Grand Rounds Recap 3.11.20
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Airway Grand Rounds WITH Dr. Carleton
Some Definitions
A course of intubation is characterized by a strategy and/or a device choice.
For example: EGD, direct laryngoscope, video laryngoscope, endoscope, knife
The number of courses of reflects the soundness of the cognitive approach to the airway
An attempt at intubation is the active of trying to visualize the glottis or to pass a tube into the trachea.
Attempts occur within a course.
The number of attempts often reflects the technical skill with which the procedure is performed
Example:
Patient with multiple GSWs to the thorax. An iGel is placed to facilitate preoxygenation (1st course, 1 attempt). The iGel is removed and direct laryngoscopy is attempted three times with unsuccessful visualization using a Miller 4 blade (2nd course, 3 attempts). Direct laryngoscopy is reattempted with a Mac 4 blade, visualizing the glottis but unable to pass the ETT (3rd course, 1 attempt). The patient is eventually intubated by video laryngoscopy with a D-blade (4th course, 1 attempt).
Opportunities for QI
Appropriate depth
Female: 21cm to 23cm
Male: 23 to 25cm
If someone with an iGel is ventilating well, consider generous paralysis to prevent emesis and aspiration.
Additionally, consider intubating through an iGel blindly or endoscopically.
COVID19
138 hospitalized for COVID-19 in Wuhan, China
29% were hospital personnel
26% were admitted to the ICU
31% developed ARDS
42% were managed with NIPPV
11% were managed with HFNC
47% were managed with mechanical ventilation
Overall, there was 4.3% mortality
Transmission: droplet, but can then be transmitted via fomite when droplets settle on surfaces
There is a question of whether this virus can be transmitted by airborne transmission
Be diligent in using airborne + droplet + contact precautions, especially during procedures which generate aerosols
To minimize airborne and droplet spread:
Place a high-efficiency hydrophobic, viral/bacterial filter between the patient and the ventilation device (including resuscitation bags)
Have the exhaust filter appropriately placed on resuscitation bags
Place a mask on a patient with a nasal cannula, especially HFNC
Minimize BiPAP: standard BiPAP machine vents expired gases directly into the room without filtration
Use a ventilator to provide pressure support + PEEP with a non-invasive mask as a way to pre-oxygenation a patient prior to intubation
When intubating, strongly lean on RSI over fiberoptic intubations
R1 Clinical Knowledge: Face and Mouth INfections WITH Dr. Frankenfeld
Erysipelas
Much more demarcated borders compared to cellulitis, as this is secondary to infection of superficial skin structures
Can be treated with penicillin/amoxicillin
If bullous, more likely to be MRSA so would want to add additional antibiotic coverage
Impetigo
Classic honey-crusted lesions
Typically topical treatment is appropriate but can consider systemic treatment if there are “punched out lesions” or for more severe infections
Septic Cavernous Sinus Thrombosis
Anatomically, this is a sinus with a large number of structures coursing through, including the internal carotid artery and multiple cranial nerves
Presentation includes proptosis, opthalmoplegia, headache
With the valveless venous system throughout the cranium, it can easily spread throughout the rest of the venous drainage system intracranially
Parotitis
Viral is less likely to have intense erythema and swelling is more anterior to the mandible
Treatment is supportive care
Bacterial is more likely to have intense erythema with induration
You may be able to identify purulent drainage from Stenson’s duct
Will require treatment with antibiotics, such as Unasyn or clindamycin
Pharyngeal Infections
Viral pharyngitis can have an exudative pharyngitis, but more classically will include mucosal petechiae
Utilize appropriate testing strategies for bacterial pharyngitis, such as Centor Criteria
Also consider gonoccocal pharyngitis if the patient has high-risk sexual practices
Fusobacterium necrophorum
Can lead to Lemierre’s syndrome, which is a infectious thrombophlebitis of the internal jugular vein
Treat with penicillin and an additional agent with appropriate anaerobic coverage
The decision to use anticoagulation is heavily debated, but may be indicated for extensive disease or persistent bacteremia
Peritonsilar abscess
Hot potato voice, uvular deviation
Polymicrobial
Treatment includes antibiotics, drainage, and steroids
Drainage:
Needle aspiration is less painful that incision and drainage with a higher recurrence rate
Perform procedure on the superior pole of the tonsil
Avoid lateral structures, as this has increased risk of carotid puncture
Retropharyngeal abscess
Polymicrobial
Can extend into the mediastinum and cause mediastinitis
Utilize CT scan or lateral neck x-rays to look for thickening of the pre-vertebral space
Odontogenic Infections
Infections around the mandibular teeth typically spread to the deep neck structures
Infections around the maxillary molars typically spread into the maxillary space
Infections around the anterior teeth typically spread sublingually
Ludwig’s angina
Trismus, woody edema and edema of the floor of the mouth
This causes posterior displacement of the tongue and can lead to difficulties in airway management
Administer appropriate antibiotics, including MRSA in those at risk such as immunocompromised patients
R3 Taming the SRU: Loperamide Overdose WITH Dr. Li
Loperamide is highly protein bound and starts to have sodium blockage potential with 100-800mg per day
The misuse and abuse of loperamide has significantly increased over the last decade
This trend can also be mapped to the increased prevalence of opiate use disorder
Some patients who abuse loperamide will also take black pepper and grapefruit to potentiate the effects
Presents similar to opiate toxicity with altered mental status, miosis, and apnea or bradypnea
Slowed gut motility can lead to increased loperamide release over time
These patients may need additional naloxone dosing over time
Use sodium bicarbonate or hypertonic saline for sodium channel blockade
Other therapies include intralipid, plasma exchange, calcium, and ECMO
QI: HealthCare CHange Methodology WITH Dr. Thompson
Complicated process changes are unlikely to be adequately affected or successful when “fixed” by simple solutions.
PDSA Cycle
Plan: what will happen if we try something differently?
Define the objective
Plan for how to carry this change out
Do: let’s try it!
Carry out plan, focusing on one change at a time
Document problems
Begin data analysis
Study: did it work?
Complete data analysis and compare to predictions
Act: what’s next?
Is this change ready to implement?
Should you try something new?
Pediatric Simulation WITH Dr. Stratton
Pediatric Ultrasound
When performing a FAST exam, the first area where fluid will accumulate in pediatrics is in the pelvis.
When performing RLQ ultrasound to evaluate for appendicitis, begin your study with a linear probe where the iliac vessels overly the psoas muscle
Alternatively, ask the patient where they are having the most pain
Cases
Evan’s Syndrome: combination of ITP and autoimmune hemolytic anemia
Treatment includes steroids, IVIg
Osteomyelitis and Discitis
If patient is well appearing, considering awaiting bone biopsy before antibiotics
Be concerned about back pain in children
