Grand Rounds Recap 11.9.16

Oral Boards

Case 1

Supraventricular tachycardia (SVT) by wikimedia

Supraventricular tachycardia (SVT) by wikimedia

50 year old male with history of a “fast heart rate”, off all medications, presenting with tachycardia to range of 160, stable blood pressure.  Normal labs, clear CXR. EKG shows SVT.  

  • Cardioversion for unstable SVT
    • Hypotension, mental status changes
    • Also consider signs of end organ ischemia
      • Consider chest pain alone as an indication for electricity

Case 2

67 year old male, weak and dizzy after vomiting blood and having bloody bowel movement. History of AAA s/p repair.  Hypotensive, tachycardic, diaphoretic, pallor, febrile.  

  • Infected graft.  Consider antibiotics for febrile patient with repaired AAA that is hypotensive.  

Case 3

41 year old female, headache, blurred vision, pregnant at 37 weeks, BP 180/99, HR 110.  Progresses to seizure.

  • Eclampsia

Tips on playing the game of oral boards:

  • Be aggressive up front with your evaluation and treatment in oral boards.  
  • Consult your standard reference text for dosage if you aren’t positive what the dose is.  You’ll get scored down by saying the wrong dose as opposed to neutral for consulting.  
  • Re-assess your patient after any change in clinical presentation to identify any further actions that are needed.  
  • Introduce yourself to the patient and family.
  • If something in the patient presentation changes, step back and re-address ABC’s, IV, O2, Monitor

ED Simulation Session

Simulation #1

Patient with history of factor V leiden, on xarelto.  Fell off roof, arrives confused, cephalohematoma.  Patient’s brother had been trached and paralyzed, patient’s wife reports patient had expressed he would not want to “live on the ventilator”.  

  • This simulation provided vigorous discussion about patient and family centered communication in the emergency department.  Certainly challenging, particularly in a high-volume/high-acuity location like the SRU.  Even so, if family is present keep in mind to update and involve them in any major decisions.
  • The presented patient in this case was of young age and previously healthy.  Consider how to address the potentially reversible nature of his injury with the risk of resulting in vegetative state when discussing with patient’s family.

Simulation #2

Patient with chronic ETOH, ESLD, on rifaximin, lactulose, COPD on chronic home O2, arrives tachycardic, hypotensive, hypoxic.  

  • In contrast to the previously healthy patient, a patient with chronic illness and family members of differing acceptance of its implication.  Find common ground of understanding and express to the family what you are inferring from their actions and statements to ensure understanding before continuing with further discussion re: code status, procedures, etc.

Taming the SRU with Dr. Lagasse

GSW to left flank, middle aged male, GCS 15, primary exam negative, secondary with gunshot wound to flank, FAST adequate and negative.  History somewhat evasive, wound to liver and patient transported to OR.  Later that day same transport team bringing middle aged female who was found unresponsive lying on top of a gun, empty drug bottles found nearby, presumed intentional overdose.  Intubated pre-hospital, not much history available.  Placed on monitor and found to be hypotensive and bradycardia, sinus bradycardia on EKG with prolonged QTc.  

Sinus Bradycardia - via wikimedia -

Sinus Bradycardia - via wikimedia -

  • crystalloid, magnesium, intralipid, insulin
  • admitted to hospital and had transvenous pacemaker
  • able to be d/c on HD4

Beta Blocker Overdose

  • 5th most commonly prescribed drug class
  • Over 10,000 calls to poison control for isolated beta blocker poisoning, much higher numbers when considering multiple ingestion
  • Variable in individual properties
    • lipid vs water soluble
    • Some can have class I sodium channel blockade (propranolol)
  • Can lead to cardiogenic shock with bradycardia, hypotension, negative inotropy
  • EKG can have PR prolongation, can get QRS widening if Class I activity
  • Treatment Options
    • supportive care
      • IVF (goal for adequate preload)
        • caution for over-administration and subsequent pulmonary edema
      • Intubation
        • think about post-procedure sedation (avoid propofol, dexmedetomidine)
        • consider ketamine
      • Pressors
        • levophed or epinephrine recommended
      • Atropine, bicarb, and calcium
        • consider checking ionized calcium
    • glucagon
      • increases cAMP which increases inotropy and chronotropy
        • maximum chronotrophic response occurs in presence of normal ionized calcium
      • dosing
        • bolus: 2-12 mg q5-10 minutes, titrating
        • infusion: 2-10 mg/hr, titrating
      • high incidence of vomiting
      • very expensive
      • cumbersome to prepare, comes in 1 mg vials
    • euglycemic high-dose insulin
      • enables cardiac cells to metabolize carbohydrates and improves myocardial contractility and vasomotor tone
      • dosing
        • bolus: 1 unit/kg
        • infusion: 1-10 units/kg/hr, titrate
        • warning: serum potassium, do not start if hypokalemic until you are replacing
        • load with dextrose unless blood sugar is >400
    • IV lipid emulsion therapy
      • mechanism not certain, consider “lipid sink” theory vs free fatty acid overload for cardiac metabolism
      • dosing: no standardized dosing
        • protocol at UCMC is bolus 1.5 ml/kg bolus of 20% IFE over 30-60 minutes
          • follow with infusion of 0.25 ml/kg/min over 30-60 minutes
        • warning: this is considered off label use
      • Stored in ED pharmacy and central pharmacy
      • Reported adverse effects
        • acute pancreatitis
        • asystole and ARDS in case reports of patients receiving IFE
      • consider in cases refractory to pharmacotherapy
      • Pacing: ventricular capture can be unpredictable
      • Place a MAC for central access to permit pacemaker insertion if needed
    • Goal is to restore myocardial conduction and contractility to maintain adequate end organ perfusion

Pediatric Emergency Medicine: Pediatric Procedural Sedation with Dr. Lee

Case 1: Infant with unreduced inguinal hernia, 2 month old ex full term

  • ask yourself the question, do you want analgesia or sedation?
  • medications for infants
    • fentanyl, 1-2 mcg/kg/dose, administer 3 minutes before the procedure (max 50 mcg), may repeat 1/2 original dose every 3-5 minutes if necessary
    • midazolam: individualize dosing
    • ketamine: <3 month old contraindication
    • propofol: variable clearance and potential for subsequent adverse events
    • dexmedetomidine: insufficient experience
  • Keep in mind the exponential decrease in airway patency with infants as compared to adults when considering your airway management plans
    • Congenital abnormalities can alter your plans as well (laryngomalacia, retrognathia, etc)

Case 2: 14 year old boy with CP, tracheostomy and vent dependence, falls in PT, left posterior hip dislocation with alteration in distal perfusion.

Special populations in pediatric ASA classifications

  • Premature infants 
    • Risk factor issues with sedation, even later in life
    • Admit after sedation, can have respiratory compromise up to 24 hours after
  • <6 month old infants
    • Higher risk in propofol sedation
  • Developmentally delayed
    • Study found independent risk factor for complications of sedation with fentanyl in MRI
  • Congenital heart disease
    • Lesion and surgical stage dependent
    • Careful consideration of shunts, changes in oxygenation and ventilation can greatly affect this

Case 3: 13 year old girl with ALL, falls in basketball game, presents with post-traumatic seizure and anterior shoulder dislocation.

Ketamine in pediatrics

  • For airway and respiratory adverse events independent risk factors found to be (outcomes of stridor, apnea, desaturation):
    • <2 years old
    • >13 years old
    • concomitant anticholinergic
    • concomitant benzodiazepine
    • high IV dose >2.5 mg/kg initial or >5 mg/kg total
  • Predictors of emesis and recovery agitation (meta-analysis)
    • emesis 8.4%
      • predictors found to be increasing age, IM route, high IV dose
    • any emergence reaction 7.6%, clinically important emergence reaction of 1.2%
      • high IV dose (loading or total dose) predictor for emergence reaction
  • Updated clinical practice guideline shows ketamine does not lower seizure threshold, may actually have some beneficial anti-epileptic effects
  • For ICP increases in ketamine, if patient has intact CSF flow mechanism should not have high risk or concerns.  Patients with hydrocephalus and no CSF flow mechanism are at risk.

- Consider safety in sedation, anticipate need for neurologic monitoring and definitive imaging

Case 4: Toddler with an abscess

3 year old fully immunized girl with significant eczema with concern for fussiness, found to have large abscess.  NPO status <10 minutes. 

  • Consider topical anesthetics and local infiltration in addition to sedation, may assist with less sedation needed due to lower stimulus during procedure
    • Pediatric local anesthesia tips
      • don’t allow child to see the needle
      • warm it
      • buffer it
      • small needle
      • inject slowly
      • rub skin around the injection site before infiltration
  • NPO evidence
    • Length of NPO status does not seem to pan out in terms of risk for emesis in emergency medicine
  • Current sedation policies at CCHMC are directed through the department of anesthesia, recommending NPO status ranging from 2-8 hours (clear liquids -> solids).