Conference Summary 9/1/21

by Ivan Ivanov, DO Conference Summaries
  • Warm welcome and thanks to our PEM team for joining: Dr. Rhodes and Dr. Weber!!
  • Next week conference will be zoom, will go over some of the EMRAP cardio symposium

Dr. Kindschuh Oral updates

  • STROKE CODE
    • Will be switching from alteplase to tenecteplase (TNKase)
    • 🔈 Goal to give thrombolytics <30 minutes
    • Working on developing a script for TNKase consent.  
    • How we will get to <30 minutes TNKase administration:
      • Stroke stretcher in triage
      • Door to CT 10 minutes
      • Standardized informed consent
      • IVP TNKase as while in CT
        • Dose: 0.25mg/kg (max dose 25mg) IV bolus over 10seconds. 
        • NOT compatible with dextrose solutions
      • 🔈 How to order in epic? Type in TNKase (!!! DO NOT USE TPA !!!)
    • Thrombectomy goal DoorInDoorOut: 120 minutes 
      • July median 135 mins
      • September Inaugural quarterly stroke interventional conference
      • Working on partnering with neurointervention for education
  • GI Code
    • 888 will respond after 4pm and on weekends
    • Hand off to MICU is most important
    • Make sure to reverse anticoagulation
  • MTP
    • Step wise process, per protocol: first delivery is 4 units pRBC, six other deliveries scheduled containing platelets, FFP 1:1:1
    • Give 1:1:1 — PLT:FFP:RBC, not just pRBC
    • Do NOT CHANGE the amount of units ordered in the MTP protocol, can always send unused products BACK. 
    • Attached PDF.
  • Northwell blood cultures results you get in the middle of the night… What to do?
    • Weekday, daytime → transfer to ED office
    • Other times → email Dr. Kindschuh with MRN
  • 7a: Resident Lectures: Raj – Pediatric Respiratory Illnesses / Mike Cyd – Pediatric Ortho / Denise – Anaphylaxis
  • 830a: Robert – Tox Lecture – Marine Environmental Toxicology
  • 9a: Dr Rizzo – Podcast Jam – Quick Hits #2:
  • Organophosphate poisoning, metacarpal fractures, pediatric IV lines, abdominal stab wounds, and TXA for hemoptysis. PLEASE LISTEN BEFORE CONFERENCE***
  • https://emergencymedicinecases.com/em-quick-hits-february-2019/
  • 10a: Dr Cocchiara – Approach to ED Trauma
  • 11a: Dr Gladstein – Intubation Cases + SIM

Raj – Pediatric Respiratory Illnesses

  • Low SBP for kids (1-10yo) shortcut= 70+(2xage)
  • DDx: bronchiolitis, PNA, whooping cough, croup
  • Bronchiolitis
    • Usually in winter months
    • Age 0-2 year old
  • H&P vs ABC? ABC
    • Airway: Nasal suction w/ saline instillation
    • Breathing: Warm humidified HFNC vs CPAP (o2 >90%)
    • Circulation
  • Consider in ill kids: albuterol, nebulized epi, steroids
  • Children with fever and tachypnea make sure you give antipyretics, fever can cause children to be tachypnic (Dr. Rhodes, PEM attending)
  • Intubation
    • Tube size
      • (Age/4) + 4 [uncuffed]
        • Uncuffed: Only in neonatal period (Dr. Weber, PEM attending)
      • (Age/4) + 3.5 [cuffed]  ….. (Cuffed > 3 mo)
    • Use Miller blade
    • Insertion depth = 3 x ETT size
  • RSI/pretreatment meds
    • Atropine 
      • 20-30 min before tubing== If <1yo to decrease secretions
    • Ketamine
      • Bronchodilator
  • RSV is associated with apnea in children <6 months of age (Dr. Weber, PEM attending)
  • Bronchiolitis – Who Needs to Stay (PEM Morsels)
    • Toxic appearance (pale, lethargic), poor feeding, dehydration
    • Respiratory distress
    • <12 weeks and/or premature <34 weeks
    • Pre-existing heart, lung or neurological condition
    • immunodeficiency
  • ☀️☀️🏝🏖Coney specifics☀️☀️🏖⛱
    • URI test panel swab is the SAME as COVID 
    • Peds currently being transported out with respiratory support
    • “At Coney, if you place HFNC you will need to convert to CPAP because EMS can only transport via CPAP.” (Dr. Rhodes, PEM attending)
      • HFNC is titratable based on the weight of the child, CPAP you know exactly how much they are getting.

Denise – Anaphylaxis

  • Anaphylaxis criteria
    • Skin symptoms + respiratory/GI/Hypotension/End organ damage
    • 20% of anaphylaxis has no skin symptoms
  • Symptomatic manifestations
    • 90% cutaneous: hives, pruritus, angioedema, conjunctiva erythema and tearing
    • 20% mucocutaneous = underdiagnosed
    • 60-70% respiratory
    • 30-50% GI
    • 40-50% cardiovascular symptoms
    • <15% neuro symptoms
  • Precipitants
    • Food (most common)
    • Medications
    • Insect stings
    • Latex
    • Aerobic exercise
    • Idiopathic (rare)
  • Anaphylaxis– EMCRIT 
  • Photos
  • DDx: scombroid, atopic dermatitis, angioedema, transfusion reactions, contrast induced ‘reaction’, carcinoid syndrome, asthma
  • Treatment
    • Epinephrine IM 0.5mg (1:1000) to the lateral thigh q5/min x 3
    • Epinephrine drip (or dirty epi: 1mg code cart epi into 1L NS)
    • IVF 
    • Intubation? Fiberoptic, call anesthesia, cric ready 
    • On beta-blocker? Glucagon (careful can cause vomiting and airway obstruction)
    • Adjunctive
      • Diphenhydramine 25-50mg IVF
      • Famotidine 20mg IVF
      • Methylprednisolone 125mg IV
    • Theoretical
      • Methylene blue
      • ECMO
      • FFP
  • MONOPHASIC vs BIPHASIC reactions
    • Biphasic reaction occurs 10-20% of patients
    • Biphasic reaction is more likely in a severe reaction
    • Most biphasic reactions occur within 4 hours
  • Observe for 4 hours prior to discharge
  • Dr. Rizzo: ‘Steroid administration is dogma, no good evidence. Use epi and remove allergen.’

Mike Cyd – Pediatric Ortho

  • Pediatrics Specialty Dashboard—High Yield peds orthobullets
  • Bone anatomy review
  • Growth plate = the physis
  • Buckle = Torus fracture
  • Greenstick
  • Pathologic fractures: metabolic diseases, oncological causes, etc.
  • Stress fracture = absent on initial xray, may see healing on repeat xray 2 weeks later
  • Child abuse
    • Long bone fracture in non-ambulatory child
    • Metaphyseal corner fracture
    • Rib, sternum, scapula, spinous process
    • Multiple fracture in different stages of healing
  • Always ask MECHANISM of Injury: ask multiple times for concern of abuse. 
    • Consider peds age for ambulatory considerations: rolling over, walking, standing up
  • Salter-Harris Classification 
    • Salter Harris Fractures – StatPearls – NCBI Bookshelf 
    • Type 1 = “Straight across” 
      • Soft tissue swelling, not always seen on Xray
      • NON-OP: splint, ortho follow up outpt
      • Ex: SCFE
    • Type 2 = “Above” (most common)
      • NON-OP: splint, ortho follow up outpt
      • “Corner sign” = Thurston Holland fragment
    • Type 3 = “Low”
      • Ortho consult for Type 3-5
    • Type 4 = “Through”
    • Type 5 = “CRush/Rammed”
    • Salter Harris Management
      • Type 1 + 2 = splint and ortho follow outpatient
      • Type 3 + 4 + 5 = ortho consult
  • General treatment
    • Pain control
    • Open fracture: Antibiotics, ortho consult
    • Neurovascular exam
    • Consider compartment syndrome
  • Dr. Rizzo: ‘Push for early ambulation in Salter 1 and 2, faster return to function’

Robert – Tox Lecture – Marine Environmental Toxicology

  • Aquarist = a person who keeps an aquarium
  • Palytoxin: from Zoanthid corals, related to jellyfish, LD50 0.15-0.3 mcg/kg (super deadly)
    • Binds to Na/K ATPase
    • Causes: hemolysis of rbcs, violent contractions of heart and other muscle cells
    • Heat-stable
  • SYMPTOMS:
    • Fevers, chills
    • cough/hemoptysis, SOB
    • Nausea
    • Muscle pain
    • Bitter metallic taste
    • Burning in eyes
    • Numbness
    • Cardiac probs
    • Depression
    • High BP
    • coma/death
  • Tx: Supportive care
  • ARDS severity classification
  • Fishy Board Questions Review
    • Ciguatera poisoning = cold–hot reversal
      • Related to LARGE FISH
      • Can be passed along in breast milk.
      • Tx: supportive care
    • Scombroid poisoning = Peppery flavor
      • Histamine related
      • Tx: antihistamine, supportive
      • Sx within 10-30 mins
    • Brevitoxin poisoning = shellfish poisoning
      • VERY similar to Ciguatera –both have hot-cold reversal 
        • differentiated by food type
    • Tetrodotoxin poisoning = Parestesias
      • Fugu pufferfish
  • Rob’s environmental plea ❤
  • Beyond Sushi: Vegan Restaurant NYC – Vegan Sushi & More Manhattan 

Dr Rizzo – Podcast Jam – Quick Hits #2: (LINK: EM Quick Hits 2 Organophosphate Poisoning, TXA for Hemoptysis, Metacarpal Fracture Rotation, Abdominal Stab Wounds, Pediatric IV Cannulation)

  • Organophosphate Poisoning
    • Cholinergic symptoms mnemonic
    • Three B’s: Bronchorrhea, Bradycardia, Bronchoconstriction + Seizures (per Rizzo)
    • Treatment
      • Atropine
        • MOA: directly antagonizes Ach
        • Dries secretions: Give until chest is clear and pt is hemodynamically stable.
        • Dose titration: 1-2mg/dose to start q5min
          • Keep doubling dose until secretions are dry 
      • Pralidoxime (2PAM)
        • MOA: Restores AchE
  • TXA for Hemoptysis (post-tonsillectomy)
  • Metacarpal Fracture Rotation
    • Malrotation – bend fingers toward scaphoid, clinical dx, can miss on XR
  • Abdominal Stab Wounds
    • OR Indications
      • Hemodynamic instability
      • Bowel evisceration
      • Peritonitis
      • Impalement of the weapon/object
    • CT can miss 10-20% on abdominal injuries, will need observation and serial abdominal exams
    • Check for anterior rectus muscle violation
    • US FAST exams are great, cannot rule OUT a serious pathology
      • About 90% sensitive
      • About 80-95% specific
    • Get CT chest to r/o diaphragm injury
  • Pediatric IV Cannulation
    • Consider EMLA
    • Determine urgency
    • US: better in older kids than younger kids-be careful with the pressure you’re using to not collapse veins.
    • Secure IV!!! Use a board, tape, etc. 

Dr Cocchiara – Approach to ED Trauma

  • Next time

Dr Gladstein – Intubation Cases + SIM

  • Oral boards case
    • 28F found down on the stairs
      • Moving uncontrollably in bed
    • Initial steps in boards case:
      • “What do I see when I walk into the room?”
      • ABC
      • Monitor, O2, IV, Saturation, BG, upreg
      • Primary survey (ABCDE), undress patient, fully examine patient
      • Need to place a c-collar! (consider trauma)
    • You have 15-30sec to intubate, if unable, bag and restart
  • Intubation preparation
    • Suction
    • Oxygen (NC + NRB)
    • RSI meds
    • Video vs Miller vs Mac
  • Intubation indications (5)
    • Oxygenation
    • Ventilation
    • Protecting airway
    • Need for future procedure
    • Control of agitated patient
  • Confirm intubation
    • End Tidal CO2 
    • Auscultate for bilateral breath sounds
    • Chest XR  (2-3 cm above carina)
  • PLACE OGT AFTER INTUBATION–needs to be beneath diaphragm on CXR (~50-60cm)
  • RSI meds
  • Nasal intubation considerations: Nasal intubation: A comprehensive review

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