Grand Rounds Recap 9.11.19

Centor Criteria WITH Drs. Habib and Winslow

  • For additional information about testing for streptococcal pharyngitis, see Dr. Winslow’s post

  • Modified Centor Criteria

    • Fever (+1 pt)

    • Absence of cough (+1 pt)

    • Tender anterior cervical lymphadenopathy (+1 pt)

    • Tonsillar exudates (+1 pt)

    • Age

      • 3-15 years (+1 pt)

      • >= 45 years (-1 pt)

  • There are conflicting guidelines on the management of patients with Centor scores > 3, which are summarized in the image in the post above

  • Treatment:

    • Benzathine penicillin G - expensive, but single injection in the ED

    • PO penicillin is much cheaper

    • In penicillin allergic patients, can use cephalosporins, clindamycin, and macrolides

    • Treat symptomatically with analgesia and consider steroids

  • Streptococcal pharyngitis mimics:

    • Retropharyngeal abscess

    • Ludwig’s angina

    • Lemierre’s disease

    • Epiglottitis

    • Acute HIV

    • Mononucleosis

    • Gonococcal pharyngitis

  • Rapid Antigen Detection Testing

    • Spectrum bias - the tests’s sensitivity is affected by the Centor score

    • Send throat culture if immunocompromised

  • Benefits of treatment:

    • Decreased symptom duration (12-16 hrs)

    • Reduced suppurative complications, such as peritonsillar abscess

    • No reduction in post-streptococcal glomerulonephritis

    • Unclear if there is reduced risk of rheumatic heart disease

TTP WITH Dr. Walsh

  • Microangiopathic hemolytic anemia includes:

    • TTP/HUS

    • DIC

    • HELLP

    • HIT

Acquired TTP

  • Auto-antiboties to ADAMTS13 cause platelet aggregation and micro-ischemia resulting in hemolysis and thrombocytopenia

  • Occurs in 3/1,000,000 patients

  • More common in women (75%)

  • More common in African Americans

  • Causes:

    • Pregnancy

    • Infection

    • Medications including quinolones, ticlodipine, and clopidogrel

  • 90% mortality if untreated

  • Natural history

    • Neurologic dysfunction

    • Cardiac ischemia

    • Renal failure

    • Death

  • Incidence of signs or symptoms:

    • Thrombocytopenia: 96%

    • Anemia (hematocrit < 30): 97%

    • Gastrointestinal symptoms: 69%

    • AKI: 53%

    • Weakness: 41%

    • Major neurologic finding: 41%

    • Minor neurologic finding: 26%

    • Bleeding: 35%

  • Elevated troponin and cardiac complications portend much poorer outcomes

  • PLASMIC Score:

    • Components

      • Thrombocytopenia

      • Hemolysis

      • Active cancer

      • History of solid-organ or stem-cell transplant

      • MCV < 90 fL

      • INR < 1.5

      • Creatinine < 2

    • Scores > 5 indicate significantly higher risk for having TTP

  • Treatment:

    • Plasma exchange

    • Steroids

    • Rituximab may be indicated to special situations

  • For a more in-depth review of TTP check out this Annals of B Pod Article from earlier this year

R4 Case Follow Up WITH Dr. Nagle


  •  ADA Guidelines

    • Resuscitation with normal saline - which has largely been debunked in the literature

    • Correction of potassium

    • Initiation of insulin therapy, without bolus

  • Providers may need to deviate from these guidelines for severely ill DKA patients

Airway Management

  • Intubation through iGel blind success rate: 70-80%

Family Presence during Resuscitation

  • Literature

    • No change in outcomes whether family is present during cardiac arrest resuscitation

    • Benefits for decreasing rates of stress and PTSD for staff

    • Increased rates of acceptance and decreased rates of PTSD for family

    • No change in medicolegal outcomes

  • How to facilitate this:

    • Patient in cardiac arrest with expected poor outcome

    • Ensure team member comfort

    • Update family members and assess appropriateness

    • Patient and room prepped

    • Use clear statements

Access to Medications

  • DKA: costs $5.1 billion annually for ED costs

  • DM: costs $327 billion annually

  • Insulin costs have increased 252% over the last decade

Controversies in Cardiac Arrest Management WITH Dr. Hogan

  • More than 356,000 out of hospital cardiac arrests annually

  • Less than 11% OHCA survive to hospital discharge

  • Key principles in ACLS:

    • Perform high-quality CPR

    • Identify shockable rhythms

    • Identify and correct reversible causes of arrest


    • Endogenous opioids may have a cardiodepressant effect

    • Naloxone may prolong AP refractory period and be anti-arrhythmogenic

    • Naloxone may also release endogenous catecholamines

    • Saybolt 2010: naloxone led to a rhythm change in cardiac arrest in 13 of 36 patients

      • All responders got at least 1 other treatment

      • Not all rhythm changes were good

    • Most of the biochemical mechanisms, though, are theoretical and unproven

    • Bottom line: standard measures should take priority over naloxone with no recommendations specifically for opioid-induced cardiac arrest


    • Neutralizes acidosis in cardiac arrest

    • Vukmir 2006: a subgroup of patients with cardiac arrest > 15 minutes had trend toward higher ROSC

    • Can overshoot physiologic parameters quickly, including worsening alkalosis and hyperosmolality

    • Kim 2016: more ROSC @ 20 minutes with bicarb administration

    • Chen 2018: blood gas analysis-guided bicarb administration leads to higher survival

    • Ahn 2018: no difference in outcomes, but increase in pH and bicarb with sodium bicarbonate adminsitration and increased bagging

    • Many retrospective reviews showing no benefit and possible harm, including increased mortality, worsening neurologic outcomes

    • AHA guidelines: routine use is not recommended but can be considered in special situations, such as TCA overdose and hyperkalemia

      • Dose is 1 mL/kg of 8.4% NaHCO3 (1 mEq/mL), which is postulated to raise pH by 0.1 to 0.15


    • Uses

      • Position of the tube

      • Quality of chest compressions

      • Return of spontaneous circulation - jump of 10 mmHg or absolute increase over 40 mmHg

      • Strategy for further treatment

      • Termination of resuscitation

    • Don’t let a high EtCO2 prevent you from terminating a resuscitation in the appropriate clinical scenario

Pediatric Simulation and Oral Boards

Oral Boards 1

  • The patient is a 3yo M with three days of sore throat, drooling, and decreasing neck ROM. Febrile with decreased PO intake. No voice changes, vomiting, cough, rhinorrhea. Fully vaccinated. Exam with pain with extension of neck.

  • Dx: PTA

  • Obtain lateral neck x-ray and look for prevertebral widening

  • Keep the patient calm and minimize external stimuli

  • This is much more insidious progression than epiglottis, but consider managing the airway prior to transfer depending on the clinical scenario

Oral Boards 2

  • The patient is a 17yo M with history of sickle cell disease presenting with chest pain and shoulder pain. He is tachypneic, hypoxic, with decreased breath sounds and rales in the L base.

  • Dx: Acute chest syndrome

  • Obtain a CXR in all patients with a history of sickle cell disease presenting with symptoms consistent with acute chest syndrome

  • Treatment: ceftriaxone, azithromycin, exchange transfusion

  • Fluids: if no signs of dehydration, start on maintenance IVF

    • Bolus only indicated if septic or signs of severe dehydration

Simulation: Post T&A Bleed

  • The incidence of bleeding from the adenoids is extremely low

  • Classic time frame for a tonsillar bleed is 8 days post-operative

  • Options to control hemorrhage:

    • Tonsillar sponges soaked in epinephrine or TXA

    • Silver nitrate

    • Nebulized versus systemic TXA

    • Surgical exploration

  • Can use laryngoscope handle as tongue depressor and a light to get better visualization of the bleeding

  • Try to avoid intubation in hemorrhagic shock

    • If forced to act, consider doing an awake look without paralysis

  • The blood volume for a child is 80 cc/kg, so can use this as a guide for how much blood a younger patient has lost

  • PRBC transfusion volume typically starts at 10-20 cc/kg

    • Give plasma after 40 cc/kg PRBC