Grand Rounds Summary 10.11.17

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ULTRASOUND of the dyspenic patient WITH DR. STOLZ

Air is the enemy of the lung US. 

When ultrasounding the lung there is no right or wrong probe. The linear probe has better resolution for superficial tissues and may be more useful in diagnosing a pneumothorax. If you are looking at deeper lung tissues consider using the curvilinear probe which has better resolution for deeper tissues. 

Artifacts:
A lines are hyperehoic horizontal lines that are evenly spaced and generally remained fixed. 
B lines are hyperechoic vertical, narrow lines that start at the pleural line and extend all the way to the far field. A positive finding is three B lines in one rib space. A positive B line finding represents alveolar interstitial fluid which can be due to ARDS, pulmonary edema, atelectasis, pneumonia, and other etiologies.
Z lines are hyperechoic linear, broad, short lines that arise from the pleural line but do not extend into the far field and move with the pleura. This is a normal finding that is also called a comet artifact.

Pneumothorax (PTX)

When scanning for a PTX it is important to look for lung sliding, a lung point, and the absence of B lines.  You can also use M mode (motion over time) to look for the absence of sliding. The absence of lung sliding in M mode will appear as the same signal in both the near and far field. No lung sliding does not always mean there is a PTX, especially in the critically ill patient. However, finding a lung point is 100% specific for PTX.

Pleural Effusion

When looking at a pleural effusion on ultrasound you cannot tell the etiology of the effusion. Ultrasound signs that can be evidence of a pleural effusion are anechoic areas above the diaphragm, loss of the mirror image artifact, and spine sign. When evaluating for the spine sign you are looking for the hyperechoic "bumpy lines" (spine) that, in a patient without a pleural effusion, will end at the diaphragm. However in the setting of a pleural effusion (positive spine sign) the "bumpy lines" (spine) will extend beyond the diaphragm. 

Pulmonary Edema

Looking for the location of B lines may help to figure out the etiology of the pulmonary edema. Bilateral consider cardiogenic pulmonary edema vs unilateral B lines may be evidence of pneumonia or a more focal process.

Pneumonia

On ultrasound, consolidation of the lung is often described as hepatization of the lung. This is when the lung appears similar on ultrasound to the liver. Other findings that you can see on ultrasound can be a positive spine sign, air bronchograms, fluid bronchograms, B lines, pleural and subpleural consolidation, and pleural and subpleural fluid. Air bronchograms appear as hyperechoic lines that create a "dirty shadow" behind them. A dirty shadow is often described as a white shadow whereas a clean shadow is described as a black shadow. Air bronchograms on ultrasound are thought to be due to air trapped with fluid around it. Fluid bronchograms show fluid filled bronchi outlined in hyperechoic lines. This is due to edema of the lung next to the bronchus. Pleural consolidation are represented by abnormal pleural lines that appear bumpy on ultrasound. 

Consultant of the month: Patient safety with Dr. Hebbeler-Clark

Incident reports put a notice into the system that something has occurred that is outside of normal operating procedures. Incidents are classified as harm, near miss or error, and procedural or logistical issues. The most concerning incident reports generate a root cause analysis which can also be termed swarms. The purpose of calling a swarm is to quickly, in as real time as possible, evaluate the recent situation that generated an incident report in order to evaluate the process or system. After evaluating the system or process, the swam then creates action items to which specific individuals create action strategies to help address the identified deficiency. The least reliable action strategies are education and training, rules, policies, and procedures. The goal of the swarm is to create a culture of safety.  Ideally, a swarm should occur within 72 hours of an incident being reported. Swarms are legally protected meetings.

A sentinel event is a patient safety event that results in death, permanent harm, or severe temporary harm of a patient. 

Congenital heart disease in the ED with Dr. Lipshaw

Congenital heart disease (CHD) is the most common congenital malformation. About 1/3 of CHD is not picked by at the time of nursery discharge. Screening for nursery discharge is obtaining pre and post-ductal oxygen saturation. The most common CHD are ventricular septal defects (VSDs) and atrial septal defects (ASDs). At the time of birth, the PVR decreases and SVR increases causing the foramen ovale to close and the ductus arteriosus to reverses its direction of flow. In utero, the ductus arteriosus causes blood to flow from the left to the right heart, specifically from the PA to the aorta. This direction of flow reversed at the time of birth.

Gray Baby: Presents in Shock

Presents days to weeks after birth. Primarily due to left sided obstructive lesions which prevent blood from getting from the LV into the aorta. Often due to hypotrophic left heart, critical aortic stenosis, or interrupted aortic arch.

Blue Baby: Presents with Cyanosis

Presents a few weeks after birth. Due to the closing of the ductus ateriosus. In these heart lesions the ductus is necessary to keep blood flowing to the pulmonary artery. Often caused due to truncus arteriosus, transposition of the great vessels, pulmonary atresia, tetralogy of fallot (TOF), or total anomalous pulmonary venous return (TAPVR).

Older Baby: Presents with Heart Failure 

Usually presents weeks to months after birth. Usually has left to right shunting such as VSDs and PDAs. Signs: tachypnea, crackles, retractions, hepatomegaly, poor feeding and poor weight gain. Often treated with lasix and milrinone in the setting of shock.

VSD murmurs: May not be initially present at birth. May not hear a murmur with large VSDs due to no turbulence. 

Single Ventricle Patients

How blue are they usually? These patients will appear blue especially depending on their stage of repair. Utilize family members who often know the child's baseline SpO2.

Beware! Intubation causes large alterations in cardiac physiology which may lead to cardiac arrest. If you have to intubate it is important to have adequate fluid resuscitation to augment return of blood flow to the pulmonary system. 

Evaluation of the Possible CHD Baby

Physical exam can often show cyanosis, murmur, and blood pressure and pulse discrepancy. 

Hyperoxia Test: Helps to differentiate cyanosis 2/2 cardiac (shunt) versus pulmonary abnormality. This test is preformed by giving 100% FiO2 for 10 minutes, PaO2 should rise >150-200mmHG, PaO2 <100mmHg is suggestive of a shunt.

CXR: Cardiac disease should show cardiomegaly, defined as a cardiothoracic ratio >60%.

TAPVR: Snowman sign on CXR

TOF: Boot shapped heart

Transposition: Egg on a string 

Management of the Possible CHD Baby

Supplemental O2: Decreases PVR, sats of 80s% are probable, but varies depending on stage of stage

Fluids: Be cautious, give an initial 10cc/kg bolus and reassess

Prostaglandin E1 (PGE1) helps keep the duct open. Continuous infusion should have some affect within minutes, starting dose is 0.05-0.1mcg/kg/min. Apnea is a major side effect.  If you are caring for a patient who develops apnea with PGE1 infusion these babies often require intubation. The recommendation is to prophylactically intubate prior to transfer. However, Meckler at al found elective intubation as a predictor of transport complication to have an odds ration of 20.

Remember to always keep sepsis high on your differential!

Case follow up with Dr. Teuber 

Priapism is an erection not associated with sexual stimulation lasting an extended period of time.

Types of Priapism:

  • Ischemic
    • Painful, fully erect penis
    • Urologic emergency
    • Damage starts to occur at 4 hours
  • Recurrent
    • Can be associated with heme diseases such as sickle cell
    • Erections start off as short and resolve spontaneously but tend to last longer and longer until it is full blown priapism
  • Non-ischemic
    • Usually due to penile or perineal trauma, fistula formation
    • Partially erect and usually non-painful penis
    • Not a urologic emergency
    • Must rule out urethral injury if caused by trauma with a UA and a RUG

Workup: CBC, retic, Hg electrophoresis, UA, UDS, corpus cavernosum blood gas (you will see acidosis and hypoxia on the blood gas in ischemic priapism)

Treatment:

  • Analgesia with dorsal penile nerve block
  • Use butterfly needle, 3 way stop cock, IV tubing, 10cc syringes and a bag or normal saline
  • Insert butterfly needle at the 3 or 9 o'clock and aspirated until brighter blood returns
  • Then irrigate via the 3 way stop cock and aspirate the saline after each infiltration of the normal saline
  • Then infiltrate the corpus cavernosum with phenylephrine 100-500mcg q3-5 minutes until detumescense, 1 hour passes or you have reached the max dosing of 1000mcg in 1 hour
  • Mix your phenylephrine by using 10mg/mL phenylephrine. Squirt out 1/2cc from a 10cc NS flush and draw up 1/2cc of phenylephrine, mix thoroughly, this gives you 500mcg/mL

Call urology for close follow up and assistance in this procedure if you are unable to get detumescence in 1 hour.