Grand Rounds Recap 11.8.23

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airway grand rounds WITH dr. carleton

  • Difficult airway algorithm: when should we RSI?

    • When you are forced to act immediately 

    • When reoxygenation and intubation is likely to be successful and a patient is able to tolerate a period of apnea (is not likely to become profoundly hypoxic nor hypercarbic) 

  • How to perform a successful awake look intubation when RSI not indicated:

    • Preparation 

      • Optimize patient positioning and other characteristics prior to an attempt. 

    • Physiologic optimization 

      • Mitigate adverse effects of underlying illness and sedatives

      • Consider fluid boluses and pressors. If refractory hypotension, will need to consider awake look intubation. 

    • Preoxygenation

      • Standard: NRB with apneic oxygenation, sit upright 

      • Tough to preox: BiPAP/HFNC, DSI, BVM through apneic period 

      • Cannot preox: awake intubation 

    • Pharmacology 

      • Sedative: weight risks and benefits of sedative with patient’s physiology 

      • Topicalization: both topical lidocaine ointment and nebulized/atomized aqueous lidocaine 

    • Endoscopic intubation

      • Difficult skill because of lack of practice. Diagnostic naso/oropharyngoscopy is a great way to learn the skill. 

      • Consider preloading the tube either in the nare or into the William’s airway in the mouth. 

      • Jaw thrust will open the posterior oropharynx and clear secretions to improve visualization. 

    • Prevention of hypoxia 

      • Use adequate preoxygenation and procedural oxygenation. Consider using HFNC during an endoscopic awake look.

r1 clinical knowledge: Heavy metals WITH dr. boyer

  • Heavy metals can be found all around us, from environmental sources to everyday items. 

  • Presentations can vary widely depending on the metal and route, therefore HPI will be most helpful for diagnosis. 

  • The most important treatment is to remove the toxic source, whether that be through removal from the environment, external or whole bowel irrigation, or surgery. 

  • Chelation is reserved for cases of end-organ damage or life threats, but should be initiated as quickly as possible to be most effective.

consultant corner: acute leukemia WITH dr. curran

  •  The diagnosis of acute leukemia is almost never a medical emergency. The time from diagnosis to treatment does not affect outcomes in patients with AML. However, complications of AML (including possible complications present at time of diagnosis) can be.

  • Workup:

    • CBC with differential

    • Peripheral smear

    • CMP 

    • LDH 

    • Uric acid 

    • Coags 

    • Close follow up with bone marrow biopsy (can be done outpatient)

    • Immunophenotyping, cytogenics, and molecular mutation testing will also be performed in clinic and will yield appropriate management

  • Complications of acute leukemia

    • Leukostasis

      • Can be seen in WBC 50-100k.

      • Leukocytes release cytokines and other products that lead to small vessel occlusion.

        • Most common in AML due to their cytokine release.

      • Presentation

        • Dyspnea (most common)

        • Headache, dizziness, confusion

        • MI

        • Renal dysfunction

      • Treatment

        • Leukapheresis (although data on this is very limited)

    • Tumor lysis syndrome

      • More common with lymphoid diseases (DLBCL, ALL, CLL) 

      • Can happen spontaneously or after treatment of malignancy (to include both steroids and chemotherapy) 

      • Diagnosis 

        • Elevated uric acid 

        • Hyperkalemia 

        • Hyperphosphatemia 

        • Hypocalcemia 

      • Treatment 

        • IVF resuscitation 

        • Rasburicase if elevated uric acid (to prevent nephropathy) 

        • Treat all associated electrolyte abnormalities 

    • APML

      • Most often patients present in DIC 

      • Diagnosis

        • CBC with diff with pancytopenia

        • Peripheral smear 

        • Coags consistent with DIC 

      • Management

        • Administer ATRA (all-trans retinoic acid)

        • Call heme/onc

pediatric simulation: DKA WITH our cchmc colleagues

  • Presentation can be vague, therefore one must have a high index of suspicion. Abdominal pain, nausea, vomiting, and dehydration are common. 

  • Management 

    • IVF resuscitation: will want to give at least 20 cc/kg bolus, however there has been some discussion about doing this in two 10 cc/kg boluses to avoid cerebral edema (as noted below, recent evidence has not supported this). 

    • Insulin: continue drip at 0.1 u/kg/hr and adjust dextrose as needed above until the gap closes. 

    • Dextrose: will need to closely monitor glucose while providing insulin. 

      • CCHMC two bag system: helps balance between dextrose and non-dextrose containing fluids. Run fluids at approximately 1.5-2x maintenance IVF. 

      • Glucose < 200 - 250 → add dextrose (D5 or D10 depending on rate of glucose drop) 

    • Potassium repletion 

      • K > 6.0: no potassium 

      • K 4.0 - 6.0 : given 40 (half KPhos and KCl)

      • K < 4.0: given 60 (half KPhos and KCl)

      • K < 2.5: consider repleting prior to starting insulin 

  • Complications 

    • Cerebral edema: recent data do not support that IVF resuscitation does not directly lead to cerebral edema. While we are often cautious with IVF, volume and rate of fluid administration does not cause cerebral edema.

pediatric AIRWAYS WITH our cchmc colleagues

  • Neonate 

    • Positive pressure ventilation is key in neonates 

    • If ventilation is not improving oxygenation, first reposition the mask and optimize patient positioning with a shoulder roll to align the axis 

    • Use your pediatric resources to help prepare sizing and dosing in neonates and children 

      • ETT sizing rule of thumb for neonates: Gestational age x 10 = ETT size 

  • Infants

    • Sudden onset stridor = foreign body until proven otherwise 

    • McGill forceps will be best tool for retrieving a foreign body 

    • If foreign body is seen below the cords, may have to right mainstem the ETT to advance the FB and later perform bronchoscopy to remove.

pediatric EKGS WITH our cchmc colleagues

  • Normal age related changes seen on pediatric EKGs:

    • RV strain pattern

    • Sinus arrhythmia

    • Shorter PR and QRS intervals

    • Slightly peaked P waves

    • Prolonged QTC

    • Q waves in inferior and precordial leads

  • Abnormal findings

    • Complete heart block: think about metabolic, infectious (Lyme), structural/post-op changes, CHD

    • Wide QRS complex: WPW, electrolyte abnormalities

    • RVH: Pulmonic valves stenosis, tetralogy of fallot, primary pulmonary HTN

    • LVH: aortic stenosis, coarctation of the aorta

    • RBBB: common after congenital heart disease surgical repair

    • Prolonged QT: congenital vs acquired

    • ST elevation: rarely ischemic but can represent ALCAPA or coronary aneurysms (untreated Kawasaki)

    • ST depression: pericarditis

    • Q waves: in I/aVL could represent ALCAPA, with syncope could be HOCM

    • Brugada: coved ST segments in V1-V2 and/or saddle back ST in V1-V2