Conference Notes 4-9-2013

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McKean        Trauma Lecture

69 yo patient with htn/dm in a significant mvc.  Pt is transiently hypotensive on arrival but still talking. There is a BP difference between upper extremities

Harwod comment: Need an EKG in this situation in addition to usual trauma resuscitation.  BP difference in arms could be due to aortic injury or chronic vascular disease.

CXR shows wide mediastinum.  Lungs look clear.  FAST exam is negative.   Thought at this time is probable aortic injury.

Salzman comment: Pt is using his abdominal muscles to breathe and pt is going to CT scan.  Probably need to consider intubation.  Salzman then made an argument against tubing at this point due to risk of worsening hypotension with induction/worsening vascular return and taking more time prior to sending to CT and burning the time that patient has some relative stability.   Difficult call on what to do.  There was general agreement that Trauma team made the right move and sent patient to CT without intubating prior.  

Harwood comment:  Need to evaluate successive data points over time to decide what to do.  If all clinical data is trending down then you have to tube.  If the data points are trending flat and not particularly downward then make a run to the scanner without tubing prior.

Salzman comment:  Indictions for evaluation of aorta are decel injury of 35 mph or greater, T strike MVC of significant force, fall of varying height depending on patient’s age/body habitus/specifics of fall.  Most aortic injuries occur just distal to the left subclavian artery.  There is a ligamentous tether near this point.

CT showed aortic injury, liver and splenic injury.  Pt also had a pneumo.  (Harwood got Kudos from Salzman for picking up the subtle pneumo  from the back row on CXR that was shown during this presentation.)  CT showed intraperitoneal blood.  So there was a discussion of why the initial FAST was negative.   Consensus was to do serial FAST exams because the test may be dynamic.   Barounis comment:  Trandelenburg position may bring intraperitoneal blood into Morrison’s pouch and make it more visible.

Pt coded.   Salzman comment: Bilat chest tubes placed. Pt had right sided pneumo.  Left side was tube was placed to see if aorta ruptured into left hemithorax.  No blood in left thorax.   Pt was taken to OR.   Belly was full of blood, far in excess of what the CT and the FAST demonstrated.  Pt coded again in OR and died.

In the end, This patient was not salvageable with his comorbidities and his severity of injuries.  Everything was done rapidly and appropriately.

Take home points:  Early transfusion, use cell saver and level 1 transfuser.   Transient hypotension is a marker of instability.  Be sure to save any blood coming out of chest tubes to transfuse back into patient. Do repeated FAST scans in unstable patients. An early FAST may miss smaller amounts of intraperitoneal bleeding.

Harwood comment: Bleeding may have slowed when pt was hypotensive resulting in negative FAST.  When pt was resuscitated his bleeding increased resulting in CT findings of intraperitoneal blood and later more severe OR findings of massive intraperitoneal bleeding.  

Salzman comment: For ER docs working in rural environments the decision to transfer this patient should be early.   He would start the transfer process as soon as he saw the initial CXR showing the wide mediastinum.

Gottesman               Bleeding Disorders

Hemophilia A: Deficiency of factor 8.

Hemophilia B: AKA Christmas disease is a deficiency of factor 9.

Mild disease 6-40% of either factor.

Moderate disease 1-5% of either factor

Severe disease <1% of either factor.  These patients may spontaneously bleed.

Hemarthrosis/muscle bleeds:  Warmth, paresthesias or pain.  Re-assess frequently for developing compartment syndrome.   Treat pain with opioids.  Avoid NSAID’s and ASA.

For oral mucosal bleeding you can replace the particular factor and give a mouthwash using Tranexamic acid.  Pharmacy can mix up tranexamic acid in an oral solution for an 8.4% concentration.

Head bleeds: Give Factor replacement prior to getting CT.

Iliopsoas bleeding can cause vague back or abdominal pain/paresthesias.   Elise comment: is there something specific about this muscle group?  Allisa: It can hold a lot of blood and is not directly visible/palpable so it has to be evaluated by CT. So you need to be aware of this.

There was some discussion of whether a hematologist needs to be consulted to give factor replacement.   All faculty felt this can be given unilaterally by an ER doc.

Avoid IM injections in hemophiliacs.  It can cause bleeding.

Hemophilia treatment centers have been shown to reduce mortality by 40% over six years.  Erik comment: Hemophiliacs know this fact and tend to go to those centers for their treatment. That’s why we don’t see that many of these patients.

Barounis comment: Simple way to remember treatment is 50u/kg factor 8 for serious bleeds (Head, GI, other life threats) and 25u/kg factor 8 for less serious bleeds (hemarthrosis, hematoma in soft tissue, etc).  For factor 9 replacement double these doses to 100u/kg and 50 u/kg.   Elise comment: Remember that epistaxis is considered a serious bleed.   Allisa: giving factor replacement too fast(faster than 2 minutes)is  painful for patient

FFP can be used if you don’t have factor 8 or 9 to give, or you don’t know the specific cause of the coagulopathy. However, volume precludes using this FFP effectively to correct factor deficiency.  Elise comment: Head bleed with undiagnosed clotting disorder give FEIBA.  Allisa agreed. Volume is not an issue with FEIBA. .  Pharmacist: FEIBA infusion rate is 2u/kg/min.

Patients who have inhibitors treat with FEIBA.

Mild bleeds can go home.  Admit for life threatening bleeds, concern for compartment syndrome, pain control, needing 3 or more doses of factor replacement.

There are people who develop acquired hemophilia due to autoimmune cause. Most commonly in post-partum women over age 60.

Von Willebrand disease: most common bleeding disorder.  Mucosal bleeding/bruising.   Minor bleeds treat with 50u/kg of vW/F8 complex.    Major Bleeds 100u/kg .

In kids with no history of clotting disorder who have large hematomas following  mild injuries ask if there is any family hx of clotting disorders.

You don’t need to have documentation that someone has hemophilia to treat them.  If they say they have it, believe them and treat them as indicated.  If they have their own factor replacement with them use it. 

Ptt should be abnormal in most hemophilia patients with severe disease.

Erik: Bleeding time is no longer available at ACMC.  Substitute is platelet function assay.

 

Clotting pathways from Up to date

Herrmann/Paquette    Oral Boards

Case 1.  50yo female with Pneumonia/afib/thyroid  storm   Critical actions:IV abx, beta blocker, PTU, Potassium iodide, and glucocorticoids.   Lovenox for afib.

Case 2.   4wo child with meningitis    Critical actions: Abx choice is amp and cefotaxime.  Cefotaxime instead of ceftriaxone at this age to avoid displacement of bilirubin from protein binding sites.   There was Discussion of whether vanco should be given in this case.  Consensus that it was not needed unless you have some indication of MRSA.

Discussion between Elise and Harwood and Barounis about whether a well appearing 6 week old infant who has a clear cut ua showing infection also needs LP.   Elise referenced study showing that @1% of infants under 28 days had concomitant UTI and meningitis.  These infants with both illnesses  were ill appearing.   No children over 28 days who were well appearing had concomitant meningitis and UTI.

Case 3.   21 you male with appendicitis     Critical actions: Pain control, IVF and have surgery take patient to OR

Schroeder    Parental Questions

>50% of parents believe a fever is present even if the child’s temp is less than 38C.

60% of pediatricians believed that a fever >104 was harmful.

Parents think a fever is a disease not a symptom.

Fever and heat stroke a entirely separate entities.  

Currently it is thought that a fever that is particularly high( >104) is not associated with higher risk of bactermia.   Current vaccines have decreased the incidence of pneumococcus. Pneumococcus previously was a cause of higher fevers and higher wbc counts and thus kids with high fever before pneumovax was introduced were more likely to be bacteremic. This is no longer the case.

Tylenol vs motrin: Relatively equal efficacy.   Head to head studies have had variable results.  Alternating antipyretics every 3 hours carries some risk of dosing misadventures by parents.

Girzadas comment: Easy dosing short cut is 1 tsp of either acetaminophen or ibuprofen for every 10 kg.  You can fine tune beyond that with the conversion of  1ml for every 2 kg.  Example 15 kg kid gets 1.5 tsp.   17kg kid gets  8.5ml.

Simple Febrile seizures are harmless.  They are due to circulating cytokines.  No need to do any further work up or LP if the child looks well after the seizure.  Do your usual eval for source of seizure.  Dr. Schroeder said he treats a simple febrile seizure as if it didn’t happen when he is evaluating the child.  He does however validate the parents’ concerns about their child.  He understands how scary it can be for a parent to see this happen in their child.

Vomiting kids:  Tell parents to have child drink with spoon for the first hour.  If they don’t throw up they can move on to drinking with a cup.   BRAT diet is no longer recommended.  Restart regular diet as soon as possible.   Ice cream is a good choice.  Avoid spicy, fatty, sugary foods.  Sugar free foods can worsen diarrhea.  Routine restriction of milk is not recommended.   Probiotic can be helpful for diarrhea. Florastorkids 250mg po q day.  Yogurt bacteria may not survive into the child’s gut.

Constipation:  Unhurried toilet time scheduled every day.  Take advantage of gastrocolic reflex.  Have child sit on toilet 5-15 minutes on toilet 20-30 min after breakfast and dinner.  Miralax is Bill’s go to medicine.  More palatable to kids.  Give until child is having bowel movements then wean them off over a week by decreasing the dose by half every 3 days. Harwood comment: Miralax is a very safe drug. He gave the example of a child he saw on miralax for a month who was having diarrhea and child had no electrolyte abnormality. 

Feeding:Overfeeding is very common in young children and is frequently the cause of GERD. Don’t give water to childen under age 2months. They can develop hyponatremia very easily. Have to be sure parents are not over-diluting their kid’s formula.

Teething: Give the child a wet washcloth that was cooled in the freezer to gnaw on.   Topical teething gels can cause methemoglobinemia from the local anesthetic.

Crying: 6 weeks is the height of newborn fussiness.  The average child cries for about 3 hours a day at 6 weeks.   5S’s for comforting the child: swaddle, lie on side, soothing sound, swing (motion), sucking.  You can use in step wise cumulative order.   Bill’s key was a good swaddle.   Gas drops have not been shown to help colic. Infant homicide increase at the 2^nd week of life and peaks at 8 weeks of life which correlates with the natural history of colic.     

Strep throat is uncommon under age 2. False positive rate equals or exceeds the true positive rate.  Risk of rheumatic fever due to strep is very low under age 2.  You don’t have to treat under age 2.

Umbilical hernias: 90% close by age 4.  Complications are rare.  No surgery under age 5-6. If greater than 1.5 cm then unlikely to close.

Frazier        5 Slide F/U

21 you female with chest pain after tonsillectomy.  CXR showed pneumomedisatinum.   Barium swallow suggested by Thoracic Surgery showed hypopharynx perforation.  CT showed mediastinal air as well. Pt started on Unasyn. Repeat esophogram 3 days later showed resolution of perforation.  Pt never spiked a fever.  She did well.   Review of case reports demonstrates that It is not known if this complication is usually due to intubation or surgery.  Treatment is observation for hypopharyngeal perforation.  If pneumomediastinum is from esophageal perforation, pt requires surgery.   This differs from spontaneous pneumomediastinum which can be discharged without treatment.

Harwood comment: this is most likely due to surgery not intubation.  This has also been reported in the dentistry literature.

Balogun  5 Slide F/U

9 mo child with rash for 2 days.  Rash around mouth and distal extremities.  Pt had been brought to 2 separate outside ED’s before this ED visit and was on augmentin and mupirocin and bactrim.   Positive Niklolski’s but no mucosal lesions.   No mucosal lesions differentiates Staph Scalded skin syndrome  from Steven Johnson’s syndrome. SJS has mucosal lesions 98% of the time.  This patient had SSSS.  SSSS has perioral crusting and kids are well appearing.  SSSS is due to exfoliative toxin.  Treat SSS with IV  fluids using parkland formula and give IV clindamycin.