Grand Rounds Recap 4.10.24

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Ultrasound Grand Rounds: The Tell-Tale Cardiac Ultrasound WITH Dr. broadstock

  • Right ventricle evaluation  

    • RV size 

      • Moderate RV dilation is when RV:LV ratio is greater than 1:1 

      • Studies show this is 98% specific and 50% sensitive for PE 

    • TAPSE (Tricuspid annular plane systolic excursion) 

      • Greater than 1.8 cm is normal

      • Hazard ratio in patients with abnormal TAPSE in normotensive patients is high even though the patient is currently hemodynamically stable 

    • Acute vs chronic right heart strain

      • Acute 

        • McConnell’s sign: apical hypokinesis with RV free wall hypokinesis 

        • Will be present in all causes of increased RV pressure including PE, pulmonary HTN, etc. 

      • Chronic 

        • Increased RV free wall thickness 

  • Left ventricle evaluation and LV failure 

    • EPSS (E-Point Septal Separation) 

      • Normal < 7 mm 

      • Ensure that M-Mode is as perpendicular as possible to the mitral valve 

      • Limitations include: 

        • Aortic regurgitation 

        • Mitral stenosis 

        • Atrial fibrillation 

        • Septal hypertrophy

        • Wall motion abnormalities 

    • Fractional shortening 

      • Measurement in the change in size of LV cavity from systole to diastole 

      • Normal > 25% 

    • Visual estimation 

      • Estimation of the difference in cavity size from diastole to systole

      • Actually found to be the most accurate with practice (approximately 20 scans with appropriate feedback) 

      • Tachycardic hearts often look better than they really are (and vice versa for bradycardic hearts) 

  • Cardiac tamponade 

    • Pericardial effusion 

      • Measure the largest pocket of fluid at end diastole 

      • > 20 mm is a large pericardial effusion 

    • RA systolic collapse 

      • Earliest sign of cardiac tamponade 

    • RV diastolic collapse 

    • Plethoric IVC 

      • Most sensitive sign for cardiac tamponade (Sn 97%) 

      • If there are US findings consistent with tamponade with collapsible IC, try giving IVF 

    • MV inflow variation 

      • Change in MV inflow related to respiratory variation 

  • POCUS in Cardiac Arrest 

    • POCUS can be a helpful tool in arrest 

    • There is poor inter-rater reliability between providers for determining organized myocardial contractility with valve movement 

    • Be cautious not to prolong pulse checks or resuscitations for ultrasound

dei: embracing individuality WITH dr. irankunda

  • Names matter. 

  • Correct pronunciation and understanding of personal narratives is important.  

  • There is history behind a person’s name which often has deep and personal meaning. 

  • There is a close relationship between names and identities. Chronic mispronunciation can lead one to feel marginalized, disrespected, and undervalued. 

  • Ask people how to pronounce their name and listen carefully to where the person puts emphasis and inflections. 

  • The sooner you correct people, the better. Offer people tips and guidance on pronunciation.

pediatric emergency procedures WITH our cchmc colleagues

  •  Needle cricothyrotomy 

    • Indications 

      • Can’t oxygenate and can’t ventilate in patients < 10 years of age 

      • Obstruction proximal to vocal cords: 

        • Epiglottitis 

        • Facial trauma 

        • Angioedema 

        • Foreign body 

    • Contraindications 

      • No absolute contraindications 

      • Relative contraindications 

        • Tracheal transection 

        • Known underlying abnormality such as tumor or abscess 

        • Inability to identify landmarks 

    • Equipment 

      • 14G over the needle catheter 

      • 3mL syringe with saline 

      • Attachment to the BVM 

        • 3.0 ETT adapter directly into angiocath 

        • 3 mL syringe + 7.0 ETT adapter into syringe

        • 10 mL syringe + 7.0 ETT with balloon inflated inserted into the syringe 

        • Standard IV tubing + 2.5 ETT adapter  

  • Umbilical vein catheter 

    • Indications 

      • IV access in neonates < 48 hours of life  

      • May advance to 5-7 days in specific situations 

    • Equipment 

      • Catheter: 3.5 Fr < 2.5 kg and 5 Fr for all other neonates 

      • UVC tray 

      • Normal saline flush 

    • Steps of procedure 

      • Clean the stump

      • Tie the stump for hemostasis 

      • Cut the stump 

      • Attach stockcock and flush to catheter and flush 

      • Insert catheter 3-4 cm and aspirate until you see blood flow

neonatal potpouri WITH our cchmc colleagues

  • Staph scalded skin syndrome (SSSS)

    • Up to 80% babies colonized with staph within the first few weeks 

    • Babies more commonly with SSS due to poor immune syndrome

    • Presentation 

      • Erythema, more common in skin folds

      • Tender to touch 

      • Easy separation of epidermis with traction on skin 

    • Management 

      • IVF (similar to burn management) 

      • Nafcillin +/- clindamycin 

      • If concern for MRSA, vancomycin 

  • Inguinal hernia 

    • Risk factors 

      • Prematurity 

      • Developmental hip dysplasia 

      • Family history of hernias 

      • Diagnose with ultrasound

    • Management

      • Attempt reduction with adequate pain control

      • Urology or pediatric surgery

        • Will need relatively urgent outpatient surgical management if not incarcerated as the risk of incarceration in the future is high.

  • Neonatal mastitis 

    • More common in females 

    • Most commonly staph 

    • Usually isolated SSTI without associated SBI. No further workup for SBI is indicated. 

    • Management 

      • Antibiotics with staph coverage

      • Most spontaneously drain and do not require I&D

  • Hypothermia in neonates 

    • Varying definitions with consensus < 36-36.5 

    • Prevalence of SBI in hypothermic babies is comparable to febrile neonates 

    • Management 

      • Recreate environmental conditions and recheck temperature 

      • Consider full SBI evaluation vs observation