Grand Rounds Summary 8/12/15

Visiting Lecturer Series with Dr. Matt Dawson

1) On Technology, Emergency Medicine, and New Frontiers

Today’s tech explosion is leading to health innovations that may make some big differences leading to big changes. Here’s a sneak peak:

• In the near future drones may roam the sky to deliver life saving epi pens, defibrillators and instructions of how to use them. Until SkyLab takes over... 

• Portable ultrasound? Pocket VL?  (Hey don't we already have those...)

  • http://www.tamingthesru.com/blog/acmc/ultrasound-in-hems

  • Using the King Vision Laryngoscope

• CHEER Trial: Too young to die? Try ECMO. Australia did and in a trial of 26 people, 14 went on to live and many with excellent neurologic recovery. 

• TEE: A small number of point of care ED docs are using this successfully to better evaluate causes of shock with good results, low risks (0.03% perf rate), and little training

• Are minimally invasive, continuously monitoring TEE probe images going to find themselves nestled next to the pulse ox waveform and tele read? Wait for it…

Each year nearly a million people in Europe suffer from a cardiac arrest. A mere 8% survives due to slow response times of emergency services. The ambulance-drone is capable of saving lives with an integrated defibrillator. The goal is to improve existing emergency infrastructure with a network of drones.

2) On Medical Wearables

Do you want to know when someone within a quarter mile of your cardiopulmonary-resuscitating-hands arrests? How about when your child pees themselves or has a fever? There’s an app for that. 

• Check out The Good SAM App, sign up and maybe get an alert to save a life...

3) On Nerve Blocks

• If done well, can reduce the risks of sedation, need for monitoring, and pain for both you and the patient.
• Ideally, you want to inject right next to the nerve; however in practice it is incredibly difficult to transect a nerve and fear of nerve damage while performing blocks should be minimal.
• Compartment syndrome is essentially a never event when doing these blocks. 
• These are clean procedures, not sterile. 
• Use an LP needle. 
• Dawson uses lidocaine and bupivacaine essentially exclusively as they are minimally associated with LAST (lidocaine associated systemic toxicity).
• It is important to perform these as a step-by-step process: In transverse, sight the needle tip then move the probe, sight the needle tip, move the probe. In longitudinal you can follow the needle the whole way but it is difficult to move along the 1 mm axis of beam. 
• Whom to avoid? Excited delirium and other non-participating patients, open fractures, elevated compartment pressures, vascular injury, neurologic injury
• Dr. Dawson had no training on blocks in residency. He became good at them because he read, watched videos, scanned normal anatomy and repeated before attempting the blocks. Then he attempted a lot of blocks. You too can master this skill. 
• Check out this link from Dr. Dawson's Ultrasound Podcast for videos on how to perform nerve blocks:  Ultrasound Podcast including interscalene, supraclavicular, infraclavicular, axillary, femoral, sciatic and posterior tibial
  • Ultrasound Guided Nerve Blocks Part 1
  • Ultrasound Guided Nerve Blocks Part 2
  • Femoral Nerve Block
  • Interscalene Nerve Block
  • Supraclavicular Nerve Block

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Peds-EM Combined Lecture with Dr. Fain

Recognizing Pediatric Malignancy in the ED

Basic Facts:

• 150/1 million new cases, 1 in 7000 children (between 0-14)

• Survival is 70-80% overall

  • 4th leading cause of childhood death (10% of all childhood deaths)

  • Males and adolescents have worse prognosis

• Often has nonspecific symptoms, insidious onset and may mimic common disorders

ALL- Acute Lymphocytic Leukemia

• 30% of all childhood cancer
• Presentation may be MSK pain (21-38% of new diagnoses), LAD (super common in kids, many well children have lymphadenopathy-> if  >1cm is considered enlarged) present in 50% of children at the time of diagnosis of ALL, testicular enlargement (rare, usually unilateral, painless)
• Increased utilization of PMD is common in the months prior to diagnosis.
• Peripheral blood anomalies associated with leukemia
• Blasts in a peripheral smear are diagnostic but not always present

60% of brain tumors in kids are posterior fossa tumors. These commonly present with N/V. Supratentorial commonly presents with HA.

• Who gets imaged?
  • Persistent HA that wakes from sleep
  • Occurs upon wakening
  • <3 yrs old
  • Associated with AMS
  • Vomiting (persistent, increasing in frequency)
• Highest OR is headaches that affect sleep and absence of a family history of migraine headache

Neuroblastoma- most common extracranial solid tumor in kids

• Signs and symptoms are a function of location
• 2/3rd are intraabdominal with most on adrenal glands
• Bone and bone marrow mets are common (60-70% will have mets at time of diagnosis)
• Associated with paraneoplastic phenomena

Wilms tumor (Nephroblastoma)

• 4th most common pediatric tumor
• Most commonly presents as a painless abdominal mass