Grand Rounds Recap 10.13.21
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Conflict Resolution with Drs. Leenellet and McDonough
Take time to plan and assess what you want out of a difficult conversation and where the other person is coming from. Think through the best and worst case scenarios, as well as the possible long-term fallout. Assess what your own visceral response to conflict is, and implement strategies to mitigate it:
Box breathing
Awareness of your physical posture (and how it affect your mood)
Pause to allow yourself and others to process the situation
Seek to understand the conflict from the perspective of each side, including:
The stance are they entering this conflict from
Each person’s interests
Concerns or bias that each side may bring to the conflict
Pressures that are affecting each person
The ultimate goal that each side would like to walk away with
Consider each person’s response type:
Flight responses (avoidance, silence, sarcasm, withdrawal) have a high risk of leading to conflict between what is said and the non-verbal cues that are given.
Accommodation responses may lead to short term solutions, but cause long term issues.
Fight or violent responses risk permanent damage to the relationship and may escalate the situation.
Compromise will require give and take from both sides.
Collaboration can lead to an ideal, win-win, outcome.
General principles of conflict resolution:
Reflect before you begin: Others don’t make you mad, the story that you tell yourself about their feedback/actions make you mad. Evaluate the story and where you started from.
Seek first to understand the other person’s perspective.
Invite the other person to the conversation.
Focus on the goal: you are not in it to win the argument, you are looking for a mutually satisfactory solution.
How to implement these strategies effectively:
Meet at a neutral location
Sit near the person and prevent the appearance of a power differential
Be open to discussion
Start with an assessment of the situation and then let them talk
Make the end goals clear before discussing solutions
Listen effectively and use open ended questions
Start with neutral facts then explain your feelings
Outline specific issues
Separate the person from the problem
R3 Taming the SRU: Postpartum Hemorrhage with Dr. Kimmel
Postpartum hemorrhage
≧ 1 L of blood loss or blood loss with signs of hypovolemia, regardless of the route
Primary - in the immediate 24 hours after delivery
Secondary - in the 12 weeks after delivery
Prevention during the third stage of labor
Pitocin 10ug IM at time of delivery of the anterior shoulder
Uterine massage
Umbilical cord traction
Etiology - The 4Ts
Tone (uterine atony) causes 70-80% of cases
Risk factors: prolonged labor, IOL, prolonged pitocin, chorioamnionitis, multiple gestations, polyhydramnios, uterine fibroids
Management: Empty the bladder, evacuate clots, perform uterine massage, tamponade devices, transfusion.
Medication management of postpartum hemorrhage:
Stage 1: Oxytocin 20 u/hr for 2 hours (10u IM if no access), can be increased to 40 u/hr. Methergine 0.2 mg IM and repeat dose at 2 hours if ongoing hemorrhage (contraindicated in hypertension)
Stage 2: Hemabate 0.25 mg IM q 15 min for up to 8 doses (contraindicated in asthma)
Stage 3: Tranexamic acid 1000 mg IV over 10 minutes, may repeat at 30 minutes
Bakri Balloon can facilitate tamponade. Ensure that traction is applied once inserted. The aspiration port can be used to assess for continued bleeding. A foley balloon or the gastric balloon of a Blakemore or Minnesota tube can be used if a Bakri Balloon is unavailable
Alternatively, the uterus can be packed from one cornu to the other to the cervical oz. Gauze can be tied together to prevent retained foreign body.
Trauma (lacerations)
Risk factors: precipitous/uncontrolled delivery, operative vaginal delivery
Management: Early identification of lacerations and repair of vulvar or perineal lacerations. Harder to detect cervical and higher vaginal lacerations that are often well vascularized. Consider IR or OR for embolization or repair in the event of uterine artery laceration.
Tissue (retained placenta)
Risk factors: manual removal of placenta, prior uterine surgery, risk for placenta accreta spectrum (increased with prior placenta previa or C-section)
Management: Thorough examination of placenta to look for abnormalities and manual exam of the uterus or BSUS. Attempt manual extraction.
Thrombin (coagulopathy)
Risk factors: placental abruption, amniotic fluid embolism, existing coagulopathies
Management: Transfuse as needed with focus on correcting coagulopathies. Cryoprecipitate is indicated if there is concern for DIC.
Transfusion:
Indicated if 1.5 L of blood loss or vital sign abnormalities
Start transfusion with 2 U pRBC, then proceed with 1:1:1 balanced transfusion. Consider MTP activation, and replace calcium.
R1 Clinical Knowledge: Toxic Gas Exposure with Dr. Chhabria
Toxic Gas: a gas which is capable of causing damage to living tissues, impairment of the central nervous system, severe illness, or in extreme cases, death when it is ingested, inhaled, or absorbed by the skin or the eyes (carbon monoxide, cyanide, hydrogen sulfide, hydrogen fluoride, chlorine, chloramine, ammonia, nitrogen oxides)
Asphyxiation: Condition of deficient supply of oxygen to the body that arises from abnormal breathing (argon, helium, nitrogen, methane, CO2)
Carbon monoxide:
Most common toxic gas exposure
Combustible source vs. noncombustible sources (hemolysis)
MOA: Hb has 218 fold greater affinity for CO than O2 and myoglobin has 60 fold higher affinity for CO than O2. Oxygen is displaced from hemoglobin, resulting in a leftward shift of the oxyhemoglobin dissociation curve, leading to increased affinity for O2 and relative tissue hypoxia.
Presentation:
Odorless, tasteless, colorless
Symptoms:
Mild (HbCO > 15%): Fatigue, headache, dizziness, confusion, nausea, vomiting
Moderate (HbCO > 30%): Ataxia, syncope, tachypnea, dyspnea, chest pain, rhabdomyolysis
Severe (HbCO > 50%): Hypotension, arrhythmia, myocardial ischemia, respiratory depression, coma, seizures
Diagnostics and Management:
Clinical diagnosis, but COHb level via spectrophotometry is the gold standard and SaO2 via pulse co-oximetry will be decreased
Treatment:
Largely supportive - remove from the environment, 100% FiO2 for 4-6 hours
Hyperbaric oxygen treatment can be considered if there is evidence of significant end organ damage, HbCO > 25%, pregnant with HbCO >15%, or neurologic changes are present
Goal is resolution of symptoms and HbCO <5%
Cyanide:
Source: inhalation (smoke), ingestion (sodium nitroprusside, cyanogenic glycosides in fruits), or skin absorption (industrial chemicals)
MOA: Cyanide binds Fe3+ in Complex IV, which inhibits the electron transport chain, leading to inhibited ATP production. The body then resorts to anaerobic glycolysis and lactic acidosis results. NMDA toxicity also occurs.
Presentation
Bitter almond scent is rare
Early: anxiety, headache, dizziness, confusion, mydriasis, bright retinal veins, hyperventilation, tachypnea, tachycardia
Late: decreased consciousness, seizures, paralysis, coma, hypoventilation, apnea, hypotension, arrhythmia
Diagnosis is largely clinical, but serum chemistry, lactate, and blood gasses can support the diagnosis
Treatment:
Decontamination
Supportive Care: 100% O2, activated charcoal if warranted
Hydroxycobolamin binds with CN, forming cyanocobalamin (vitamin B12)
Adult dosing: 5 g IV over 15 minutes
Pediatric dosing: 70 mg/kg up to 5 g IV over 15 minutes
Adverse events: allergic reaction; transient discoloration of skin, mucous membranes, urine, and secretions; increased in BP; renal injury
Sodium nitrite induces methemoglobinemia which avidly binds CN, preventing further binding to cytochrome oxidase
Adult dose: 300 mg IV over 2–4 minutes
Pediatric dose: 6 mg/kg u300 mg) IV over 2–4 minutes
Adverse events: excessive methemoglobinemia, vasodilation
Sodium thiosulfate increases enzymatic conversion of CN to plasma thiocyanate that is excreted in urine
Adult dose: 12.5 g IV over 10 to 30 min
Pediatric dose: 250 mg/kg up to 12.5 g IV over 10 to 30 min
Hydrogen Sulfide:
Source: often industrial (oil/gas), natural (volcanos, hot springs), cleaning products, sewers, wells
MOA: Inhibition of cytochrome oxidase/ETC; central uptake can lead to apnea
Presentation
Rotten egg odor
Similar to presentation of patients with cyanide poisoning plus corneal ulcerations, pharyngitis, nausea, vomiting, hemoptysis
Early: anxiety, headache, dizziness, confusion, mydriasis, bright retinal veins, hyperventilation, tachypnea, tachycardia
Late: Decreased consciousness, seizures, paralysis, coma, hypoventilation, apnea, hypotension, arrhythmias
Knockdown effect: sudden LOC with high concentrations
Diagnostics and Management
Clinical diagnosis, but urine metabolites may be present in chronic exposure
Adjuncts: chemistry, lactate, VBG
Treatment:
Supportive care and sodium nitrate as above for cyanide toxicity
Hydrogen Fluoride:
Source: Refrigerants, herbicides, pharmaceuticals, gasoline, electrical components, fluorescent lights, industrial etching glass or metal
MOA: Fluoride ions bind intracellular calcium and magnesium leading to liquefactive necrosis and systemic electrolyte disturbances
Presentation: eye irritation, airway irritation, dyspnea, pulmonary edema, ARDS, pulmonary hemorrhage
Diagnosis is clinical
Treatment:
Decontamination
Supportive care
Calcium gluconate (IV and nebulized)
Take Home Points
Use clinical presentation to determine possible exposure
Decontaminate
Provide supportive care and stabilize the patient
Contact poison control
Manage appropriately once inciting agent identified
Pediatric Emergency Medicine: Trauma with The PEM Fellows
Children are not small adults:
Different anatomy yields different injury patterns
Children have less stable cervical spines and less rigid bones
Airway considerations:
Disproportion between the cranium and midface, combined with a large occiput causes passive neck flexion that can be remedied by sniffing position.
Relatively large tongue and tonsils can cause obstruction that may benefit from an airway adjunct.
Superior larynx and vocal cords increase risk of deep intubation. ETT depth = [Age (in years) / 2] + 12
Cricothyroid membrane is not easily palpable in children < 12 y/o
Breathing Considerations:
Respiratory rate decreases with age
If using BVM, avoid excessive volume or pressure
Use appropriately sized chest tubes per the Broselow tape
Circulation considerations:
Vitals vary with age
Children have increased physiologic reserve and can maintain MAP in loss of up to 30% of blood volume.
Tachycardia may be the only vital sign abnormality in a significant hemorrhage
The ratio of body surface area to body mass is highest after birth, so younger children are more sensitive to burns or hypothermia
Disability Considerations:
Note that there are differences in how GCS is evaluated based on age and a child's abilities. Use the pediatric GCS scale
The trajectory of the GCS is more important that any single number
Blunt head trauma: the PECARN Head CT Rule can be used to risk stratify children who are safe for discharge, require observation, or should receive a head CT
C-spine Trauma:
The younger the child is, the higher the fulcrum level of their cervical spine, leading to a higher likelihood of high C-spine injury. Additionally children have greater ligamentous flexibility that increases the risk of SCIWORA, as vertebrae have more room to shift.
NEXUS rule is for all patients >1 year of age, but a very small proportion of the included patients were less than 8 years of age.
Blunt thoracic trauma:
Increased compliance of the chest wall makes pulmonary contusion more likely than rib fractures.
Diaphragmatic rupture, aortic transection, major tracheobronchial tears, flail chest, cardiac contusions are rare.
Blunt abdominal trauma: Shock in traumatically injured children is most likely due to abdominal trauma. Clinical exam and laboratory studies (ALT, lipase) can be used to risk stratify patients who may need cross-sectional imaging. No decision rule adequately predicts or rules out significant abdominal trauma.
Extremity injuries: Growth plates are the most common site of fracture
