Grand Rounds Recap 12.13.17

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quality improvement and knowledge translation: asthma with drs. Spigner and Klaszky

1 in 12 people in the US have asthma equating to 2 million ED visits per year

Mild Exacerbations
Bronchodilators
Duoneb + 2 albuterol treatment back-to-back has sound evidence and is strongly recommended
MDI + Spacer is equivalent to a nebulizer treatment however there is a cost and resource benefit to a nebulizer in our ED

Steroids
Meta-analysis show 18% absolute risk reduction of relapse with 8 day prednisone taper
When given within an hour, NNT of 8 for steroids (treat 8 people with steroids, save one an admission)
Prednisone versus 2 doses of dexamethasone spaced 2 hours apart: equivalent outcomes but unlike CCHMC, at UC we do not currently have the capabilities of sending people home with their second dose
Prednisone versus 1 dose of dexamethasone: not non-inferior (but close), Can be considered in someone who you feel will get their scripts filled
Route of administration: globally no difference between IV/PO/IM
Dose: 40-60mg of prednisone PO = 50mg of methylprednisolone IV = 8-12mg of dexamethasone PO or IM

When First Line Treatments Fail
Generally determined by vitals (RR >20 or SpO2 >92%) or WOB (1-2 word sentences correlate with moderate to severe exacerbations)
Magnesium
Needs to be IV in order to obtain benefit
NNT for preventing hospital admission (not preventing intubation) is 14 so consider this early in treatment
Leukotriene antagonists (ie montelukast)
No robust data to support administration in the acute setting
Subcutaneous beta agonists (ie terbutiline)
Cochrane review in 2007 (three studies, only one including adults) showed no difference in hospitalization and no difference in length of stay
Bi-level NIPPV
Controversial with no robust data in asthma as opposed to COPD
Recommend a trial before intubation however these patients need frequent reassessments versus  the COPD where you can "set it and forget it" for an hour
Continuous Albuterol
Good data in a severe exacerbations (PEF <200) with little to no adverse effects
Heliox
No difference in hospitalization reates however significant improvement in FEV
Avoid in hypoxic patients as this causes a decrease in FiO2 in order to administer
Epinephrine
Alpha agonist to decrease inflammation and beta agonist to bronchodilate
No outcome based studies
Several studies show safety
Ketamine
One study in 1996 of placebo versus bolus and drip of ketamine
No difference in outcomes when examined independently
Intubation
Does not fix the underlying problem, often difficult to manage on the ventilator
 

r3 taming the sru - Burn resuscitation with dr. Summers

Young male patient with a history of psychiatric disease, presents with suicide attempt via self immolation
Vitals: tachycardic, tachypnea, normal BP
Exam: 1T5, 95% TBSA with third degree burns, spared palms soles and small area of left flank

Classifying Burns

  • Epidermal/1st degree: erythema with blanching, intact sensation, mildly painful, almost all heal on their own
  • Superficial Partial Thickness/2nd degree: erythema, moist blisters which blanch, intact sensation with severe pain, most heal on their own
  • Deep Partial Thickness/2nd degree: white/erythema, dry/waxy, less blanching, decreased sensation, less painful, most require grafting to heal
  • Full thickness 3rd degree: white, charred, dry, leathery, no blanching, insensate, almost all require grafting to heal


Inhalational Injury
Classic Teaching

  • History: LOC, prolonged exposure, CPR on scene, closed space
  • Physical: Singed nasal hair, carbanaceous sputum, facial burns, stridor/hoarseness, respiratory distress, obtunded
  • 20% increase in morbidity 

Newer studies show that evaluation of physical exam findings do not adequately predict inhalational injuries
If you have concern and the patient does not clearly require intubation have a low threshold to perform bedside NP scope
Also remember to consider cyanide poisoning in the coding burn patient

Disposition
One study showed 25% of patients were inappropriately transferred while 40% were inappropriately not transfered
General Rules For Transfer

  • Any 2nd degree >10%  TBSA
  • Any 3rd degree >1% TBSA
  • Burns involving the face, hands, feet, genitals, perineum or major joints
  • Inhalational injury
  • Electrical/chemical burn
  • Burn + trauma
  • Burns in high morbidity groups (elderly, immunocompromised, etc)

Things to Consider Before Transfer
1. ABCs/Cooling/Dressings/Labs

2. Fluid resuscitation
Zone of coagulation, zone of stasis (can save with fluids) and zone of hyperemia
10% TBSA requires IV hydration while at 20% TBSA patients are at risk of shock physiology
Parkland Formula: 4ml x kg x TBSA (1/2 over first 8 hours, 1/2 over next 16 hours)
More reliable: titrate UOP to 0.5-1 ml/kg/hr
Fluid Creep: we often give 200% the fluids patients actually need due to ...

  • TBSA overestimation
  • Weight errors
  • Not paying attention to UOP goals
  • Responding to tachycardia

Too much fluid leads to increase in hydrostatic pressure in the burn and can cause worsening edema (both pulmonary and in the skin) and can lead to compartment syndrome
Triad of circumferential deep burn + inflammation + aggressive fluid resuscitation = recipe for disaster

3. Escharotomy
Indication: >20% TBSA, inadequate ventilation, impaired perfusion, clinical suspicion
Bovie is preferred however we will likely be doing this with a scalpel
Prep/drape, mark with a marking pen to avoid important anatomy, cut to subcutaneous fat and then use finger to run incisions and break up fibrous bands
Try to avoid fascia to limit risk of infection
Extend to unburned skin to truly release pressure
Consider ulnar nerve, common peroneal nerve and saphenous vein
Wrap with silvadene/kerlix, alginate dressing or vaseline soaked gauze
Leave the hand for the experts

pediatric em combined conference

Simulation Case
3 month old male presenting with hypoxia in the mid 80's, apnea spells, congestion and increased WOB x 2 days
Hypoxic, hypotensive and tachycardic with coarse breath sounds
Labs: hypoglycemia, pH 7.03, PCO2 72, BE -12
Initially responds to high flow nasal cannula and suctioning however with time baby becomes more hypoxic and hypotensive with 20 second apnea spells requiring bagging and ultimately intubation
DDx: bronchiolitis, pertussis, myocarditis, congenital heart disease (although less likely due to age), CAH, NAT
Diagnosis: brionchiolitis
High Flow NC: 1.5 -2L/kg to start however no good data to support that this prevents intubation
Also no good evidence for albuterol in bronchiolitis (can muddy the picture and take up resources)
Racemic epinephrine has some evidence for symptomatic control in the short term
RSI: Age < 12 months atropine (.02 mg/kg) is indicated, strongly consider in the bradycardic patient of any age and also consider if you're giving second dose of succinylcholine. During intubation try to use video in available, don't take your eyes off the chords and then use a helper to pull lip out of the way
Great podcast on bronchiolitis can be found here

Oral Boards Case 1
4 month old male with difficulty breathing, tactile temps, immunized, + sick contacts, Tylenol at home (last dose 12 hours ago), usually takes 6 oz q 3-4 hours, now only 1-2 oz, decreased UOP, noticed stridor today with a barky cough, has gotten stridor in the past with congestion and with crying
PMH: Full term, no issues during delivery or after birth
Exam: Moderate distress with audible stridor (inspiratory and expiratory), no crackles or rales, retracting, oropharynx normal, red spot on right cheek present since birth and growing
Vitals: 99% on RA, RR 60, HR 141, Temp 37.1 rectally
No improvement with racemic epinephrine, also given steroids
Ddx: croup, foreign body, tracheal lesion, RPA, tracheitis
Obtain CXR and airway film which shows steeple sign with asymmetric tracheal narrowing
Dx: tracheal hemangioma
If you see a hemangioma on the face/chin region consider that there may be one present in the subglottic regio
These lesions grow the fastest from birth to 18 months
Croup typically seen in toddlers (2-6 classically) so expand your differential for stridor outside of this age range especially

Oral Boards Case 2
19 month old female presenting after a seizure, stiff and shaking while dad was holding her, lasted for 7 minutes,  eyes rolled up, "out of it" afterwards but continuing to improve, fussy this AM with tactile temps, runny nose and cough x 3 days, wife with URI symptoms, no prior episodes
Vitals: HR 160, BP 90/62, RR 22 Temp 39.6, 99% on RA, BG 76
PMH: Full term otherwise healthy
Exam: Clinging to dad, slightly fussy, regards, good tone, says Daddy, moving all four extremities
Dx: simple febrile seizure

Simple

  • 6 months to 5 years of age (hard cut-offs)
  • Generalized (no focal findings)
  • Less than 15 minutes
  • Single episode
  • Received no medication (ie midazolam from squad)
  • Neurologically normal child on exam/history with normal development on history
  • Fever (and seizure) is not caused by meningitis, encephalitis, or other CNS illness/process

Complex

  • Focal findings
  • Longer than 15 minutes
  • Multiple episodes / more than one in 24 hours

Status

  • Longer than 30 minutes

Diastat or not? Usually not after a simple febrile seizure, can consider with complex
Neurology referral? Again, can consider in complex
Scripting with parents: 1 in 3 kids will have another febrile seizure after the first one, 1 in 2 kids will have recurrence after the second febrile seizure, 1% risk of epilepsy in general public which increases to 2% after one febrile seizure
Don't forget to identify a source for the fever (UTI, URI, pneumonia, gastro, abdominal source, etc)
Great primer on febrile seizures here