Grand Rounds Recap 12.14.22

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EMS Grand Rounds w/ Dr. Fisher

Updates in the 2023 SW OH Protocol

  • Prehospital Ketamine for Agitation

    • Background:

      • Prospective observational study showed faster time to sedation with 5mg IM ketamine (5 min) vs. 10 mg IM haloperidol (17 min)

        • Haldol patients required redosing

        • Intubation higher in ketamine group (39% ketamine vs 5% haloperidol)

      • Retrospective studies with mixed reviews, some with safe adverse effect profile, some with high rates of intubation (up to 23%) though could be confounded by additional sedatives given

      • Prospective study at Hennepin showed time to sedation was ~4 minutes, but with high intubation rate (57%), though may be influenced by practice pattern (one physician intubated 36% of patients)

      • Retrospective review examining 4 mg/kg vs 3 mg/kg found no difference in adverse events, but increase in staff assaults after decrease

      • Retrospective study looked at coingestions which may increase rate of intubation with ketamine sedation. Use of cocaine was associated with higher rates of intubation in this study.

      • 2022 systematic review of ketamine use 

        • Showed large variation of intubation rate, but most are happening in the hospital after arrival

        • Of all 3476 patients, 16% intubation rate

        • However, in these studies, a large proportion of intubations were performed by a handful of physicians and those practice patterns may skew data

      • Takeaway: if using prehospital ketamine for sedation, be prepared to manage the airway

    • Protocol

      • Must be 16 or older

      • Medically indicated restraint (when patient is danger to themselves or others)

      • Use least restrictive form of restraint possible

        • Verbal de-escalation

      • Physical restraints must be easily removable without a key. Secure to cot and not the ambulance

        • If PD puts on restraints, must come with the crew to adjust restraints as needed for patient safety

      • Patients should not be transported prone

      • Extremities and vitals should be frequently assessed

      • Chemical restraints may be used with or without physical restraints

        • Versed 10mg IM available

        • Ketamine 4mg/kg (IBW) can be used in place of versed

      • Chemical sedation requires cardiac monitor, pulse ox, EtCO2, addressing hypoxemia, hypoglycemia, and paramedic must be present

  • Other updates in the SW Protocol

  • Pain dose ketamine

    • Dose increased from 0.1 mg/kg IV/IO to 0.2 mg/kg IV/IO

    • Can also add to 100 mL and run it over 15 min

  • Push dose epinephrine in pediatrics

    • Dose 1mcg/kg of 10 mcg/ml solution every 2-5 minutes

  • Removal of adenosine from stable wide complex tachycardia protocol

  • Blood glucose treatment threshold changed from less than 70 to less than 60

    • For awake patients, they may take oral glucose

    • Emphasis to go to D10 instead of D50

  • Digoxin removed as contraindication for calcium administration for hyperkalemia

  • Refined refusal of transport protocol

    • If parent or guardian are not present, minor can be left in the care of a responsible adult (ie. minor school bus accident does not require all parents to show up and sign refusal for transport)

  • EMS are mandatory reporters of suspected child abuse or neglect and must report suspected abuse directly to state officials, and not just the receiving healthcare provider

R4 Simulation: aortic dissection w/ Drs. Zalesky, ijaz, and chuko

  • Case: 37 y/o M presenting for chest pain 

    • EKG with STEMI 

    • CXR with wide mediastinum and enlarged aortic knob 

    • High concern for aortic dissection

    • CTA

      • Type A dissection

  • Epidemiology

    • 3:100,000 person years

    • Risk factors

      • Known aneurysm

      • Family history

      • Hypertension

      • Old age 

      • Atherosclerosis

      •  Marfan Syndrome

      • Turner Syndrome

      • Ehlers-Danlos syndrome

      • bicuspid aortic valve

      • history of aneurysm or dissection repair

      • Cocaine use

  • Types

    • Stanford 

      • Type A: includes ascending aorta

      • Type B: only involves  descending aorta

    • Debakey

      • 1: entire aorta

      • 2: ascending aorta

      • 3: descending aorta 

  • Signs and Symptoms 

    • Pain in chest or back present in 90% of patients

    • Ischemic injuries can also cause other syndromes

      • abdominal pain

      • myocardial infarction

      • acute kidney injury

      • paraplegia

      • limb ischemia 

    • Blood pressure

      • Normotensive to hypertensive 

    • Pulse deficit

      • May only be present in 15-25% of patients 

  • Diagnostics

    • CXR can be normal in 10-15% of patients

    • CT angiography is the ED diagnostic study of choice

    • There are no validated tools to rule in or rule out aortic dissection

  • Treatment

    • Goals controlling blood pressure and heart rate, which decreases aortic wall pressure

      • titrated to a heart rate less than 60 bpm and a systolic blood pressure of 100 to 120 mmHg

      • Esmolol is the classic medication due to rate predominant effect and quick on - quick off halflife. 

        • Bolus of 500mcg/kg then drip of 50mcg/kg

      • Labetalol

        • 20mg IV bolus followed by 10mg to 80mg repeat boluses q10 mins. For a maximum dose of 300mg

      • Can also use CCB like nicardipine

        • 5mg/hour titrate by 2.5mg/hour to a max of 15mg/hour

      • Must control HR before adding vasodilator medications

    • If hypotensive, consider fluids and if needed, vasopressors (though vasopressors can increase wall stress on the aorta)

R3 Taming the SRU: anterior cord syndrome w/ Dr. Martella

Very Uncommon

  • 1.5% of all vascular neurologic pathologies annually

  • Many present with acute chest pain, back pain, shortness of breath and flaccid paralysis

Key to early recognition is a good neurological exam:

  • Primarily motor symptoms; flaccid paralysis, will have loss pain/temp sensation

  • Fine/light touch sensory exam preserved

  • Localized to just below the lesion

Identify Life Threatening Causes

  • 4% of anterior cord syndrome presentations are caused by aortic dissections

  • Additional causes: spinal cord ischemic infarctions, AVMs, vasculitis, disc herniation

MRI for Timely Diagnosis

  • There are various case reports of intra-arterial and IV tPA for ischemic spinal cord infarctions with good recovery

R4 Case Follow-Up: TUMOR LYsis syndrome w/ Dr. Winslow

Patient with CLL presenting with shortness of breath and fever

  • found to have WBC >170k, elevated uric acid and LDH, hyperkalemia, AKI, and peripheral smear showed blasts; concerning for spontaneous tumor lysis syndrome secondary to blast crisis

Pathophysiology of TLS: 

  • Lysis of tumor cells (either secondary to cytotoxic therapy or spontaneous)

  • Lysed cells release contents: potassium, purine nucleic acids (broken down to uric acid), phosphorus, and lactate

  • Hyperphosphatemia leads to chelation of calcium and resultant hypocalcemia; leads to deposition in the kidneys and resultant renal insufficiency

Spontaneous Tumor Lysis Syndrome (TLS)

  • Risk stratification of TLS by malignancy

    • Low

      • CLL, CML, peripheral lymphomas, Hodgkin lymphoma, solid tumor

    • Intermediate

      • AML with WBC > 25, CML on biologics, lymphoma with elevated LDH

    • High

      • ALL, AML with WBC > 25, Burkitt's Leukemia or Lymphoma, Plasma cell leukemia

  • Richter Transformation

    • Transformation of CLL (chronic lymphocytic leukemia) into more aggressive diffuse large B cell lymphoma

    • Typically driven by spontaneous mutation, transformation rate 0.5-1% per year

    • Clinically present with enlarging lymph nodes, hepatosplenomegaly

    • Poor prognosis, 10 month average survival from time of diagnosis

    • Rate of TLS – 1.08%

  • Complications of TLS

    • Uric acid and Calcium Phosphate deposition in renal tubules leads to acute kidney injury and acute renal failure

    • Kidney injury results in hyperkalemia, which can predispose to dysrhythmias

    • Other electrolyte derangements can lead to seizure, lethargy and altered mental status

  • Cairo-Bishop Classification

    • Laboratory TLS (>=2 of the following)

      • Uric acid >=8mg/dL or 25% increase from baseline

      • Potassium >=6 mmol/L or 25% increase from baseline

      • Phosphorus >=4.5 mg/dL or 25% increase from baseline (adults)

      • Calcium < 7mg/dL, or 25% decrease from baseline

    • Clinical TLS (>=1 of the following)

    • Creatinine > 1.5 times the upper limit of normal

    • Cardiac arrhythmia/sudden death

    • Seizure

  • Therapeutics

    • Hydration – goal UOP is 100cc/hr

      • Use non-potassium containing fluids

      • Can augment UOP with diuretics if needed

    • Do NOT treat asymptomatic hypocalcemia

      • Can result in increased calcium phosphate deposition

    • Oral phosphate binders can be used if patient is tolerating PO

      • If ARF or significant hyperkalemia - > dialysis

    • Rasburicase catalyzes breakdown of uric acid into allantoin, which is excreted in urine

      • Robust evidence to support lowering of plasma uric acid (PUA) levels

      • Single dose may be adequate for sustained decrease in PUA

      • Evidence for reduction in mortality and need for renal replacement therapy is mixed in adults, but good evidence exists in pediatrics

      • Treatment is expensive (~$14,000 for 70kg patient per dose)

    • Allopurinol is not effective for TLS, cannot improve pre-existing hyperuricemia

Pediatrics Lecture: Visual Diagnosis w/ Dr. Carron

Pathologies to look up and know:

  • HSV

  • Neonatal acne

  • Erythema toxicum (benign)

  • Transient neonatal pustular melanosis

    • Idiopathic benign condition of newborns present at birth characterized by vesicles, superficial pustules, and pigmented macules on the chin, neck, forehead, chest, buttocks, back, and, less often, on the palms and soles

  • Umbilical granuloma 

    • Common 2-4 weeks, sometimes friable/bloody, responds to silver nitrate, stays within borders of umbilicus

  • Umbilical polyp

    • Less friable/bloody, doesn’t respond to silver nitrate, pedunculated tissue that protrudes from umbilicus, part of gut tissue

  • Omphalitis

    • Foul smelling drainage, surrounding erythema, induration, tenderness often septic

    • Risk factors: PPROM, chorioamnionitis, home birth, nonsterile cord cutting, lotus birth

    • Mortality 7-15%

Common causes of red urine in newborns

  • Brick dust urine = Urate crystals from concentrated urine, normal <1 week

  • Pseudomenstruation

  • Circumcision

Summer penile swelling

  • “Lion’s mane penis”

  • Chigger bites to the penis

  • Soft and generally without significant tenderness

  • Treatment with oral antihistamine, cool compress

Conjunctivitis:

  • Kawasaki Disease

    • Bilateral conjunctivitis with limbic sparing

  • Viral conjunctivitis

    • Usually bilateral without limbic sparing

  • Bacterial conjunctivitis

    • Usually unilateral, with purulence

Pott’s Puffy Tumor

  • Osteomyelitis of frontal bone with subperiosteal abscess

  • Complication of bacterial rhinosinusitis

  • Tender swelling with fever, headache, vomiting, lethargy and photophobia

Dacryocystocele

  • Obstruction of lacrimal duct proximally and distally

  • Bluish swelling

  • Superior displacement of the medial canthus

  • Elective ophthalmology follow up

Acute hemorrhagic edema of infancy

  • Cutaneous small vessel vasculitis, possibly triggered by viral/bacterial infection, antibiotics, immunizations

  • Age 4-24 months

  • Triad: large purpura (extremities and face), edema (hands and feet), low grade fever

  • Resolves in 1-3 weeks

Seymour fracture - distal phalanx fracture involving growth plate, high rate of OM, mallet finger, nailbed injury; usually requires operative repair

Bucket handle fracture - metaphyseal fracture, concerning for NAT

C2 on C3 subluxation tolerable up to 2mm until age 7