Grand Rounds Recap 09.23.20
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Global Health Grand Rounds WITH GUEST LECTURER DR. LUKE MESSAC
Scarcity of resources severely impeded medical treatment of patients in Malawi prior to their independence in the 1960s
User fees were introduced on the day of independence, however significantly reduced patient volume at the local hospitals - the fees were renounced a few months later and Malawi has never implemented a user fee for healthcare again
Global health advocacy and increased global health spending in the later 1990s and throughout the early 2000s made it feasible for patients in South Africa to get affordable HIV therapies to combat high mortality rates
In the setting of COVID-19, several EDs and healthcare facilities have now been experiencing scarcity of resources in the US - we as physicians will need to continue to advocate for our patients to ensure we have the appropriate equipment and ability to care for the sick
R4 CASE FOLLOW UP WITH DR. MODI
Patient in his 20s that is intoxicated and presenting after falling from a 25 foot height. He presents with a GCS 3, reactive pupils, and no spontaneous movement on transport. Noted to be hypothermic, bradycardic, and hypoxic on ED presentation. He was intubated with etomidate and succinylcholine for airway protection and hypoxia. His secondary exam is notable for a scalp laceration with skull depression and deformity to the left wrist. FAST exam is negative. Head CT is notable for a subdural hematoma with 7mm midline shift, pneumocephalus, and depressed skull fractures. CT C-spine notable for C4-C5 fractures. Patient is taken to the OR emergently with neurosurgery.
Management of traumatic brain injury
Primary brain injury: direct damage from head trauma
Secondary brain injury: worsening of primary injury from systemic insults
Hypoxia, hypotension, anemia, hypercarbia, hyperpyrexia
Head of bed at 30 degrees - reduces intracranial pressure to reduce cerebral edema
Prevent hypotension - will decrease cerebral perfusion pressure and cause ischemia of brain tissue
Prevent hypoxia - can increase mortality by almost double (dose dependent)
Maintain normocarbia - hypercarbia leads to vasoconstriction, leading to decreased cerebral perfusion and risk of ischemia
Avoid anemia - apply direct pressure on scalp lacerations, address hemorrhage from other wounds
Avoid hyperpyrexia - increased metabolic stress
Does ketamine lead to increased ICP if used during induction for intubation?
Systematic review of 101 adult patients, 55 pediatric patients, ketamine does not increase ICP in severe TBI [Zeiler, 2014]
Systematic review of 127 adults, 87 pediatrics, ketamine does not increase ICP in non-traumatic neurological illness [Ziler, 2014]
Is 3% HTS or mannitol better for acutely lowering elevated ICP?
Meta-analysis of 438 patients there was no significant difference in HTS or mannitol as first-line for patients with elevated ICP caused by TBI
RCT of 120 patients with severe TBI, 3% HTS more effective than mannitol and mannitol/glycerol groups [Patil, 2019]
Do steroids assist in reducing edema?
RCT of >10,000 patients with head injury (GCS less than or equal to 14) noted that corticosteroid use in head injury leads to higher morality (21% vs 18%) without improved functional outcomes
In follow up the patient had a decompressive craniectomy with SDH evacuation, was discharged to rehab and several weeks post-injury, has complete recovery of the neurologic deficits and is being evaluated for his ability and safety to drive.
R1 Clinical Knowledge: DERMATOLOGIC EMERGENCIES WITH DR. DIAZ
Stevens Johnson Syndrome (SJS)/ Toxic Epidermal Necrolysis (TEN)
Severe mucocutaneous reactions with skin loss, mucosal loss, and systemic symptoms
SJS <10% Total Body Surface Area (TBSA) ; SJS/TEN overlap with 10-30% TBSA involvement; TEN >30% TBSA
Mortality increases with increased TBSA involvement
Type IV hypersensitivity reaction usually drug-induced
Anticonvulsants, allopurinol, antibiotics, immune-modulators, NSAIDs
Clinical presentation
Fever, malaise, URI followed by mucocutaneous involvement (oral > ocular > urogenital) usually 3 days - up to 8 weeks after inciting event
HIV is a risk factor itself + additional risk of HAART therapy
Management
Supportive care
Diagnosed with biopsy - requires dermatology consult early in course
Rocky Mountain Spotted Fever
Tick-borne, rickettsial rickettsia
Clinical presentation
Fever, headache, rash followed by a maculopapular rash around the wrists/ankles that progresses to disseminated petechiae
Influenza-like presentation in the summer
Treatment
Doxycycline for everyone - children and pregnant women included
Mortality of 20-30% reduced to 0.5% with antibiotics
Empirically treat if suspicion is high
Necrotizing Soft Tissue Infections
Fulminant tissue destruction, systemic signs of toxicity, and high mortality
Risk factors: penetrating trauma, recent surgery, immunosuppression, diabetes
Two types:
Polymicrobial (type I) - more common in older individuals with other comorbid conditions
Comprised of complex organisms
Monomicrobial (type II) - more commonly involves MRSA or Group A beta-hemolytic strep infections
Clinical presentation
Typically in extremities - erythema without sharp margins
Pain out of proportion to exam
+/- systemic illness
Evaluation
Labs are non-specific; plain radiographs with poor sensitivity - CT is typically a better imaging modality
LRINEC score >6 is concerning, but if suspicion is high regardless of score it should not decrease your pre-test suspicion
Treatment
Broad spectrum antibiotics + clindamycin for toxin-production
Surgical management is definitive therapy
R2 QI/KT NEONATAL RESUSCITATION WITH DRS. WINSLOW & ZALESKY
90% of neonates have a successful transition to the extra-uterine environment; 10% require minimal resuscitation; 1% require extensive resuscitation
Definitions
Preterm <37 weeks
Term 37-41 weeks
Postterm >42 weeks
Fetal Circulation
Blood flows from umbilical vein -> ductus venosis -> foramen ovale OR ductus arteriosis -> umbilical arteries.
At birth, baby breathes -> fluid in lungs is absorbed -> air fills lungs -> lung vasodilation.
Delayed cord clamping for 30-60s if infant and mother otherwise appear well
Decreased to no change in mortality at discharge
Decreased need for transfusion with higher hemoglobin levels in first 48 hours
Some evidence for decreased intraventricular hemorrhage, necrotizing enterocolitis
Elevated peak bili, no increased need for phototherapy
No maternal harm noted
Temperature regulation in neonates (36.5-37.5)
Neonates rely more on thermogenesis as they do not vasoconstrict or shiver in response to cold as much as adults
Large study including >23,000 neonates in Nepal demonstrated inverse relationship between initial axillary temperature obtained after birth and neonatal mortality
Can place patient in a plastic bag to achieve normothermia if other neonate-specific equipment is available
Amniotic fluid/meconium
No difference in mortality or intubation when performing routine suctioning versus no suctioning when delivered through meconium-stained fluid. If needed, perform it
Airway and ventilation
Suction only if airway is obviously obstructed by fluid - otherwise it can elicit a vagal response with reflex bradycardia
RCT of 140 term infants demonstrated that without suctioning the neonate, oxygen saturations rose higher faster with improved Apgar scores when compared to those with suctioning [Gungor]
If hypoxic, starting FiO2 at 21-30% and escalating had no adverse effects compared to starting FiO2 at 100% in neonate, and prevented the neonate from hyperoxia [Kapadia, 2013; Rook, 2014]
If hypoxic, CPAP level of 8 [Support, 2010; Dunn, 2011] with PEEP 5 [Szyld, 2014] was safe for neonates. Use of CPAP increases risk of pneumothorax, however no significant adverse outcomes with this pneumothoraces per the literature
If hypoxic, T-piece ventilator is the safest and most consistent way to deliver oxygen with less risk for increased peak airway pressures [Oddie, 2005] vs. ETT with ETCO2
Circulation
CPR
Ventilation - 3:1 compression to ventilation ratio with 100% FiO2 during compressions
EKG superior to palpation of pulse (which can be grossly inaccurate in both pediatrics and adults during a cardiac arrest) or pO2 [Kamlin, 2006]
Compression - lower ⅓ of sternum [Orlowski, 1968] with 2 thumb technique [Udassi, 2010]
Intravascular access
Umbilical vein cannulation
Remember - two arteries, one vein
Tie cord at the base of the umbilical cord with umbilical tape -> cut the cord for a fresh, clean end -> stabilize umbilical vein with forceps -> insert pre-flushed umbilical catheter to 3-4cm while aspirating for blood -> flush catheter with saline -> tegaderm to secure
IO - proximal tibia is preferred site, and this is placed quicker than umbilical vein catheter. However, unclear bioavailability of medications administered through IO for neonate
Peripheral IV
ET administration of epinephrine followed by positive-pressure ventilations to disseminate medication prior to resuming chest compressions
ET epinephrine (0.05 - 0.1mg/kg) vs IV epinephrine (0.01-0.03mg/kg)
Retrospective cohort of >110,000 births, 0.05% required epi
Higher total doses of epi if first dose was ET
Increased mortality in those who received ET epi
Other studies demonstrate that there is decreased bioavailability with ET epi versus IV epi
Volume resuscitation
Consider in neonates not responding to PPV, CPR, and epi
Retrospective cohort of 23 infants requiring CPR
13 received volume expansion (20ml/kg) for bradycardia (10) or hypovolemia (3)
Volume expansion group had lower MAPs, more acidotic, longer length of resus
Glucose
Risk factors for hypoglycemia - preterm birth, very low birth weight, maternal obesity/diabetes
Treat with 40% dextrose gel or IV D10 @ 2ml/kg
Goal glucose >45 - heel stick is the way to go!
WELLNESS CURRICULUM WITH DRS. LAURENCE, ROBLEE, SKROBUT & URBANOWICZ
“Health is a state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity” - WHO, 2013
Domains of happiness: PEMRA (positive emotions, engagement, meaning, relationships, accomplishment)
Positivity - focus on gratitude, savoring your “now,” and optimism
Be engaged with what you are doing and what commitments you have
