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Which first-line vasoactive drug is the best choice for children with fluid-refractory septic shock? A prospective, randomized, blinded study of 120 children compared dopamine versus epinephrine in attempts to answer this debated question in the current guidelines for pediatric sepsis.
Bottom line: Dopamine was associated with an increased risk of death and healthcare–associated infection. Early administration of peripheral or intraosseous epinephrine was associated with increased survival in this population.
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What Matters in Cardiac Arrest?
- Approximately 500,000 adults suffer sudden cardiac arrest each year in the United States.
- The most important components of cardiac arrest care that have been shown to improve outcomes are:
- High-quality CPR with little to no interruptions
- Defibrillation for ventricular arrhythmias
- Optimal post-arrest care
- Target an SpO2 of 94-98%
- Target an ETCO2 of 35-40 mm Hg (PaCO2 of 40-45 mm Hg)
- Targeted temperature management
- Early cardiac catheterization
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A 15 months old male with no past medical history, presenting with two days of decreased oral intake and decreased urine output. The exam was notable for minimal tenderness of abdomen. During an oral fluid challenge in the ED, the patient had a single episode of bilious vomiting. The ED physician ordered an ultrasound study and the results are shown below. What is the diagnosis?
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Using 1.5 mg/kg or 2 mg/kg of IV ketamine led to less redosing compared to using 1 mg/kg IV.
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Recently a review paper was published regarding the duration of observation in heroin overdose patients who received naloxone.
It made several conclusions regarding heroin overdose:
- Treat (naloxone) and release in a prehospital setting may be safe.
- Short observation period (minimum of 1 hour) for heroin OD patients who were treated in the ED may be safe.
- Bystander and first responder naloxone administration is effective and safe.
It should be pointed out that this is a review paper of limited number of articles with variable quality. Additionally, the clinical history of “heroin use” may be unreliable as fentanyl and novel synthetic opioids are also sold as “heroin.” Providers should exercise appropriate clinical judgement when caring for these patients.
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It is well documented that when left to our own respiratory devices we will consistently over-ventilate patients presenting in cardiac arrest (1). A simple and effective method of preventing these overzealous tendencies is the utilization of a ventilator in place of a BVM. The ventilator is not typically used during cardiac arrest resuscitation because the high peak-pressures generated when chest compressions are being performed cause the ventilator to terminate the breath prior to the delivery of the intended tidal volume. This can easily be overcome by turning the peak-pressure alarm to its maximum setting. A number of studies have demonstrated the feasibility of this technique, most recently a cohort in published in Resuscitation by Chalkias et al (2). The 2010 European Resuscitation Council guidelines recommend a volume control mode targeting tidal volumes of 6-7 mL/kg and a respiratory rate of 10 breaths/minute (3).
It is well documented that when left to our own respiratory devices we will consistently over-ventilate patients presenting in cardiac arrest (1). A simple and effective method of preventing these overzealous tendencies is the utilization of a ventilator in place of a BVM. The ventilator is not typically used during cardiac arrest resuscitation because the high peak-pressures generated when chest compressions are being performed cause the ventilator to terminate the breath prior to the delivery of the intended tidal volume. This can easily be overcome by turning the peak-pressure alarm to its maximum setting. A number of studies have demonstrated the feasibility of this technique, most recently a cohort in published in Resuscitation by Chalkias et al (2). The 2010 European Resuscitation Council guidelines recommend a volume control mode at 6-7 mL/kg and 10 breaths/minute (3).
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https://images.radiopaedia.org/images/3173801/1ee24da1a6fe907a27d2bf20481174.jpg
Young toddler presents with left lower leg pain. What is the diagnosis??
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Patient found pulseless after submersion in water for 20 minutes. After ROSC, patient’s GCS was 3 and pupils are dilated and nonreactive.
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It's Election Day in the US, so here are some interesting facts about Presidential causes of death:
George Washington likely died from epiglottitis on 12/14/1799
- However, "iatrogenic" should also be listed on his cause of death
- Washington was blood let for almost 2.4L of blood!!!
- He also received an enema and multiple "blistering" treatments to draw the evil humors out of his throat
- He died before his fourth doctor, who planned to perform a tracheostomy, could arrive
CLICK BELOW FOR MORE INTERESTING FACTS!
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8 year-old female with no PMH who presents with concerns for "purple patches" popping up on her arm for 2-3 days. Stated that one appeared and then, the other one appeared 12 hours later. She denied any trauma whatsoever, history of easy bleeding/bruising and did feel safe at home. The rest of the review of systems was negative.
Patient said there was mild pain when the area was touched. The rest of the physical examination was normal.
What's the diagnosis? (Image below)
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Do you have a patient with renal insufficiency who is in need of an anticoagulation bridge to warfarin? Subcutaneous unfractionated heparin (UFH) as an initial dose of 333 Units/kg subcutaneously followed by a fixed dose of 250 Units/kg (actual body weight) every 12 hours may be an alternative to admission for heparin infusion with monitoring.
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As noted in a previous post, the FASH exam is the Focused Assessment with Sonography for HIV/TB. Below are typical ultrasound images of a positive FASH exam.
Peri-aortic lymph nodes- Multiple enlarged nodes, 97.1% specific for TB
Splenic lesions – multiple ‘punched out’ lesions
The effusions often have fibrous stranding
Submitted by Dr. Laura Diegelmann
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Dynamic LVOT Obstruction
- Recent literature has indicated that dynamic LVOT obstruction can occur in critically ill patients without hypertrophic cardiomyopathy. In fact, a recent study found that this condition may be present in many patients with septic shock.
- Risk factors for LVOT obstruction include any condition that decreases afterload, decreases preload, or increases heart rate.
- Consider LVOT obstruction when your ultrasound demonstrates close approximation of the lateral wall and septum plus systolic anterior motion of the anterior mitral leaflet.
- The treatment of patients with dynamic LVOT obstruction includes:
- Increasing preload with aggressive IVFs
- Increasing afterload (phenylephrine may be a good choice)
- Avoiding inotropes
- Decreasing heart rate (often with esmolol)
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Question
30 year old female presents with a painful finger for 1 week. Finger exam showed the following. What is the diagnosis ?
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Typically, empiric treatment for lobar community acquire pneumonia (CAP) in immunized < 5 year olds (preschool) is amoxicillin (45mg/kg BID or 30 mg/kg TID for resistant S. pneumoniae) for outpatient and ampicillin or ceftriaxone for inpatient. Additional coverage with azithromycin is typically recommended for school age and adolescent patients (>= 5 years), but not necessarily for younger children unless there is a particular clinical suspicion for atypical pneumonia with history, xray findings, or sick contacts.
However, in sickle cell patient with suspicion for acute chest syndrome, azithromycin is recommended for all ages groups, as atypical bacteria such as Mycoplasma are a common cause of acute chest syndrome in patients of all ages with sickle cell disease even young children. In a prospective series of 598 children with acute chest syndrome, 12% of the 112 cases in children less than 5 had positive serologic testing of M. pneumoniae (9% of all cases had M. pneumoniae) (Neumayr et al, 2003).
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Recently, a retrospective study of unintentional buprenorphine/naloxone exposure among pediatric population was published. All patients were evaluated by toxicologists at the time of initial hospital presentation (or transfer) at the study center.
Bottom line
- 83% and 80% of the patients experienced respiratory and CNS depression, respectively.
- Majority of the patients became symptomatic within 8 hours of exposure (range not available).
- Naloxone reversed respiratory depression. Median dose for single naloxone dose: 0.09 mg/kg; median dose for multiple naloxone doses: 0.19 mg/kg.
- The reported “ceiling effect” on respiratory depression in adult does not exist in pediatric population.
- The optimal time of observation is unclear but it is prudent to observe pediatric buprenorphine exposure for up to 24 hours.
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Magnetic resonance imaging (MRI) is the method of choice for imaging the spine for the suspicion of non-traumatic disorder, such as multiple sclerosis (MS), transverse myelitis, epidural abscess, spinal cord infarcts, and spondylotic myelopathy (changes in the spinal cord due to disk herniation or osteophytes in degenerative joint disease).
If the differential diagnosis includes infection, neoplasm, demyelination or inflammation, then IV contrast should be administered.
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Recently Emergency Physicians have become far more aware of the importance of right ventricular (RV) function in our critically ill patient population. One of the methods that has been proposed to assess RV systolic function with bedside ultrasound (US) is the tricuspid annular plane systolic excursion (TAPSE). This simple bedside measurement utilizes M-mode to quantify the movement of the tricuspid annulus in systole. And while it has demonstrated reasonable accuracy at predicting RV dysfunction, adequate visualization of the lateral tricuspid annulus is not always obtainable in our critically ill patient population (1,2). In these circumstances an alternative measurement obtained in the subcostal window may be a viable option.
Similar to TAPSE, subcostal echocardiographic assessment of tricuspid annular kick (SEATAK) utilizes M-mode to assess the apical movement of the tricuspid annulus during systole. In a recent prospective observational study, Díaz-Gómez et al examined 45 ICU patients, 20 with known RV dysfunction and 25 with normal function. They compared the measurements obtained from TAPSE and SEATAK and found a strong correlation between the two measurement (Spearman’s ρ coefficient of .86, P=.03).
The small sample size and limited evaluation of RV function is far from ideal and more robust data sets are required before we cite SEATAK’s diagnostic accuracy with any confidence, but in the subset of patients where a TAPSE is unobtainable this may serve as an adequate surrogate until a more thorough echographic assessment can be obtained. 
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Question
20 year-old female presents with sore throat, right throat fullness, difficulty speaking for 2-3 days. A bedside ultrasound and subsequent CT was obtained as seen below. What's the diagnosis?
