move quickly to a surgical airway. If you are not forced to act, consider your options: awake technique, LMAs (only for children >30 kg); video or fiberoptic intubation; or a surgical airway. Remember that blind nasotracheal intubation in children younger than 10 is very difficult due to anatomy, especially their relatively large adenoids.

Case 2

The patient is an unvaccinated 4 y/o male who arrives with drooling, stridor and a muffled voice. His presentation is concerning for epiglottitis. He is in the 'blue' category on the Broslow tape.

For patients with epiglottitis, the obstruction is often dynamic, so try to keep the patient as calm as possible while you prepare for intubation. Set up similarly as you would for the previous patient: downsize the tube, be ready for rapid decompensation and prepare for a surgical airway. 

  • Needle cric can be difficult in children. Their cricothyroid membrane is high (C2-C3 in a neonate, C3-C4 in an older infant, C5-C6 in an adult) and they have a disproportionately small membrane. Additionally, their necks can be 'chubby' with difficult landmarks.
  • Most of the time, particularly in children <2 years, you are probably doing a tracheal puncture instead of a true cric. 
  • There are many proprietary needle cric devices, but none have been definitely proven to work better than an angiocath. 
  • Transtracheal jet ventilation is also an option, but you must know how to set up the system with the appropriate oxygen flow to avoid harm to the child. 

em-neuro combined conference WITH DR. NEEL

Cranial Nerve Abnormalities

  • In general when examining a patient with a neurologic problem, think about location:
    • CNS: Supratentorial, Posterior Fossa, Spine
    • PNS: AHC, Root, Plexus, Nerve, NMJ, Muscle
    • Right, left or bilateral
  • Think about timing
    • Acute and hyperacute (seconds to minutes)
    • Subacute (hours to days)
    • Chronic (>4-6 weeks)
    • Progressive or non-progressive
      • Stable, plateauing, relapsing/remitting (you have slow recovery but not back to normal, e.g., MS) or paroxysmal (it happens quickly and goes completely back to normal, e.g., seizure or migraine)
  • A complete neurologic exam includes a mental status exam, cranial nerve exam, motor strength and tone, Babinksi testing, sensory testing, coordination, gait and Romberg testing, as well as a thorough physical exam of other systems (e.g., cardiac, pulmonary, vascular)

Cranial Nerve Lesions

Case 1

A 51 year old male presents with a loss of smell for 3 years, and now has difficulty reading. He is 20/20 in the right eye and 20/40 in the left. He cannot smell coffee or soap with either nostril. On the basis of the symptoms and signs, where is the lesion? This involves CN I and II. You are getting both olfactory nerves (CN I), and only the left optic nerve. Due to the slow progression of symptoms, this is likely a slow-growing tumor. An MRI of the brain showed sarcoid. 

Case 2

A 24 year old woman presents with syncope versus seizure. She describes multiple episodes of loss of consciousness, questionable shaking movements and a postictal period. She reports a patch of numbness over the left jaw and lower face. On the basis of the symptoms and signs, where is the lesion? Her symptoms localize to the foramen ovale and frontal lobe. She ended up having a slow-growing tumor in this location.

Case 3

A 26 year old female presents with left facial droop, sensitivity to sound in her left ear and left eye pain. On exam she has left facial droop that includes the forehead. On the basis of the symptoms and signs, where is the lesion? This localizes to CN VII, as this involves the forehead. Eye exam was normal. Lyme testing, ANA and VDRL tests were all normal, and her symptoms gradually improved. 

Case 4

41 year old female with history of melanoma s/p resection presents with one year of intermittent dizziness and progressive hearing loss in the left ear. She reports left facial pain, and decreased taste of the left side of her tongue. On the basis of the symptoms and signs, where is the lesion? This localizes to CN VII and CN VIII at the cerebellopontine angle and an MRI of the brain showed an acoustic neuroma.

Case 5

A 34 year old male presents with progressive hoarseness, dysphagia and left tongue and sternocleidomastoid weakness. He reports an antecedent cough and respiratory infection. He reports a 40 pound weight loss as well as a left-sided headache, alteration in taste and decreased hearing in the left ear. On exam he has right sided uvular deviation, a hoarse voice and weakness of the L SCM. The tongue had marked asymmetrical atrophy and fasciculation. On the basis of the symptoms and signs, where is the lesion? This localizes to multiple nerves including left CN VII, VIII, X, XI and XII. MRI reveals a glomus jugulare tumor in the jugular foramen to the level of the pons.

CPC WITH DR. JARRELL

The Case - Dr. Jarrell

The patient is a previously healthy teenage female who presents to a pediatric emergency department with a cough. Her cough has been intermittent over the last two months, but has been more persistent recently. She reports a mild sore throat but denies other URI symptoms, fevers, or shortness of breath. She was treated once with antibiotics for bronchitis with no consistent improvement. She also reports recent unintentional weight loss over the past two months. She also reports vaginal discharge that she describes as thick, white, itchy and blood-tinged; she is pre-menarcheal and has been treated once for a yeast infection. She denies drug use or sexual activity. She was born in West Africa and immigrated around the age of 3. At some point as a young child she was admitted to the hospital in West Africa and may have received a blood transfusion. She has not traveled recently, but is around individuals from her home country on a regular basis.

Her vitals are normal. She appears very thin and has cervical lymphadenopathy on exam. External GU exam reveals some white vaginal discharge, and the remainder of the exam is normal. 

A BMP, CBC, coags, TSH and urine are grossly unremarkable. GC/chlamydia was negative. Her strep was negative. Her wet prep is notable for yeast. A CXR is unremarkable. UA unremarkable.

And then a diagnostic test was performed...

The Discussion - Dr. Kircher

This is a teenage female with unintentional weight loss, chronic cough, recurrent vaginal infections and possible exposure to infectious disease from West Africa.

The differential includes: 

  • MSK
    • Structural airway problem or TE fistula 
  • Psych
    • Eating disorder
    • Depression/anxiety
  • Rheum/Endocrine
    • Thyroid studies were normal, and the patient does not have DM
    • Sarcoid?
  • GI
    • Celiac sprue
    • GERD or H Pylori
  • Heme/onc
    • No lab evidence to support this
    • Immune deficiency
    • Sickle cell
  • Infectious
    • To include flu, viral URI, pertussis, TB, HIV, malaria, endocarditis, hepatitis, ebola, EBV

The Diagnosis and Discussion - Dr. Jarrell

  • The patient was found to be preliminarily positive for HIV. She was given diflucan for her yeast infection and discharged on Bactrim for PCP prophylaxis. She followed up with ID and was started on antiretrovirals.
  • A normal child can have 6-8 URIs per year (<10 years of age), up to 6 ear infections a year (2-3 years old), and up to 3 episodes of gastro per year (2-3 years); the most common secondary immunodeficiencies are malnutrition and HIV
  • In all patients for whom you expect some kind of immune deficiency, workup should include a blood glucose, CBC, BMP, UA, LFTs and HIV as well as a chest xray and a peripheral smear.
  • Make sure to get a good travel history!
  • There are an estimated 36.7 million people living with HIV worldwide; 2.1 million are children under the age of 15
  • 90% of children living with HIV are in sub-Saharan Africa
  • 30% of perinatal HIV transmission patients will present before age 2 -- but 30% will present after age 10.
  • Acute Retroviral Syndrome presents similarly in children as it does in adults, and includes fever, lymphadenopathy, sore throat, myalgias, headache and GI upset

R1 Clinical diagnostics - BNP WITH DR. Jensen

For a great introduction to BNP's use - check out Dr. Jensen's video post here

Case 1

The patient is a 67 year old female with a history of HFrEF (EF 40%) from a previous MI, HTN, DM2 and HLD who presents to the ED with shortness of breath. She reports worsening dyspnea over the past 2 days. She endorses orthopnea and LE edema. She denies any fevers, sick contacts, chest pain, or sputum production. She reports intermittent compliance with her medication regimen. On exam, she is hypertensive (190/110), saturating 93% on room air and has crackles in her lungs with lower extremity edema. 

You are concerned for acute-on-chronic heart failure exacerbation in this patient. A BNP returns at 750. What do you do with this? How do you interpret it? Should you get a NT pro-BNP?

  • Your suspicion and clinical gestalt for diagnosing acute heart failure is better than the discriminatory value of a BNP -- so order a BNP when you are not sure of the diagnosis and its result would change your management.
  • The association between an elevated BNP level and prognosis is unclear. 
  • < 100 is the negative cutoff level under which you can be fairly confident that heart failure is not at play, and < 300 is the cutoff for NT-proBNP.
  • The half-life for BNP is 20 minutes, and the half-life for NT pro-BNP is about two hours, but that date has shown that doesn't seem to matter and their ability to detect acute heart failure is commensurate, so order whichever one works for your institution.

Case 2

The patient is a 58 year old female with a history of HTN, DM2 and COPD who is presenting for shortness of breath. She reports chills, chest discomfort and a chronic cough with some increase in her baseline dyspnea on exertion. Her vitals are notable for a temperature of 99F, mild tachypnea and a sat of 94% on room air. On exam, she has faint expiratory wheezes and a small amount of pitting edema in the lower extremities. A chest xray reveals bibasilar atelectasis vs pneumonia. A CBC is unremarkable, and she has a mild troponin leak of 0.05. She has a mild AKI as well. Her BNP returns at 650. How do you interpret this value?

  • Ultrasound of the lung may be helpful in differentiating between pulmonary edema and pneumonia. 
  • This is a case where an BNP can be helpful if it is negative, but it's less helpful when it's positive in a setting of a broad differential.
  • There is no good data for "positive cutoff levels" for BNP with regards to ruling-in heart failure, as an elevated BNP can be seen in a myriad of different conditions.
  • BNP and NT-proBNP are both cleared by the kidney, which can artificially elevate these failures in patients with renal impairment or an AKI.

Case 3

The patient is a 62 year old male with history of heart failure (unknown EF), HTN, DM2, and morbid obesity (BMI 55) who presents to the ED with shortness of breath. He reports three days of shortness of breath in the setting of recent dietary indiscretions but does report compliance with his furosemide. He also reports subjective fevers and sweating. On exam, he has a temperature of 99.5, a HR of 110, and a blood pressure of 180/90. He is saturating 95% on room air and is tachypneic to 24. His exam is significantly limited by habitus, but he has some chronic-appearing venous stasis skin changes on his bilateral lower extremities with +2 pitting edema. A portable chest xray is difficult to interpret. You get a BNP on this patient, and it is 50. How do you interpret this?

  • BNP is not reliable in obese patients, and BNP is inversely proportional to BMI for unclear reasons. 
  • Use other adjuncts in this patient to determine the cause of his dyspnea.

r4 case follow up WITH DR. Miller

The patient is a previously healthy middle aged male who presented to an outside hospital with nausea, vomiting, myalgias, weakness and abdominal pain for five days. He is tachycardic to the 120s upon arrival and has diffuse midline abdominal pain. He also has a diffuse maculopapular non-blanching rash. He is hyponatremic to 125 and hyperkalemic at 5.5; his urine is notable for large blood on macro but no RBCs. A CK is 15,000. He is admitted to the hospital and has progressive worsening mental status and is intubated. He receives steroids and IVIG for possible dermatomyositis. After extensive testing, his only positive test was coxsackie. His CK continues to rise, so he goes on CRRT for persistent hyperkalemia and renal failure and is transferred to our institution.

After several days, the patient becomes hypotensive and is started on broad spectrum antibiotics. A bedside cardiac ultrasound shows a pericardial effusion. He gets a right heart cath which shows a CO of 8 and an SVR of 890 with a low wedge, reflective of distributive shock. Despite the addition of micafungin, flagyl and tobramycin, he has worsening hypotension, a rising lactate and develops DIC. A CT scan of the abdomen and pelvis reveals free air. He goes to the OR with general surgery where he was found to have a perforated cecum. After a prolonged hospital and rehabilitation stay, he gets off dialysis and returns home. 

Ultimately, on pathology, the patient was found to have perforated his cecum due to kayexalate debris embedding into the lining of the intestine, which is a very rare but known complication of kayexalate administration. While frank perforation is rare, somewhere between 1-2% of patients do have cecum irritation or necrosis from kayexalate. 

The patient's initial presentation involved severe rhabdomyolysis. Patients with CK levels that remain stable below 5000 have a very low chance of developing rhabdo, but levels above that can go on to progress to severe rhabdo. There is minimal evidence for preventative CRRT or HD, and the staple of initial treatment is aggressive IV fluid hydration (1-2 L/hr). While there is some evidence for alkalizing the urine, there's no longer solid evidence for mannitol. The goal for these patients is 300 mL/hr for the first 24 hours.