Grand Rounds Recap 1.10.24

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r4 case follow up WITH dr. yates

  • Psychiatric emergency department visits are on the rise in the United States, with roughly 15-19% of all ED visits associated with mental health diagnoses

  • Roughly twenty percent of patients presenting with psychosis have a secondary cause

  • Work up should be determined by the history and physical and may need to be broad, but all patients should receive a POC glucose

  • Be particularly cautious in patients of vulnerable populations, including pediatrics, pregnant patients, and elderly

r1 clinical knowledge: interstitial lung disease WITH dr. segev

  • Interstitial lung diseases (ILD) are rare but associated with high mortality rates, particularly following an acute exacerbation (AE-ILD)

  • Work-up for an acutely ill ILD patient should be broad to evaluate for infectious and cardioembolic etiologies, including CT chest to evaluate the lung parenchyma and a thorough cardiac work-up. Often AE-ILD is idiopathic, but treatable causes must be excluded (PNA, PE, volume overload)

  • Treatment for AE-ILD should include antibiotics for CAP coverage (specifically including azithromycin), steroids, and respiratory support; consider opportunistic infection if immunosuppressed as well as diuresis as needed for euvolemia

  • HFNC should be favored over NIPPV for respiratory support, but NIPPV can be used to stave off invasive mechanical ventilation as intubated ILD patients have exceedingly high mortality rates approaching 100%

high acuity low opportunity WITH drs. kletsel, stark, and yates

  •  While we complete procedures every day as emergency medicine physicians, some of these procedures are performed quite rarely despite them being performed in high acuity situations

  • It is extremely important to continue to review and practice these high acuity, low opportunity procedures to remain proficient in real time

  • Today we reviewed esophageal balloon tamponade, transvenous pacemaker placement, and chest wall escharotomy

pediatric simulation: Neonatal shock WITH our cchmc colleagues

  • Remember to assess if vital signs are appropriate for age

    • In neonates, a good rule of thumb is a that the goal MAP should be at least their GA in weeks

  • Differential diagnosis for neonatal shock (THE MISFITS)

    • Trauma/NAT

    • Heart disease and hypovolemia

    • Endocrine including CAH and thyrotoxicosis

    • Metabolic including hypocalcemia, hypoglycemia

    • Inborn errors of metabolism

    • Sepsis

    • Formula dilution

    • Intestinal catastrophes such as NEC or volvulus

    • Toxins

    • Seizures

  • Management of shock

    • Vascular access is key and one should consider obtaining multiple points of access, including two IOs if needed

    • Early fluid resuscitation with 20 cc/kg IVF bolus

    • Consider antibiotics when sepsis is on the differential

    • If concerned for adrenal crisis, administer hydrocortisone 2 mg/kg

  • Disposition

    • If not at a pediatric primary facility, call for transport early in critical neonates!

pediatric small groups WITH our cchmc colleagues

  • Dermatologic emergencies

    • Children can present with a wide range of rashes, many of which are benign, however identifying concerning rashes is very important.

    • Use your resources to differentiate scary from benign!

  • Children are not just small adults!

    • Remember that while we often use standard tools or dosing for adults, there is not a “one size fits all” solution for pediatrics

    • Incorrect sizing of ETT is more likely lead to airway trauma and edema than in adult intubations

    • Medications are almost always weight based dosing, so having an on-shift resource to check this dosing is key