Grand Rounds Recap 2.7.24
/Clinical pathologic case presentation - r1 diagnostics/therapeutics: Lumbar punctures - AIRWAY GROUND ROUNDS- r4 capstone - r3 taming the sru - ultrasound grand rounds
Clinical pathologic case presentation WITH Drs. Rodriguez and benoit
Syncope accounts of 3-4% of pediatric visits to the ED
Seizures, drug/alcohol intoxication, and breath holding spells are common mimics
Neurocardiogenic syncope (aka vagal event) is the most common cause of syncope in otherwise healthy children
Yet, cardiac arrhythmias can be cause of syncope in a child as well
Look for red flags: lack of prodrome, syncope that occurs in the setting of exertion, family history of sudden death, palpitations/chest pain, associated significant injury from collapse
This particular pediatric patient had intermittent episodes of syncope secondary to complete heart block and eventually had a pacemaker placed
R1 Diagnostics/Therapeutics: Lumbar Punctures WITH dr. knudsen-robbins
See the full post here
Unless you are planning to obtain opening pressure measurements, the most successful position is likely the one that you are most comfortable with and which suits the patients anatomy best. Consider removing the stylet after passing through the skin and subcutaneous tissue and consider ultrasound guidance in patients for whom a landmark based approach might be difficult.
If assessing for SAH, xanthochromia may not appear until 12 hours after onset, though may appear after 2-4 hours. Total RBC count (<500 RBCs in last tube), as well as clearance by the last tube (decrease in RBC count by at least 70% by the last tube), can be used to differentiate between traumatic taps and a SAH.
There are several recommendations regarding anticoagulation and LPs; aspirin is not a contraindication, yet INR >1.5 and DOAC-use generally are considered contraindications & warrant reversal and/or holding off on the procedure.
There are several recommendations regarding thrombocytopenia and LPs; plt <20k is an absolute contraindication and plt <50k is a relative contraindication. Can consider platelet transfusion prior to the LP based on degree of thrombocytopenia.
There are several guidelines outlining when to obtain a CT head prior to LP (but all agree that if suspecting acute bacterial meningitis you should empirically treat if delaying LP for CT).
airway grand rounds: pediatric airways WITH dr. carleton
Key anatomical differences for pediatric airways
The occiput is rather large
The high position of the larynx (aka the “superior airway”)
Epiglottis tends to be large, floppy, and omega-shaped
The trachea is short (makes ETT displacement much more common)
Key physiological differences
Mean time to desaturation is less compared to adults (healthy children only have 3-4 minute safe apnea time) due to high basal metabolic rate.
This highlights the importance of adequate pre-oxygenation with a well-fitted mask, as well as apneic oxygenation during the intubation attempt itself.
Tips/tricks of the pediatric airway
Mindful of positioning
ear-hole to jugular notch
Adjust the intubation angle
Look up during laryngoscopy
Meaning you need to get lower (closer to the floor)
Intubation should be performed quickly
Even healthy children will tend to desaturate much quicker than healthy adults
Control the epiglottis
This can done indirectly (curved blade) by engaging the hyoepiglottic ligament
Or, directly (straight blade) by lifting the epiglottis itself
Be mindful of depth of ETT placement
Do NOT recommend using formula (measurement at the lip = 3 x ETT size)
Rather length-based resuscitation tube/airway card to determine proper ETT depth for a child
Or, with direct visualization ensure that the cuff just passes the cords & then inflate the cuff
Typically recommend to use only cuffed ETTs
No significant benefit when using an uncuffed ETT
Also, use a stylet when intubating a pediatric patient
Benefits will outweigh the risks of injury
r4 capstone: making the hard decisions WITH dr. milligan
In our own education and in how we approach patient care, we can actively choose to make decisions that might be harder for us in the short-term but make us better, more capable physicians in the long-term.
Be mindful of consults: sometimes this becomes a crutch to get out of things we would best be served learning to evaluate independently. If you need to consult, commit to the thought exercise of what your next step would be if you didn't have the consultant there.
Think about better ways to control pain. This might be giving IV pain medications to complement local anesthesia for a particularly painful area or using regional anesthesia like a femoral nerve block or superficial cervical plexus block.
Help patients navigate the healthcare system. It can be incredibly challenging to be a patient in our healthcare system. The more you can involve a patient's longitudinal providers the better. Send inbasket messages and copies of visits to PCPs and outpatient providers. Consider alternative pathways that can facilitate a quicker disposition such as utilizing CCTAs for chest pain patients. Advocate for patients who need more urgent follow up or may have more barriers to obtaining follow up.
Consider starting more goals of care discussions in the emergency department, not just for patients who are actively dying. The intensity of the care plan while inpatient tends to follow that started in the ED. We have a unique opportunity to pause before getting the ball rolling and letting patients and families consider how to proceed.
r3 taming the sru: Bradycardic Arrest WITH dr. davis
3rd-Degree AV Block
Involves complete atrioventricular dissociation
Causes: congenital, MI, structural heart disease, vagal tone, hypothyroidism/hypokalemia, medications ( including digoxin, BB, CBB, etc.)
Location of the block will determine the morphology of the QRS (as a higher block may have a narrow QRS with a rate of 40-60bpm)
Evaluation in the ED: basic labs including BMP and troponin, EKG, bedside echo, CXR
Management:
Atropine: push-dose 0.5-1mg, yet mainly effective for higher level blocks (much less effective if block is occurring at the level of the ventricles)
Epi: preferred due to positive inotropic & chronotropic effects, typically administered as an infusion starting at 2ug/min (max 50ug/min)
Dopamine: stimulates beta-1 activity (inotropy > chronotropy) at lower doses (3-10ug/kg/min)
Isoproterenol: strong B1 effect on pacemaker cells (therefore primarily a chronotropic agent) and infusion is dosed at 2-10ug/min
Transcutaneous Pacing: limited by patient tolerance, as well as skin contact/pad positioning
Transvenous Pacing: as EM providers we should be comfortable with this procedure (if needed, please see the TTS post on TVP placement)
ultrasound grand rounds: ED Nerve blocks WITH Drs. Broadstock and Ramachandran
Nerve blocks should be a part of your multimodal analgesia toolbox in the ED
Basic Equipment:
antiseptic cleaner
barrier protection
needle (EchoBlock needs are specifically designed for regional anesthesia and available in our ED)
anesthetic
typically 0.5% ropivacaine (max dose at 3mg/kg
or, 1% lidocaine with epinpehrine (max dose at 7mg/kg)
Nerve blocks are typically done in long-axis (aka “in-plane” view)
your probe is typically still during this process and focused on your target
General Contraindications
Allergy to anesthetic
Overlying infectious process
Patient unable to consent to the procedure
Types of Blocks:
Forearm
Typical uses: lacerations, FB removal, reduction of fracture
Need to understand innervation of the median, radial, and ulnar nerves
Median nerve
typically in the middle of the forearm
Radial nerve
find the radial artery at the level of the wrist
then move more proximally
artery/nerve tend to travel together and separate more at the level of the mid-forearm
the nerve will be “radial” to the radial artery
Ulnar nerve
find ulnar artery at the level of the wrist
then move more proximally
the nerve will be “ulnar” to the ulnar artery
Tips/tricks
Always make sure there is no air in the tubing and always inject in a downwards fashion (given that air rises in the syringe)
Goal is to surround entire nerve in anesthetic
Typically only need 3-5cc of anesthetic for forearm blocks
Can use the built-in needle tracking features
4 dots noted at the tip of the EchoBlock needle
Newer US machines have a needle gain feature as well
Superficial Cervical Plexus
Typical uses: provides appropriate anesthesia when placing IJ lines
Basic technique
find typical view needed when placing IJ lines
then slide the probe laterally (away from midline)
look for honeycomb structure located on the lateral end of the SCM
Tips/tricks
this is a very superficial nerve
only need 5-10cc of anesthetic
Serratus Anterior Block
Typical uses: anterior/lateral fractures, laceration/abscesses on anterior/lateral chest wall, chest tube placement
Landmarks:
level of the nipple, mid-axillary line
anterior border of the latissimus dorsi & serratus muscles
This is a plane block
large volume of anesthetic is deposited and will eventually diffuse throughout the tissue
goal is to place the anesthetic on top of, or directly below, serratus muscle (near where it meets with the latissimus dorsi muscle- which appears triangular on US)
typically place 10-15cc of NS, plus 10-15cc of anesthetic
Complications
PTX (due to close proximity to the pleura)
Intra-articular Shoulder Injection
Typical uses: shoulder dislocation requiring reduction
Higher rate of misplacement when only anatomical landmarks are used, rather than US-guided
Positioning
sitting up with feet on the floor
or, supine with blankets behind the back
Probe placement
palpated the scapular spine and move more laterally to the end of it
will see displacement of the humeral head
Maintain in-plane approach throughout the procedure
needle approach should be from lateral to medial direction
aim for the joint space
typically inject 10cc of lidocaine directly into the joint space
