CED

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CED stands for Clinical Event Debriefing. I am sure most of you are aware of these sessions taking place in the north/south side. These discussions are geared towards learning from a clinical case to ultimately improve patient care. Despite the fast-paced and high-volume ED where we practice it is possible to take 5 minutes to debrief a clinical case, if you follow these simple steps:

  1. Introduction:

- explain that this discussion is only going to take 5-10 minutes

- explain that this is a safe environment and that all participants will be treated with respect

- give all participants permission to leave (if they have a sick patient, a new patient, etc)

  1. Names and Roles
  2. Case Summary (provided by the team leader)
  3. +/delta

- Start with the positives! What went well? (i.e. closed loop communication, role assignment,

tone/volume, etc)

- How can we improve? (i.e. teamwork, systems, safety, etc)

  1. Develop solutions
  2. Closing Summary

What NOT to do:

https://www.youtube.com/watch?v=-aoTW420tBs

What to do:

https://www.youtube.com/watch?v=CUvrjOAEMWw

Happy debriefing!

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CCB Toxicity

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  • CCBs are divided into 2 groups:

    • Non-Dihydropyridines (Verapamil and Diltiazem) à cause a pup (heart) problem
    • Dihydropyridines (Amlodipine, Felodipine, Nifedapine, Nimodipine and Lercanidipine)à cause a pipe (vasoplegic) problem
    • However, in large overdoses receptor selectivity can be lost and the dihydropyridines can cause cariogenic shock.

 

  • Ingestion of >10 tablets of verapamil or diltiazem XR can cause life-threatening toxicity.
  • Effects are usually seen within 2 hours following standard preparations but can be delayed up to 16 hours with XR preparations.
  • Early signs of toxicity includes a rising glucose (patients are in a drug induced hypoinsulinaemic state) and lactate.
  • Typical signs include bradycardia, heart blocks and hypotension. If left untreated they can develop refractory shock and die.

Management of CCB overdose:

  1. As always, follow ABC. Intubate if the airway is compromised. However, it is important to remember to start at a 10th of your usual induction dose + push dose pressors prior to intubation if the patient is hypotensive
  2. High dose insulin is the antidote of choice. Early administration of High Dose Insulin 1unit/kg IV bolus and dextrose 50ml of 50% dextrose (paediatrics 5ml/kg of 10% dextrose to a max of 250ml). Followed by an infusion of insulin at 1 unit/kg/hour IV and a dextrose infusion. Some patients may not require additional dextrose early in the management. This will take 30-45 minutes to start working and therefore you will need other measures to manage the hypotension.
  3. Hypotension:
  4. Calcium gluconate and atropine. However, both of these agents are unlikely to work.
  5. A vasopressor such as norepinephrine will be the most effective. Start it peripherally until you get central access
  6. Ventricular pacing rarely works but in severe cases ECMO and intra-aortic ballon pump maybe considered.
  7. Decontamination:
  8. Charcoal to those who present within 1 hour of standard preparation or 4 hours for XR preparations. Whole bowel irrigation can be considered in patients who present within 4 hours of an XR preparation of 10 or more diltiazem or verapamil tablets.

Sources:

Life in the Fastlane, UpToDate

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Epiglottitis

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-       Epiglottitis is an acute inflammation of the epiglottis and other supraglottic structures that can lead to airway obstruction -       Is a true airway emergency

-       Haemophilus influenzae used to be the most common pathogen prior to the development of the Hib vaccine. Now, common pathogens include Streptococcus pneumoniae, Staphylococcus aureus, and beta-hemolytic streptococci.

-       Due to immunizations against Haemophilus influenzae serotype b, epiglottitis has decreased in the pediatric population and is now more commonly seen between 30-50 years of age

-       The most common chief complaint is Sore throat

Physical Exam

-       Toxic-appearing, febrile, tachypneic, tachycardic, inspiratory stridor, muffled voice, drooling, anterior neck tenderness (hyoid bone)

Imaging

-       Laryngoscopy is the most accurate method to establish the diagnosis

-       Lateral soft-tissue radiograph of the neck is 88% sensitive. Image findings include a swollen epiglottis termed “thumb sign”. Absence of the “thumb sign” does not exclude the diagnosis

Evaluation and Management

-       Diagnosis is clinical and confirmed with laryngoscopy.

-       Early ENT consultation

-       Patient should remain in a position of comfort. Avoid agitation as it may precipitate airway obstruction

-       If respiratory distress or stridor is present, prepare for intubation.

-       Intubation should be performed in the OR if the patient is stable for transport. For unstable patients, awake fiberoptic intubation is recommended with an anesthesiologist present at bedside.Intubation should be attempted by the most experienced physician.

-       If intubation is unsuccessful, perform emergent cricothyroidotomy

-       Antibiotics: Ceftriaxone (50 mg/kg up to 2 grams IV) and vancomycin (15 mg/kg for concern for MRSA) are a good choice. Trimethoprim- sulfamethoxazole is an acceptable alternative for patients with PCN allergy

-       Decadron (0.1 mg/kg up to 10 mg IV).

-       Disposition: ICU.

Sources:

EM docs, FOAM EM RSS

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