Grand Rounds Recap 9.14.22
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Body Stuffers, Packers, and Pushers WITH Dr. Joshi
Body Packers
Body packing is the generally well planned ingestion of enclosed drugs for the purpose of trafficking. The colloquial “drug mule.”
Body Stuffers
Body stuffing is the hurried swallowing of either poorly packaged or unpackaged drugs to avoid prosecution.
Body Pushers
Pushing is the hurried placement of poorly packaged or unpackaged drugs into the rectum, vagina, or other orifices to avoid arrest or for sale later.
History
What type of drug was ingested?
When was the drug ingested?
How many packets were ingested?
How were the packets wrapped?
Has the patient had symptoms of gastrointestinal obstruction or distress?
Any co-ingestions?
Physical Exam
Identifying the toxidrome
Heroin: bradypnea, miosis, decreased bowel sounds
Cocaine: hypertension, tachycardia, diaphoresis, hyperthermia, seizures, collapse
Is there intestinal obstruction?
Location of the packets
Diagnostics
Decide if you need an abdominal x-ray
Packers should typically get one
Stuffers, usually not unless extenuating reason
CT Abdomen Pelvis if high clinical suspicion for packers and negative x-ray
EKG, CBC, BMP, LFTs, lipase, VBG, lactate
Troponins if the patient endorses chest pain
Treatment
Body Packers
Asymptomatic
Activated charcoal 1 g/kg up to 50 g
Whole bowel irrigation with PEG at 1-2L/hr through NGT
Observation
Symptomatic
Patients with signs of intestinal obstruction go to the OR
Treat toxidrome
Patients with sympathomimetic toxidrome and body packing have high risk for decompensation, consider early surgery consult
Body Stuffers
Asymptomatic
Observe for at least 6 hours
Admit based on clinical status
Symptomatic
Treat symptomatically
Admit for observation
Conclusions
The patient interview is a critical step in diagnosis. Utilizing an interpreter as appropriate and establishing a therapeutic relationship matters. Your history and physical exam matter.
Identify signs and symptoms of intestinal obstruction. Suspecting drug packing/stuffing will allow quicker evaluation, diagnosis, and disposition for your patient.
Conservative management will likely be the mainstay of therapy.
Asymptomatic stuffers can likely be discharged after observation period.
Asymptomatic packers should undergo whole bowel irrigation
Rib Fracture Management WITH Dr. Bryant
NEXUS Chest Rules for Blunt Chest Trauma
Derived and validated in ED for patients > 15, presenting within 24 hours
If score is 0
99% sensitive for clinically significant thoracic injury
If score >0
Consider CXR without CT
If ill appearing, consider CT
CXR and rib fractures
Sensitivity ~50%
66% rib fractures found on CT are missed on CXR
75% of these are clinically significant
Consider CT if high clinical suspicion for rib fractures
Pulmonary contusions are a delayed process and surface hours after initial injury
NEXUS Chest CT Rules
If no abnormal CXR, distracting injury, chest wall/sternum/thoracic spine/scapular tenderness and no significant mechanism, can forego CT
99.2% sensitive for major injury
90% sensitive for minor injury
Pain Control
Ketorolac
Multiple retrospective cohort studies
Some benefit to prevent pneumonia
Ketamine
No great data for single dose, some data to support ketamine infusion though some issues with side effects/hallucination
Gabapentin
Data to argue against its use, no benefit
Methocarbamol
Some data to suggest decreased hospital length of stay in trauma w/ rib fractures
Low quality evidence, low power and poor matching
Topical Lidocaine Patches
Low quality evidence, low risk of harm
Ultrasound Guided Anesthesia
Serratus block may reduce pain scores and improve incentive spirometry volumes with fewer contraindications but similar efficacy to epidural anesthesia, based on retrospective data collection
Chest binders and splints
Incentive spirometry
Good evidence, improves outcomes
Kinesiotaping
An RCT of 30 patients found improved pain control ratings using kinesiotaping plus NSAIDs, compared to NSAIDs alone, but this trial had a large number of excluded patients
Unclear benefit: TENS units, chest binders/splints
Chest plating
EAST guidelines recommend operative fixation of rib fractures after blunt trauma, most recently updated in 2017, included a conditional recommendation for treatment of flail chest with open reduction and internal fixation to reduce mortality, ICU and hospital length of stay, and duration of mechanical ventilation
Respiratory Support
NIPPV
A trial comparing NIPPV with high-flow oxygen mask in patients who remained hypoxic after regional anesthesia delivery within 48 hours after blunt chest trauma was stopped prematurely after enrollment of 50 patients when the result of an interim analysis showed a substantial reduction in intubation rates in patients on NIPPV
Worsening of pneumothorax with application of positive pressure was not commonly reported in these trials. Use of this therapeutic modality is not yet widespread; in a retrospective database analysis over the years 2007 to 2014, use of NIPPV was reported in only 1% of patients. In patients aged >65 years, it was not associated with reduced mortality.
HFNC
High-flow nasal cannula (HFNC) was evaluated in an RCT of 220 patients with rib fractures, but it did not show improved outcomes in comparison to Venturi mask
A retrospective cohort of 86 ICU patients treated with HFNC after blunt chest trauma demonstrated a failure rate of 16.2%, leading to invasive ventilation
Disposition
For patients aged >65 years, multiple studies have demonstrated improved outcomes with ICU admission, particularly for patients with >2 rib fractures or with flail chest
Battle Score
< 10 can likely be discharged
Score predicts risk of mortality
Dispo by FVC (Hamilton et al 2017)
Recommend discharge if forced vital capacity (FVC) >1500 mL, no anticoagulant use, good pain control in the ED, rib fractures that are unilateral and number <3, no hemo/pneumothorax, and no other condition requiring admission
Ribscore
Predicts need for ICU admission
Pitfalls
“The chest x-ray was negative, so we skipped the CT.”
Plain radiography imaging can be insensitive for rib fracture. For patients for whom there is high suspicion for fracture with complications, advanced imaging studies should be performed.
“The rib fractures were visible, so we treated those as isolated injuries.”
Rib fractures are frequently accompanied by visceral injury after trauma. Ultrasound or CT imaging is often needed to locate the damage to these structures.
“There were a few rib fractures, but the lungs were clear.”
Delayed respiratory failure can result from evolution of pulmonary contusion or infection over several days. With adequate pain control and respiratory support, risks for deterioration can be minimized.
“We just couldn’t get her pain under control, no matter what we did.”
Rib fractures are recognized as causing intense pain, and a multimodal approach to pain control is usually required to optimize analgesia. In cases of severe pain, opioids may improve symptoms when used at the lowest required doses, but patients should be cautioned regarding the risks of opioids.
“We went right to intubation. Patients with traumatic injuries never benefit from noninvasive ventilation.”
NIPPV can be an option for pulmonary stenting in selected patients, to avoid invasive ventilation. In well-selected patients, noninvasive ventilatory support can reduce mortality and rates of invasive ventilation.
“The patient got stuck on the vent for weeks.”
Pain from rib fractures can delay extubation, but the patient may respond to fracture fixation. Guidelines recommend considering fixation of multiple fractures, particularly flail segments, and early surgical consultation should be obtained.
“We discharged the patient from the ED with return instructions, but he came back when it was too late.”
Patients who are discharged with rib fractures need strict return precautions or inpatient observation. Suggested endpoints for safe discharge include adequate pain control, normal vital signs, and low risk for decompensation, based on patient history and examination.
“I knew he was old, but I was still surprised that trauma surgery wanted him in the ICU.”
Elderly patients are at an increased risk for decompensation after rib fractures, and each fracture drastically increases that risk. Guidelines recommend managing patients older than 65 years with inpatient observation for even single rib fractures.
“The fall didn’t sound that bad, so we skipped imaging altogether.”
In patients with osteoporosis or frailty, rib fractures can occur with even minor trauma. Scoring systems, including the Modified Frailty Index, can help predict adverse outcomes after rib fractures and assist in disposition decisions.
Air Care Grand Rounds WITH Dr. Goff, Winslow, Hinckley
AC OB Potpourri
THE MOST IMPORTANT RULE: DELIVERY IN FLIGHT IS A NEVER EVENT!
Routine Transport Considerations:
Transport in left lateral recumbent.
Obtain fetal heart rate via US or doppler every 15 minutes.
Preterm Labor:
Determine if at risk for imminent delivery: contraction pattern and frequency, cervical check by qualified / experienced provider
If at risk for delivery – deliver prior to transport and coordinate safe transport of neonate via specialized team (CCHMC)
Tocolysis: Magnesium bolus (4-6 Gm) followed by infusion (2 Gm/hr) is first line; may consider terbutaline if available at a referring facility; must document DTRs for any patient on Mg
Mg toxicity with loss of deep tendon reflexes and respiratory depression - give 2 gm Calcium IV
Neonatal Resuscitation:
Routine care: warm, dry, stimulate. Assess tone, respiratory effort, perfusion
Resuscitate by NRP if necessary
Major NRP decision points:
Respiratory insufficiency and HR >100 give supplemental oxygen
Respiratory insufficiency and HR<100 give PPV
Respiratory insufficiency and HR <60 start chest compressions; intubate; establish vascular access (consider umbilical line)
HR<60 despite interventions: give epinephrine and continue above until deemed futile.
Post-Partum Hemorrhage
>1 L blood loss following deliver; consider overall clinical condition and vitals
4 Ts cause post-partum hemorrhage: lack of uterine Tone, retained Tissue (placenta), birth Trauma, Thrombin (coagulopathy)
Routine care: fundal massage, IM oxytocin
Resuscitate: bimanual massage, IV oxytocin (40 U / 500 mL crystalloid), blood products, TXA, tamponade device
Pre-eclampsia / Eclampsia
Magnesium 6 Gm over 20 min followed by infusion 2 Gm/hr
Assess for Mg toxicity as above; treat with Ca if necessary
Supportive care (airway management, etc)
Resuscitative Hysterotomy
If unknown age gestation then assess fundal height and proceed if at the level of the umbilicus
Initiate procedure within 5 minutes of cardiac arrest; likely futile if > 20 minutes since cardiac arrest
https://www.tamingthesru.com/blog/air-care-orientation-curriculum/resuscitative-hysterotomy
Maximizing DASHH-1A
Old news
Resuscitate before you intubate
Use the McGrath
Use the RSI checklist
Bougie First
New News
All patients should be on the Air Care monitor before RSI meds
Don’t be satisfied starting with a sat < 97%
Push dose pressors if SBP < 100 mmHg
BVM for all patients during apneic period
If choosing rocuronium, use 1.5 mg/kg IBW
Use the procedure note template for documentation
Non-Accidental Pediatric Trauma WITH Dr. Hartwell
Epidemiology
600-700K children are victims of maltreatment each year
>1700 children die of abuse and neglect each year
75% of child abuse fatalities are children <3 years of age
Repeat injury occurs in 35-50% of all abuse cases
Possibility of abuse in children < 1 yo underestimated by ED clinicians in 28% of cases
Presentation
Abusive fractures often missed at initial presentation
In 21% of cases, at least 1 previous physician visit in which abuse missed
3 variables associated with missed abuse:
Male sex
Initial visit to non-pediatric ED
Extremity fracture
If all 3 factors present, probability of missing abusive fracture was 50%!
When to suspect NAT:
History inconsistent with mechanism of injury
Delays in care
Injuries in different stages of healing
Injuries in unusual locations
Changes in caregiver report
Injury inconsistent with developmental level of child
Patterned injuries
Examination (TEN 4 FACES)
Trunk
Ears
Neck
Any bruising on a child less than 4 months
Frenulum
Auricular Area
Cheeks
Eyes
Sclera
Common Fractures in NAT
Posterior ribs
Occiput
Metaphyseal fracture of proximal femur
Superior pubic ramus
Spiral oblique fracture of the femur in a non ambulatory child
Transverse humerus fracture attributed to fall
When to get head CT:
Infants < 6 mo
Rib fractures
Multiple injury or facial injury
Abdominal Trauma
2nd most common cause of death in abused children (after head injury)
Most common in kids under 2, and in the absence of other trauma
1-2% of all abused children sustain intra-abdominal injury
High mortality rate, typically secondary to internal hemorrhage or shock
Mechanism:
Direct blows or kicks to abdomen
Direct pressure (i.e., standing or kneeling on abdomen)
Abdominal organs less protected in children:
Less abdominal wall muscle and subcutaneous tissue
Pliable ribs
Liver and spleen are larger, extend caudally beyond ribs
Bladder is intra-abdominal in babies
Presentation:
Variable but can include shock, peritonitis, and/or bilious vomiting
Abdominal bruising, tenderness, or distention are no more than 50% sensitive
Imaging:
CT abdomen/pelvis with IV contrast
Labs:
AST/ALT: most helpful
Cutoff of 80 for obtaining CT
Lipase: helpful
CBC: serial H/H most useful, initial H/H less useful
Coags: helpful in court
Reporting NAT
Physicians are mandated reporters for any suspected NAT in a minor
Do not have to prove the abuse occurred
No penalty for good faith reports
Get social work involved early!
Can often get more social history and evaluate for additional risk factors
Can guide process for making a report to Child Protective Services (CPS)
If the child needs additional medical care
Transfer to pediatric center
If unable to complete NAT eval
Transfer to pediatric center
Mode of transfer: if stable can coordinate with JFS on a caseworker or trusted family member, otherwise by ambulance
If workup completed and medically stable for discharge
Per JFS
