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Are you comfortable with Intraosseous Catheter Placement in Children during a code? A pediatric code or child in distress is also distressing to care providers. Your staff may not feel comfortable with IO access in children. Read on to be more comfortable with your options as IO access in children can be difficult, especially the chubby toddlers. The basics for a patient in distress are "IV, O2, Monitor". Access is vital to giving resuscitation medications.
Indications for IO access: Any child in whom IV access cannot readily be obtained, but is necessary.
All IOs are 15G for infusion equal to central vascular access.
Different colors indicate different sizes:
- Pink=15 mm
- Blue=25 mm
- Yellow=45 mm
Preferred sites:
- Proximal tibial (place a towel in popliteal fossa to bend the leg, pinch tibia and 1 finger width below the patella inferior and medial if you can’t palpate the tibial tuberosity)
- Distal tibia (proximal to medial malleolus by 1 finger width)—preferred in older children
- Proximal Humerus (internally rotate humerus and 1 finger width below surgical neck)
- Distal Femoral (1-2 finger widths superior to femoral epicondyles)
Kids-do NOT use the sternum or distal radius
The reference from NEJM has videos to review placement and different tools (manual, EZ IO, and autoinjector).
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Does IV magnesium have a role in the management of acute migraine headache in the ED? A new study says yes. [1]
Intervention
- 35 patients received IV magnesium 1 gm over 15 minutes.
- 35 patients received IV dexamethasone 8 mg + IV metoclopramide 10 mg over 15 minutes.
- Each group contained men and women.
- Initial pain score 8.2 in dexamethasone/metoclopramide group vs. 8.0 in magnesium group.
What They Found
Magnesium sulfate was more effective in decreasing pain severity at 20-min (pain scale 5.2 vs. 7.4) and 1-h (2.3 vs. 6.0) and 2-h (1.3 vs. 2.5) intervals after treatment (p < 0.0001) compared to treatment with dexamethasone/metoclopramide.
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As you get ready to celebrate the coming of a new year, it is important to be safe while you are having a good time.
Injuries seen during holidays, such as new years, include:
- Firework related injuries
- particular hand and ocular
- Celebratory gunfire related injuries
- including occasional deaths
- Motor vehicle crash related injuries
- particularly due to increased drinking and driving
If you are working, be ready to see increased alcohol and injury related visits.
If you are off and plan to celebrate, be sure to identify a designated driver or an alternate means of getting home.
Have a Happy and Safe 2015!
Cartoons Kill: A new high-risk patient for critical illness & death
This past month, the BMJ published an impressive retrospective review that analyzed nearly 80 years of data to find that animated characters in children’s films are in fact at a very high-risk for death when compared to characters in adult dramas.
Films ranged from 1937 (Snow White) to 2013 (Frozen) and were compared against the two highest gossing dramatic films in that same year. The authors found that nearly two thirds of the children’s animated films contained an on-screen death of an important character compared to only half in adult dramas.
Fatalities were most commonly the result of:
- Defenestration/falls (11%)
- Animal attacks (11%)
- Drowning (6.7%)
- Gunshot wounds (6.7%)
- Other mystical causes (6.7%)
Other high-risk animated characters include the parents of the protagonist (17.8% mortality) and nemeses (28.9% mortality). Median survival time was approximately 90 minutes (much less than the usual ED LOS!)
Notable early on-screen deaths included Nemo’s mother being eaten by a barracuda 4 minutes into Finding Nemo, Tarzan’s parents being killed by a leopard 4 minutes into Tarzan, and Cecil Gaines’ father being shot in front of him 6 minutes into The Butler.
The author’s intention was to point out the psychological impact of death on young children, but I think the authors also highlight an important, high-risk patient population that could present to your ED.
Bottom Line: Animated characters should be aggressively resuscitated and strongly considered for admission to a higher level of care should they present to your ED, as they appear to be at high-risk for death and rapid decompensation.
May all of you have a happy and safe 2015!
Reference
1. Colman I, Kingsbury M, Weeks M, et al. CARTOONS KILL: casualties in animated recreational theater in an objective observational new study of kids' introduction to loss of life. BMJ. 2014;349:g7184.
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Question
19 year-old male complaining of left arm pain one week after injecting anabolic steroids into his sholder. What's the diagnosis?
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Holiday Heart
- Holiday heart commonly refers to alcohol use and rhythm disturbances, particularly supraventricular tachydysrhythmias.
- The most common rhythm disorder is atrial fibrillation (AF), which usually converts to normal sinus rhythm within 24 hours and antiarrhythmic therapy is typically not indicated.
- Analyses of ECGs in patients who have consumed a large quantity of alcohol show prolongation of the PR, QRS, and QT intervals.
- 2014 AHA/ACC/HRS updated guidelines for nonvalvular AF utilize the CHA2DS2-VASc (congestive heart failure, hypertension, age ≥75 years [doubled], diabetes mellitus, prior stroke or TIA or thromboembolism [doubled], vascular disease, age 65 to 74 years, and sex category) score for assessment of stroke risk.
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Knee Dislocation
Following reduction and immobilization, a thorough vascular assessment should follow. Any signs of vascular injury should prompt immediate vascular consultation (pallor, absent or diminished pulses)
1) Palpate popliteal and distal pulses
2) Measure ankle-brachial index (*ABI) (<0.9 = abnormal)
3) Duplex ultrasound (if available)
*ABI ratio of SBP in lower (DP/PT) and upper (brachial) extremities.
**Evaluation is often institutional specific. Discuss with your consultants.
A) If strong pulses normal ABI and normal u/s admit patient for observation with serial vascular examinations.
B) If the limb is still well perfused but the pulses are asymmetric or ABI is abnormal or US is abnormal then consult vascular surgery and obtain arteriogram (expanding role for CTA here).
C) If pulses are weak or absent or distal signs of ischemic limb then obtain emergent vascular consultation for surgical repair.
Cyanotic (right to left shunt) Congenital Heart Disease (CHD) lesions can be easily remembered with the 1,2,3,4,5 method.
1- Truncus Arteriosis (ONE trunk)
2- Transposition of the Great Vessels (TWO vessels flipped)
3- TRIcuspid Atresia
4-TETRAlogy of Fallot
5- Total Anomolous Pulmonary Venous Return (TAPVR=5 words/letters)
A few other important DUCTAL-DEPENDENT lesions: Coarctation of the Aorta, Hypoplastic Left Heart Syndrome, and Pulmonary Atresia.
Patients present to the emergency department within the first week of life in severe distress, including hypoxia, tachypnea, and hypotension. The above cyanotic CHD all reflect DUCTAL-DEPENDENT lesions, meaning they need a widely open PDA (which closes in the first week of life) to maintain sufficient oxygenation for viability.
These patients will not survive without timely intervention with prostaglandin (PGE1), so be sure to initiate this life-saving medication as soon as possible! Side effects include apnea…be prepared to intubate your neonate!
Delirium has long been recognized as a common disorder of the geriatric ED population (seen in up to 20% of patients above the age of 65 years), but how good are we at detecting it?
Studies show that the diagnosis of delirium is made in the ED in only 11-46% of patients, which means that more than half go undiagnosed. The problem is, the risk of death at 3 months increases by 11% for every 48 hours of delirium the patient experiences, and so does their length of stay and functional decline. It is mostly missed in patients who have a baseline cognitive dysfunction, such as dementia.
So what can we do about that?
Treat delirium as a neurolgical emergency; be vigilant about diagnosing it and treating it. There are a lot of neurocognitive tests that can be used for diagnosis (such as the mini-mental status exam), but they are usually too cumbersome to use in an ED setting. The CAM (Confusion Assessment Method) has been extensively studied and has a sensitivity and specifity of about 95% to diagnose delirium. It includes the acuity of onset, fluctuant course, inattention (the hallmark), disorganized thinking and/or altered level of consciousness.
Bottom Line? Don't forget to screen your elderly patients for delirium and treat them accordingly!
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Treating ischemic strokes with interventional therapies (e.g., clot retrievers, stents, intra-arterial tPA, etc.) is nothing new, but there has never been a randomized control trial demonstrating benefit until recently.
The prospective MR CLEAN trial evaluated whether interventional therapies (i.e., either mechanical intervention or intra-arterial tPA) would confer benefit; patients were included if there was an acute occlusion within the proximal intracranial portion of the anterior cerebral circulation.
90% of patients received alteplase prior to randomization; there were 233 patients in the intervention group (alteplase + intraarterial intervention) and 267 patients in the usual care care arm (alteplase only); all patients were treated within 6 hours of symptoms onset
The primary outcome was functional independence at 90 days; an absolute difference of 13.5 percentage points favoring the intervention group was found. There were no significant differences in mortality or symptomatic intracerebral hemorrhage.
Despite these exciting results, we must pause and ask why this was this the first randomized trial demonstrating benefit when previous trials could not? Here are three blogs posts that deep dive this question and raise even more questions:
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Question
Hand pain following fist versus face. What's the diagnosis and what nerve block would you use?
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Brugada Syndrome
Brugada syndrome is an inherited arrhythmogenic channelopathy described by ST-segment elevation in the right precordial leads and an increased risk of sudden cardiac death.
There are 3 electrocardiographic patterns:
Type 1 – Coved morphology w/ST-elevation >2 mm, followed by a negative T wave in at least 1 right precordial lead
Type 2 - Saddleback morphology w/ST-elevation >2mm, with a positive or biphasic T wave
Type 3 - Either coved, or saddleback morphology with <2mm ST-elevation
Type 1 pattern is often underestimated because of its sporadic/fluctuating appearance on ECG, which can be either spontaneously occurring or drug-induced (drug-induced variant has a more favorable prognosis).
Fever has been a well-documented culprit in unmasking Brugada pattern by increasing the sodium channel dysfunction & accelerating the late sodium current inactivation.
A recent study in a large population of patients with type 1 Brugada attempted to identify other patterns unmasking Brugada using 24-hour holter monitoring. * There is now evidence that there is a higher prevalence of type 1 Brugada pattern from 12pm-6pm & unmasking by fast and a large meal, showing influence by glucose intake and insulin levels.
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Now that respiratory season is upon us, we are faced with an increasing number of bronchiolitis children. The updated clinical practice guidelines for managing these kids were recently published and emphasize supportive care only.
Some of the key points:
-When clinicians diagnose bronchiolitis on the basis of history and physical examination, radiographic or laboratory studies should not be obtained routinely.
-Medications such as albuterol, nebulized epinephrine or steroids should not be administered routinely in children with a diagnosis of bronchiolitis.
-Nebulized hypertonic saline should not be administered to infants with a diagnosis of bronchiolitis in the emergency department
-Clinicians may choose not to administer supplemental oxygen if the oxyhemoglobin saturation exceeds 90% in infants and children with a diagnosis of bronchiolitis
-Clinicians may choose not to use continuous pulse oximetry for infants and children with a diagnosis of bronchiolitis.
Check out the full guidelines for the quality of evidence and rational behind these recommendations.
The bottom line is that not much really works, and we just need to support their respiratory effort and ensure hydration.
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It is believed that administration of beta-blocker administration in patients with cocaine chest pain will produced increased vasoconstriction due to “unopposed alpha effect.”
Several retrospective studies on the use of beta-blocker in patients with cocaine-induced chest pain concluded the use of beta-blocker to be safe.
So is the unopposed alpha effect just a theory?
Lange RA et al. 1990 Ann Internal Med
Design: randomized, double-blind, placebo controlled trial.
30 (38- 68 years old) patients undergoing cardiac catherization for chest pain evaluation were studied.
Cocaine (intranasal administration) resulted in:
- Increased myocardial oxygen demand
- Increased coronary vascular resistance 22%
- Decreased coronary sinus blood flow: 10%
Administration of propranolol (intracoronary infusion) resulted in additional:
- Increase coronary vascular resistance 19%
- Decrease coronary sinus blood flow by 15%
- No additional change in myocardial oxygen demand
Complete coronary occlusion observed in 1 patient with ST elevation
Epicardial coronary arterial segment constriction >10% in 5 patients.
Bottom Line: Lange RA et al. 1990 demonstrates that the “unopposed alpha effect” does occur in coronary artery when beta-blocker is administered in a setting of acute cocaine exposure. Overall, the use of beta-blocker in the ED management of cocaine-induce acute chest pain is not a prudent option. It is unknown if the cocaine dose, last use of cocaine (days), or CAD history influence the “safety” of beta-blocker initiation/use during inpatient hospitalization.
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Background: As discussed previously, influenza (flu) is a common respiratory disease that causes significant morbidity and mortality worldwide (see pearl from October 1. 2014). We are now in the midst of the current flu season.
Current Update: This year’s vaccine was only a partial match (<50%) for the current influenza A (H3N2) circulating virus, so there is a significant potential for a “bad” flu season with widespread disease and severe illness. Currently, influenza is now widespread throughout the US, with some states reporting more activity than others. The CDC has a weekly surveillance map that highlights current disease spread.
Bottom Line:
- Remember that influenza annually causes between 250,000 and 500,000 deaths worldwide.
- Your emergency department will likely see many individuals with influenza this year, even if the patient received the vaccination.
- Know your emergency department protocols and policies for cohorting influenza patients and addressing droplet isolation precautions.
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Attachments
How does it present?
- Fever, cough, sore throat, runny nose, muscle aches, headaches, fatigue, diarrhea (in children especially)
Who cares…I got my vaccine! Does the vaccine work this year?
- There has been some antigenic drift this year in the influenza A (H3N2) type virus.
- 52% are anti-genically different than the H3N2 vaccine virus.
- So the vaccine is less effective this year but it can give some cross-protection (in addition to protection against the other strains used in the vaccine)
- CDC recommends still getting the vaccine (http://www.cdc.gov/flu/protect/vaccine/vaccines.htm)
- 91% of samples reported to the CDC have been influenza A this year
Can I test for this?
- Rapid influenza diagnostic tests check for antigen detection
- Pooled sensitivity of 62%; specificity of 98%
- False negatives are common
- Good technique during sample collection is important
The CDC is recommending treatment...wait I thought we were done with Tamiflu?
- Benefits: shortens the duration of symptoms (day or less), reduces the risk of complications, reduces the risk of death among hospitalized patients
- Risks: side effects (see below)
- A recent Cochrane review revealed that treatment did not really help reduce complications and most of the data on anti-viral agents is biased (Roche funded) and hotly debated
Who is at risk/who deserves consideration for treatment?
- Hospitalized patients with influenza
- Old people (>65)
- Children
- Pregnant women
- Chronic medical conditions (asthma, COPD, diabetes, or heart disease)
- American Indians and Alaskan natives
- Chronic immunosuppression
- Institutional outbreaks (nursing homes, correctional facilities)
Pearls of treatment
- Treat as early as possible (<48hours from symptom onset)
- 5 days of treatment; twice daily dosing. Wt based for children. Renally dosed.
- Oseltamivir: used for more severe influenza cases
- Zanamivir: 7 years or older; IV Zanamivir is currently in Phase III clinical trials
What are the side effects of anti-viral agents?
- Don’t use zanamivir in patients w/ pulmonary disease
- Transient neuropsychiatric events for oseltamivir
- Nausea, vomiting, diarrhea are common both both
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Question
A patient is intubated for respiratory failure and the post-intubation CXR is shown on the left. 30 minutes later the patient desaturates and another CXR is obtained (the one on the right). What’s the diagnosis and what should you do?
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Not So Benign: Benign early repolarization (BER) effects in STEMI
- Benign early repolarization (BER) has been associated with increased risk of sudden cardiac death and ventricular fibrillation (VF) in patients with and without structural heart disease.
- Acute STEMI is associated with high incidence of ventricular arrhythmias and the most frequent cause of sudden cardiac death in the adult population.
- BER has been associated with arrhythmogenicity, however the prognostic importance of this ECG finding in patients with STEMI has not been well elucidated.
- In a recent prospective study of STEMI patients, BER was associated with higher rates of in-hospital ventricular arrhythmias and mortality; It is an independent predictor of long-term mortality beyond well-known other parameters.
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- Irregular bowel movements and constipation are a common complaint pediatric complaint.
- The majority of cases are functional, but providers should take extra care to rule out organic causes like Hirschsprung's disease particularly during the neonatal period.
- 1 in 5000 incidence, with abnormal innervation of the distal colon resulting in tonic contraction, and obstruction of feces.
- In most cases, the agangionic segment is limited to the rectosigmoid area.
- Symptoms usually begin in the first month of life and consist of obstuctive complications such as abdominal distension, bilious vomiting, and poor feeding.
- Rectal examination should be done in all patients with constipation, and often reveals a narrowed high-pressure region adjacent to the anal sphincter.
- Barium enema, anal manometry, and rectal biopsy all aid in the diagnosis.
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Should beta blockers be withheld in cocaine-chest pain patients?
A new study retrospectively compared patients who received beta blockers as an inpatient to those who did not. Even though the beta blocker group had higher risk clinical characteristics, there was no difference in the composite primary end point of myocardial infarction, stroke, ventricular arrhythmia, or all-cause mortality within 24 hours of beta blocker use.
Important Limitations
The potentially dangerous interaction between beta blockers and cocaine is likely a much larger issue in patients with very recent cocaine use in the setting of a catecholamine surge. A retrospective analysis likely doesn't include those patients.
Application to Clinical Practice
While this study doesn't answer the question about beta blocker use in acute cocaine toxicity, it does provide some reassurance about the safety of beta blockers given for cocaine-related chest pain.