POTD- Foreign body aspiration

Did you know that over the holidays ER vists across the country >10 fold!

Most related to the decorations so be careful decorating your tree! Luckily most injuries are non-fatal!

With my massive family we've seen lacerations, sprains,  and most recently a pretty impressively crushed hand from a not so coordinated person carrying a heavybox, but we also had the scary moment when my 7mos old niece found her brothers toy on the ground and naturally put it in her mouth, she was fine with no ingestion or aspiration but just in case lets talk foreign body aspiration...

Normal presentations goes something like this... My child was playing on the floor and the next thing I know they were coughing and now they are making a funny noise and look like they are struggling to breath.

So what do you?

First  AIRWAY of course.  Does the child need immediate interventions? If so now is not the time to be a hero.. page ANESTHESIA and ENT fast! Try and maintain the child as calm as possible and in a position of comfort ( this may include keeping the kiddo head down!) Try and slip a pulse ox on and monitor but often less is more and letting the parent hold and comfort them can be better.

Get set up to intubate and have a surgical airway kit ready.

Intubating may involve pushing the object R mainstem so have all hands on deck.

For patients who are not in respiratorydistress, lets talk workup.

Starting with location.

• Laryngotracheal- uncommon but life threatening and often present in distress
  • Stridor, wheezes, dyspnea, hoarse voice
  • These kids need airway protection and STAT ENT and anesthesia consults!
  • Try is airway protection and RIGID BRONCH

• Large bronchi-
  • Cough, wheeze, hemoptysis, dyspnea, choking, SOB, decreased breath sounds
  • Will also need Rigid Bronch emergently!
• Lower airway- Little distress after the initial episode

What if you're not sure and just suspect a FBA? Follow this algorithm:

• Xrays should include inspiratory and expiratory films or Left decubitus in younger kids
• If you think its higher up inlay the neck ate PA and lateral views
• Xray findings of lower FB include:
  • Hyperinflated lung- lucency distal to obstruction
  • Atelectasis
  • Mediastinal shift away from the FB

Management:

• All children with high suspicion of FBA should be observed and schedule for a bronch
• Rigid> Flexible as it provides better visualization and access for removal of the FB
• Thoracotomy if bronchoscopy is unsuccessful

Complications:

• Atelectasis
• Pneumonia
• Bronchiectasis
• Abx should be started post procedure

Stay safe everyone and enjoy your holidays!

Alternative Headache Therapies

Hi everyone! For today's POTD, let's think outside the box when it comes to acute headache management in the ED. Headaches in general are one of the most common chief complaints we see in the ED. We have our tried-and-true drug cocktails -- an antidopaminergic drug (ex: reglan, phenergan, compazine), +/- benadryl, +/- toradol -- but what happens if those fail?

1) Other drug therapies: a) Sumatriptan 6 mg subcutaneously, or 10-20 mg intranasally [exercise caution in pts with cardiovascular disease] b) Dihydroergotamine 0.5-1 mg IM or IV [nausea is common; also exercise caution in pts with cardiovascular risk factors] c) Valproic acid: 300-1200 mg IV

2) Sphenopalatine ganglion block: Decent amount of anecdotal support for its efficacy (although no large studies yet), and very easy to do! - Soak long cotton-tipped applicators in your choice of local anesthetic - Insert nasally and apply firm pressure until you meet resistance at the posterior wall of the nasopharynx - Leave in place for 5-10 min; bask in the glory of your migraine-stopping powers https://www.aliem.com/2017/03/trick-sphenopalatine-ganglion-block-primary-headaches/

3) Occipital nerve block: https://www.youtube.com/watch?v=JGLOaZpZwqU - Consider this for patients with primarily occipital distribution of their pain! - 1 mL of 0.5% bupivacaine injected over the greater and/or lesser occipital nerves (located along the imaginary line between the occipital protuberance and the mastoid process, as shown in this photo)

4) Cervical paraspinous nerve block: https://www.youtube.com/watch?v=oy1lggvxV9Y - Similar concept to the occipital nerve block; consider this for your cervicogenic headache patients - 1.5 mL of 0.5% bupivacaine injected approx 2-3 cm bilaterally to C6-C7, to a depth of 1-1.5 inches

References: https://www.aliem.com/2016/05/managing-migraine-headaches-complicated-patients/ http://www.emdocs.net/headache-management-best-current-evidence-ed/ http://rebelem.com/alternative-headache-therapies/ http://www.annemergmed.com/article/S0196-0644(16)30301-8/pdf https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3737484/

Guillain Barre

Today a patient presented with b/l LE weakness, something we've all probably seen a couple times in the south side and something that is ofter dismissed by ED providers. One thing to consider and evaluate for is Guillain Barre Syndrome, it is a extremely common MISSED diagnosis.

Only 25% of patients were accurately diagnoses their first visit, with the average of 2 visits needed to be correctly diagnosed!!!

The team this morning, thought of GBS, which of course is the first step, and astutely worked up the patient appropriately. So lets talk GBS!

What is it? Acute immune-mediated polyneuropathy

• Acute monophasic paralyzing illness approx 88% provoked by a preceding infection
• Mcc: C, jejuni, CMV, EBV, HIV, and now Zika!
• Can also be from immunization, trauma, surgery and bone-marrow transplantation

Variants:

Symptoms?

• We all learn the ascending b/l LE weakness, but can start in the arms in 10% of patients
  • 90% of pts will have decreased or absent reflexes in UE or LE
• CAN BE PAINFUL! This is due to nerve root inflammation
• Up to 10-30% develop respiratory failure requiring intubation
• Also a/w dysautonomia and SIADH
• 50% have facial palsies or oropharyngeal weakness

Clinical Course:

• Prodromal illness--> 5-7days then onset of neuromuscular symptoms
• Rapidly progressive weakness/parethesias ( can be difficulty climbing stairs or walking)
• Plateau 2-4 weeks, often bedridden
• Recovery
• Can be rapidly progressive form with quadriplegia and resp failure within 48hrs!
• 4-15% mortality
  • Complications include: sepsis, ARDS, PE, cardiac arrest

Workup:

• PE: AREFLEXIA!
• Basic labs for evaluation of other etiologies of complaints
• LP w/ CSF showing albuminocytologic dissociation (high protein normal wbc)
• EMG testing as inpatient  

Management:

• 25% require intubation! 
• Think of the 20-30-40 Rule when deciding to intubate:
  • FVC <20 
  • Max Inspiratory pressure <30
  • Max Expiratory pressure <40
• Plasma exchange and IVIG are most efficacious if started within the first 2 weeks of symptoms
  • Get CSF first!
• NO ROLE FOR STEROIDS

Sources: EMDocs, Uptodate, EMRAP