When your Nose Knows Best

A new sick patient rolls into the busy Emergency Department, satting in the low 80s. As you prepare for a likely intubation, you appropriately assess your patient and see

PLUS THIS:

Hopes at bagging this patient's O2 sat up for pre-oxygenation start to dwindle as quickly as your fit summer body over the holiday winter season.

If only there was another way... but wait! Rudolph isn't the only nose that can be useful this holiday season!

Nasal trumpet for ambu bagging:

1. Collect Supplies: nasal trumpet, 6.0 ETT, ambu bag and access to oxygen. 

2. Separate ETT connector from ETT.

3. Connect ETT Connector to Nasal Trumpet

4. Connect joined ETT Connector-Nasal Trumpet to your ambu bag attached to the high flow oxygen (>>15 L/min, crank it all the way on)

 5. Place into patient's nasopharynx, seal patient's mouth, and bag!

Thanks to Anya for her photography skills!
As always, comments, feedback and input appreciated!

Happy airways and holidays to all! 



References:

Dr. David Saloum's clinical teaching (even though he was not aware that this would be become today's pearl - thanks anyway!)

Fancier double trumpet anesthesia option article: http://anesthesiology.pubs.asahq.org/article.aspx?articleid=2492128

Blunt Cardiac Injury Guidelines

To trop or not to trop? Here's a brief review of the 2012 EAST trauma guidelines for BCI. 

What is BCI, anyway?

Describes a range of injuries due to blunt thoracic trauma: wall motion abnormalities, myocardial contusion, valve injuries, focal wall dilation, coronary injury, pericardial rupture, wall rupture

Right heart most commonly affected as it is most anterior.

Who to work up?

According to 2012 East guidelines: “patients with any significant blunt trauma toanterior chest should be screened.”

Also consider BCI in patients with persistent unexplained tachycardia, cardiogenic shock, or hypotension not explained by other injuries.

Now that I suspect BCI, what should I do?

Screening:

Screening consists of an EKG (Level 1 evidence) and a troponin (Level 3 evidence). Early studies suggested that EKG alone is sufficient to diagnose BCI, however multiple studies since then show that such an approach does not capture the small percentage of BCI patients that present with normal initial EKG and positive troponin. 

A normal EKG and troponin rules out BCI (even in the setting of a sternal fracture, which is not predictive of BCI). Several studies show that the addition of troponin raises the NPV to 100%. Same screening approach is supported for pediatric pts.

Management & Disposition: 

Management is supportive; severe trauma may require surgical repair. 

Patients who have a new abnormality on EKG (arrhythmias, ST changes, heart block, PACs or PVCs, ischemic changes, etc) must be admitted to a telemetry floor for continuous monitoring. 

A new dysrhythmia or hemodynamic instability warrants an echo, preferably TEE over TTE.

Note that degree or persistence of elevation of troponin does not correlate with prognosis.

The chicken or the egg…did an MI precede the MVA or is it BCI?

It is important to differentiate which patients need cath with anticoagulation and which patients would be harmed from it. Can be differentiated via ekg-gated CT angiocoronaries.

Read more at:
http://www.aast.org/blunt-cardiac-injury
https://www.east.org/mobile/practice-management-guideline/96

It's getting hot in here - Pediatric Fevers

So, it's winter. Kids get sick. But really, 8-10 times a year is normal, so they're sick all the time! And they present to the ED with FEVER!!!!

What do you think about and what do you do with FEVER!?!?!?

- Fever = 38 degrees Celsius or 100.4 Fahrenheit

- Subjective fever per parents? Believe and work up/treat appropriately based on clinical presentation

- Determine exact onset and calculate fever duration (if since last night, it is only 1 day since <24 hours)

- Ask T-max
Thorough exams must include throat, ears, skin, oropharynx!

If suspect infectious etiology, treat with antipyretics:

Acetaminophen: 15 mg/kg every 4 hours, PRN

Ibuprofen (6 months and older): 10 mg/kg every 6 hours, PRN

The "alternating" approach of treating every 3 hours (Acetaminophen at 9, Ibuprofen at 12, Acet. at 3, etc) can help keep the kiddos' fever under control and keep them happy, hydrated, and hopefully home!

What to do!?

0-28 days infant: 

Orders: CBC with differential, Blood Culture, BMP, UA with culture, LP with CSF gram stain/cell count/culture/possible viral culture. +/- HSV PCR. +/- stool culture if presenting with diarrhea. CXR

Pathogens: Group B Strep, E. Coli, Listeria. Consider HSV

Treatment: Ceftazidime or cefotaxime + Ampicillin (for Listeria). or Gentamycin + Ampicillin. +/- Acyclovir (< 21 days, seizures, rash, mom w/ lesions)

**No ceftriaxone: ceftriaxone displaced bilirubin and places patient at increased risk for Kernicterus 

Dispo: Admit

29-60 days Infant: 

Similar to above, but more experienced pediatric clinicians may use clinical judgement regarding LP. In general, most general EM physicians should practice more conservative management and pursue LP. 

*Philadelphia/Rochester/Boston criteria for infants vary, hence the debate.*

Orders: CBC with differential, Blood Culture, BMP, UA with culture, LP with CSF gram stain/cell count/culture/possible viral culture. +/- HSV PCR. +/- stool culture if presenting with diarrhea. +/- CXR if respiratory symptoms. 

Treatment: Ceftazidime or cefotaxime + Ampicillin or Ceftriaxone. Skin infection: +vancomycin

Dispo: often admit, but again, clinical judgement. If you diagnose a UTI in a well appearing, eating infant and labs are normal WBCs, no bandemia, normal CSF, consider 1 dose of ceftriaxone and 24 hour follow up (be mindful of patient's family's education, access to healthcare/the hospital, reliability, health literacy, etc.). Do what is best for the patient. See reference from CHOP for an example:  https://www.chop.edu/clinical-pathway/febrile-infant-emergent-evaluation-clinical-pathway. Again - do what is best for the patient and appropriate for your level of pediatric training/experience. 

Acute Otitis Media: 

Bacteria: Strep pneumo (~80%), H. flu (especially if unvaccinated), Moraxella

Treatment: high dose Amoxicillin 90 mg/kg per day divided into 2 doses (to overcome strep pneumo's penicillin binding protein and H. flu's beta lactamase). If resistant, Augmentin (dose based off the amoxicillin) 

Pneumonia: 

Most common pathogens: 

< 3 weeks: E. coli, Group B Strep, Listeria

> 3 weeks: Strep pneumonia

UTI: 

RSV/Bronchiolitis: Usually < 2 years old. Supportive care, often HFNC. Babies < 6 months are high risk and give good return precautions if child is well enough to go home.

Influenza: keep in mind children < 5 are all high risk, but children < 2 are at greatest risk. 

Treat with oseltamivir, even if after 48 hours for high-risk patients (young, immunosuppressed, asthmatic, renal disease, DM, neuromuscular disease, pregnant, long term care facilities). 

Oseltamivir dosing is BID for 5 days: <1 year old: 3 mg/kg. >1 year old and 15 kg or less: 30 mg. 

15-23 kg: 45 mg.  23-40 kg: 60 mg. > 40 kg: 75 mg.

Group A Strep Throat: Under 3 years old, do not develop Rheumatic heart disease so often do not require antibiotic treatments

Treatment: Low dose Amoxicillin. 45 mg/kg divided into 2 doses. 

Pyogenic Joint Infection: Most common age group is < 3 years old. 

Pathogen: Staph aureus is the most common pathogen and often with preceding trauma or URI

Treatment: Need ortho consult and include MRSA antibiotic coverage

References:

https://www.chop.edu/clinical-pathway/febrile-infant-emergent-evaluation-clinical-pathway

Harriet Lane - the whole book is a reference gem, but looked up each topic