Conference Notes 10-25-2011

EM-EDS JOINT CONFERENCE   MANAGEMENT OF HEMATOLOGIC  ILLNESSES

If patient has fever and clinically has acute chest syndrome  give ABX ASAP irregardless of CXR findings.  Antibiotics in a sick febrile patient with SCD can be lifesaving.

Acute Chest Syndrome: Dispo can be floor or PICU depending on clinical picture.  Transfusion is also dependent on clinical picture.  Decision should be made in concert with hematologist.

Supplemental oxygen should be given routinely in acute chest syndrome.   Supplemental oxygen does not need to be given routinely in painful crises.

TTP is rare in the pediatric population. 

ITP Management: Don’t give steroids without consulting hematologist.  There is controversy about steroids prior to bone marrow biopsy.  At ACMC hematologists rarely give steroids intially. Concern is that steroids may obscure diagnosis of leukemia.    IVIG is more commonly given by hematology.   Treat if mucosal bleeding.  These patients tend to have worse outcomes.  WinRho is similar to rhogam.  Can only give to Rh pos patients.  WinRho can’t be given in anemic patients.   Algorithm: If mucosal bleeding or platelets around 10-20K  give IVIG if there is a response that is confirmatory of ITP. In subsequent events give dexamethasone.    In a child with platelets less than 50K and head injury get CT.

Leukemia:  Check PT/PTT because APL versions of AML can cause DIC picture.  If leukemia presents with respiratory distress think T-cell or Burkett’s or Lymphoblastic.  There may be a mediastinal mass due to these.   IV fluids are critical to preserve renal function.  Be alert for tumor lysis syndrome with high potassium, uric acid and phosphate.   If febrile over 101 give abx for neutropenic fever.     Think leukemia in a child with bone pain, pallor,  splenomegaly, persistent lymphadenopathy, normocytic or macrocytic anemia, or any cytopenia.   Steroid use in a patient presenting with symptoms due to leukemia can delay diagnosis and it may alter the leukemia that requires a more toxic chemo regimine.

STUDY GUIDE  QUESTION SLAM TOXICOLOGY

Urinary alkalization for ASA and chlorpropamide.  3amps of NaHCO3 in 1L of D5W and run at 200ml/hr.  Shoot for a urinary ph of 7.5-8.5.   Monitor the K closely.

For TCA OD  Look at AVR on the EKG an look for a wide,tall  terminal R wave.  Treat seizures due to TCA’s with benzos and phenobarb.    TCA’s have sodium channel blockade,  alpha blockade, gaba antagonism,  and anticholinergic properties.   IV Sodium Bicarb for QRS widening or arrhythmia.

Most common finding in Serotonin Syndrome is myoclonus.   Tx: remove offending agents and give cyproheptadine.

MAOI  with severe hypertension tx with short acting antihypertensives.  There is risk of severe hypotension with long acting antihypertensives.   If ingested more than 1mg/kg, the patient should be admitted to ICU.   Beta Blockers  are contraindicated.

Tyramine reaction: severe occipital or temporal headache within 90 minutes of dietary amine ingestion in patient on MAOI. 

Neuroleptic Malignant Syndrome:  Magnesium for prolonged QT to avoid Torsades.  External cooling is indicated.  Benzo’s can help rigidity.   Use rocuronium for intubation instead of succinylcholine.  IV fluids and supportive management is indicated.  Dantrolene may be tried.

Lithium Overdose: Tx with saline and Kayexelate. Next step for severe overdose is dialysis (lithium >4, sustained release preps, increasing level, level not improving with saline and kayexelate).   EKG may show long QT, st depression and t wave inversion.   Treat seizures with benzos.  Don’t use phenytoin.

 Number 1 factor related to respiratory depression with a benzo is another coingestant.   Cirrhosis may also increase risk.

Isopropyl alchol: Fomepizole is not indicated because acetone is not more toxic than isopropanol.   Upper GI Bleed is classic finding.   Hemodialysis for severe overdose.

Naloxone drip rate for massive opioid overdose (body packer) is 2/3 of the initial effective bolus dose per hour.  Be prepared for a very agitated patient on waking.

Highest risk of ACS with cocaine use is in a chronic regular user.  (90% of cases).  Men more common.  ACS usually occurs within 3 hours of use.   Cocaine also increases athrogenesis.

MARK HINTON   TOXIC ALCOHOLS

Ethylene Glycol  is metabolized to toxin glycolic acid and oxalic acid (calcium oxylate crystals in kindey).

Osmolar Gap= 2X NA + Glucose/20 + BUN/3 +ETOH/5.  Should be less than 20.

Methanol Toxicity is metabolized to formic acid.  Formic acid causes acidosis and vision loss.

TX for EG and Methanol:  ETOH or Fomepizole.  Fomepizole has less side effects (less gi irritation, cns depression and hypoglycemia).   All patients should get dialyzed.   IV bicarb can be used for acidosis.  Folic acid supplement for methanol.   Pyridoxine for ethylene glycol.

Isopropanol:  Severe cns intoxication,  risk of gi bleed and hypotension.  Less toxic  than methanol and ethylene glycol.   Metabolized to acetone.   In kids check for hypoglycemia.   Elevated osmolar gap.  No severe acidosis.  “Ketosis without acidosis”  Treat with supportive care.

DAN NELSON  CHEST PAIN IN KIDS

Dangerous Causes: ACS, cardiomyopathy, arrhythmia, PE, pneumothorax, aortic dissection,  mediastinal mass, perforated esophagus,  perforated ulcer.

Ask about family history of sudden death or connective tissue disorders.

Benign early repolarization: Consider  in the following groups: young, male, African American.   ST-T segments are concave up.

Juvenile T wave pattern: females more common than males.  Normal up to 8yo, or into adolescence in athletes.  T wave inversions v1-3.

Sinus arrhythmia causes variation in HR with respiration.

Long QT syndrome: Can be related to certain meds.  500ms is definitely abnormal

Hypertrophic Cardiomyopathy: Consider when ekg shows lvh.  Big S waves anteriorly and Big R waves laterally.

WPW: Short pr interval with delta wave.   Orthodromic conduction has narrow complex.  Antidromic  conduction causes wide complex.

Brugada syndrome: Due to a genetic sodium channel abnormality.

CHRISTINE KULSTAD   FAST TRACK EMERGENCIES

Skin tears:  If skin will approximate use steristrips to close, and cover with non-adherent dressing. If there is more tissue loss try adaptic or hydrogel/duoderm.  Hydrogel or duoderm can stay in place for one week.    You can use tissue adhesive as well for wounds with little tissue loss.

Absesses: Give pre-procedure pain meds/sedation.   Give anesthesia twice.  Initially in skin on roof of abscess then make incision and relieve pressure. Then give anesthesia to remainder of abscess cavity.  No evidence that irrigation improves outcome.   Don’t need sterile gloves.  Probably safe to irrigate with tap water instead of saline.   Use U/S.    Needle aspiration is not effective.   Probably safe to not pack small abscess in otherwise healthy person.   Don’t need to pack abscess tightly.  Pack loosely.  Don’t need iodoform gauze.   Can use any type of ribbon gauze.   

DAB KAMAN-MALLABAN  PATIENT FALLS

Number of fall in ACMC 50-60 falls per month.

If we don’t  decrease our number of falls, we will lose reimbursement dollars.   It is important to work as a team to prevent falls.

Communicate with nurses, leave cart rails up, give patients opportunities to toilet, walk them to bathroom.  

If patients have a yellow wrist band they are a high fall risk. 

New Motto  “No one falls”

Injury Potential from Fall:  Age,  Bones (osteoporosis, cancer),  Coagulation (Coumadin, plavix)

Obviously it is important to make sure you have the correct patient and correct labeling of all specimens.

Do a time out before all procedures.   It is a Red Rule.  

DAVE BAROUNIS      THERAPUETIC HYPOTHERMIA PROTOCOL   ICEP PRESENTATION

Previous research has shown improved outcomes in cardiac arrest patients.

56 month period of study at ACMC.  

Inclusion: ROSC from any rhythm

Goal:  Get temp to 33 degrees C in 4 hours.  Cooled for 24 hours.

Results: 160 patients with ROSC.   73 with ROSC were excluded.   The most common rhythm was V-Fib.  Overall Mortality for patients treated with hypothermia was 70%.     Good Neuro  Outcome (CPC 1-2) of survivors treated with hypothermia  was 14%.    In patients treated with normothermia 71% died but good neuro outcome was  4%.   Various sub groups were analyzed.

Conclusion:  In unwitnessed arrest there was no benefit from hypothermia.  In witnessed V-Fib arrest there was survival and neurologic benefit from hypothermia.