Grand Rounds Recap 9.11.19
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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
DKA
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
Naloxone
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
Bicarbonate
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
ETCO2
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
