Conference Notes 6-12-2012

Conference Notes 6-12-2012


Case #1:  Hypoplastic Left Heart Syndrome

MISFIT mnemonic : Metabolic, Inborn Errors, Seizures, Formula problems (hypernatremia/hyponatremia), Intestinal disasters, Toxins, Sepsis.  

If neonate presents with hx of fever but afebrile in ER.  Panel recommended partial septic workup with CBC, blood culture, and urine dip and observation period with recheck of temp.  If you admit for obs, if you want to give antibiotics, you have to do LP.  

In sick neonate you want to get an ABG.   

Go rapidly to IO line if you have difficulty getting IV access in a neonate.  Bolus IV fluids in rapid fashion over about  5 minutes.  You may have to give by push syringe thru iv/io.

Hyper-oxygenation test is not reliable.  It can give misleading results and increase pulmonary flow and worsen patient’s condition.  Similarly the BNP test has no utility in this age group.  Very ill hypoplasts have normal BNP’s.

Agreement among panel that if patient is unstable don’t do lp prior to antibiotics.  But Dr. Collins pleaded to get at least a blood culture prior to antibiotics.

Dr. Roy: If child is grey color (poorly perfused)not cyanotic you have to work up sepsis/cardiac/in-born errors/non-accidental trauma.  

Panel: nightmare baby is shocky baby with low normal O2 sat.  Gotta treat sepsis and at the same time work up cardiac and in-born errors and non-accident trauma.  Panelists suggested giving both antibiotics and prostaglandin if you can’t get a rapid echo and need to transfer patient.

Pre and Post Ductal Pulse Ox measurement (pulse ox on right hand and either foot) can be a sign of ductal dependent congenital heart disease.    Could be used in ER.  If one measurement is less than 90% or is significantly lower than the other measurement the test is abnormal.

Too much oxygen in these kids is more dangerous than too much fluids.  20cc/kg bolus was considered safe  by all panelists.

Case #2:   Evaluate for sepsis first because it is most common,  congenital heart dz and inborn errors are much less common.   Again, ABG was touted as a useful test by the panel in the undifferentiated ill neonate.   Panel felt Ammonia level was not a test to be getting in all these kids until you have considered other diagnoses.  Ammonia levels can be unreliable in the acutely ill child.  

Sam Lam: Inborn error of metabolism kids look sick, vomiting, shocky.  Labs will show hypoglycemia and acidosis.     Dr. Collins pleads again for blood cultures and antibiotics in this kid because sepsis is still the most common diagnosis.   If you do an LP the most important test is the culture.   If you have enough fluid then get cell count, gram stain, protein, and glucose.   Extra fluid can be saved for HSV pcr later if indicated.


Lovell chiming in to emphasize my favorite pearls from joint Peds/EM conference:

Common things common:  r/o sepsis, peds cards problems before worrying about inborn errors of metabolism (really rare) in a sick neonate-think about and treat both.  Get the blood culture before antibiotics, but defer the LP in shocky kids-stress of LP can make them worse.  

Hyperoxia test probably not helpful due to mixed lesions being able to mount reasonable sats, and putting cyanotic heart lesion kids on high flow oxygen can make them worse (adversely affect perfusion).  Instead, think about doing a O2 sat on right arm and either leg (pre/post ductal) to look for discrepancy and pick up ductal lesions.




Dave discovered that single coverage ER’s can be a lonely place for a doc.

People don’t really question you that much as an attending.

Pacemaker mediated tachycardia is best treated with a magnet or pacemaker computer rather than cardioverting.

Not every ED operates the same as ACMC.   They may manage afib and other problems differently than we do.

Dave had to treat a case of trachea-inominate fistula bleeding.  This is frequently a lethal complication of tracheostomy.

From Robert’s Clinical Procedures in EM Text: Control of innominate artery bleeding by digital pressure. Be aware that minor bleeding may be a sentinel event, and a harbinger of a subsequent major hemorrhage. When major bleeding occurs and a cuffed tracheostomy tube is present, overinflation of the tube cuff may temporize (see text). When this is unsuccessful or a cuffed tube is not available, use the illustrated maneuver; digital pressure should be applied to the anterior tracheal wall through the tracheostomy. The index finger is placed within the trachea and then pulled against the anterior tracheal wall, allowing the airway to remain partially open. The artery is compressed between the index finger and the thumb—placed over the neck. Digital compression of the innominate artery is a temporizing procedure, until definitive (operative management) of the bleed is obtained.

Success comes mostly from the relationships you build with others.  It has much less to do with how good you are.

Dave’s Top Suggestions for year 1

  1. Be nice
  2. Never yell
  3. Mirror the behavior of your favorite attending
  4. Be decisive and have a plan
  5. Don’t take yourself/status too seriously
  6. Learn everyone’s name quickly
  7. Work less than in Residency
  8. Spoil yourself then SAVE ALOT!!!!!
  9. Get a good financial planner
  10. Develop another work interest.
  11. Be generous with your time/money/espertise
  12. Don’t prescribe  narcs or benzos to friends/family


Palliative care is symptom management, communication, and coordination of care.

ED is critical setting for pt’s with cancer and other terminal illnesses because we initiate the trajectory of care.

Patients with cancer or other chronic illnesses: 94% have physical symptoms, 72% have financial concerns.

Goal: Cancer patients go to ER only once in last 30 days of life.

Palliative Care does the right thing for the patient and also saves $.

Case #1: Hospice Patient in the ER.  They may come for increased symptom,  new problem, self referral for stress/inability to cope.

New care model for advanced cancer is a relative gradient of cancer therapy and palliative care.  This is a change from the past which was cancer treatment alone until it was determined unsuccessful then palliative care.

Hospice Myths:  Pt’s have to be DNR to be in hospice.   Hospice does not treat infections.  Hospice withholds parenteral nutrition.    Hospice has to be revoked on arrival to ER.

ER staff should call hospice staff.  Identify trigger for ED visit.   If deterioration is imminent discuss with pt and family.   Give family/patient emotional support.    Dispo can be home, hospice, revoke hospice.

IV decadron makes cancer patients feel a lot better.  It relieves symptoms from tumor burden.  It will also increase appetite.

Treatment of Nausea: There is more than zofran.   Benzos, antihistamines, raglan, compazine, haldol 2-5mg IV (blocks the chemoreceptor trigger zone), droperadole is another option.

Treatment of Constipation: Use a combination of a stimulant and a stool softner.   Senna and colace is a good combination for constipation prophylaxis. Harwood recommends Pericolace as a combo med with both senna/colace.    Methylnaltrexone blocks opioid receptors in gut.  Works like a miracle but is expensive.     If patient comes to ER with constipation Erin recommends  giving lactulose from above and ducolax from below.


Case #2: Dementia Patient

Dementia is a progressive terminal disease which is irreversible.  There are identifiable stages.  Stage 7c with loss of ambulation and not speaking, they have less than 6 months to live.

It is ok, if in your medical judgment the patient is going to die soon, to decide for the family that the patient is DNR.   If they assent to this decision, you make the patient DNR.  

Delivering Bad News:  Advance prep, build a relationship, communicate well, deal with reactions, encourage and validate emotions.      Find out what they know, be frank but compassionate, allow silence/tears,  summarize and repeat info, encourage questions.   

Things not to say: I understand how you feel.  It could be worse. Nothing more can be done. We all die. Avoid euphemisms, use the word death/dead.

Case #3:  Patient with metastatic lung cancer in extremis.   Husband screaming “do something!”

Erin stabilized patient with intubation and pressors.   Then had long discussion with husband.  Daughter comes and says “mom never wanted to be on a ventilator”.  It was decided to extubate patient in ER.  Dyspnea treated with morphine.

Treat dyspnea with: oxygen, fans may be effective, morphine 2-5mg Q15-30 min (this is symptom treatment not euthanasia), ativan 0.5, humidiity , elevate head of bed, educate family, treat secretions with atropine.

Oral morphine 15 mg is a reasonable starting dose q4 hours for cancer patient failing norco.

SubQ dosing of opioids is less painful than IM dosing.

Don’t start a patient new on a fentanyl patch in the ED.  You can increase the patch dose for someone already using a fentanyl patch.

ACMC has a Palliative Care Team 684-8117.  Dr. Kozyckyj and Lynn Sevic, RN.