Conference Notes 10-30-2012
Barounis Peds Joint Conference Bronchiolitis
Case 1: 7wk child with bronchiolitis HR=180, T=39, P/O=97%
Is albuterol indicated: Suctioning is critical. Nasal occlusion may make it that you don’t hear wheezing. Dr. Horowitz from ICU said a trial of one albuterol or one racemic epi is reasonable. Dr. Akhter also felt a trial of albuterol is reasonable. If there is a response you can continue with nebs. Dr. Akhter said if child has risk factors for asthma like parental history or food allergies then he is more likely to benefit from bronchodilators. Dr. Roy said this decision making tool is more useful in an older kid. Dr. Roy discussed one hospital system that had a “suction shack” aside from the ED that kids with bronchiolitis would go to multiple times per day for suctioning. He continued that in a child with distress, it is hard not to use bronchodilators. Barounis talked about the Cochrane Review that found that there was no benefit from bronchodilators in bronchiolitis. Dr. Roy said that if there is no response to initial few nebs then stop. Dr. Akhter said though that it can be hard to guage patient resonse to bronchodilators.
Hypertonic Saline: Dr. Bill Schroeder says no evidence for effectiveness. Dr. Horowitz agreed. Dr. Akhter said 3% saline nebs are for bronchiolitis, 7% saline nebs for CF. Barounis showed the Cochrane review that demonstrated 3% saline shortens hospital stay by about a day. Dr. Akhter said that the Cochrane Review may have suffered from author bias. Akhter “I have been less than impressed with the effectiveness of 3% saline. But it is a benign therapy that is safe to use.”
Racemic Epi: Bill Schroeder uses with the sicker kids as a trial of therapy. Occaisionally it helps. Dr. Horowitz uses in kids with nasal plugging predominantly to gain the alpha effect to vasoconstrict the nose and upper airways. Dr. Akhter uses it empirically as a trial and if it helps you can continue. Dr. Roy said this whole discussion is frustrating because there is no treatment that has clear data showing improvement.
Steroids: Dr. Bill Schroeder does not routinely use steroids unless there is a family hx of asthma and child is improving from bronchodilators. Horowitz does not use steroids in a child this age. He will use steroids in an older child who may have asthma. Dr. Roy said no unless there is risk for asthma. Barounis- how about a 12 month old kid who responds to bronchodilators? Akhter said Cochrane review demonstrated no benefit in bronchiolitis. However, if you think it is asthma give steroids. Lovell comment: If steroids are given for bronchiolitis at first visit, then when they come back 2 months later with a respiratory illness steroids are often given again for probably no good reason. Akhter responded that if kids are returning to ED multiple times then they likely do have asthma an may benefit from steroids.
Racemic Epi and Steroids: NEJM Article showed some benefit. Dr. Roy questioned the validity of the study and suspects bias in the study group looking at racemic epi for bronchiolitis. He did not want to give a lot of steroids to possibly prevent some admission.
Dr. Collins question, 3% saline nebs for outpatients? Akhter yes it is safe to use. Harwood question: How many children have died at Hope from bronchiolitis? Horowitz: usually they do fine but some end up on ventilators. Congenital heart disease kids can have problems. Dr. Roy said that he can’t recall any kids dying from isolated bronchiolitis. Dr. Harwood said if kids can feed and their O2 sats are 92% or higher they can be discharged after suctioning. All these kids survive. Very young and those with congenital heart disease are higher risk. Another audience membr comment is that Medicaid will not cover home suction machines this winter. We need to get Nosefrieda devices in the ED.
CXR: Dr. Akhter said the CXR has only about a 1% diagnostic yield in kids with likely bronchiolitis. Bill Schroeder doesn’t routinely get CXR for bronchiolitis. Dr. Horowitz said babies with bronchiolitis can specifically get RUL atelectasis (considered fairly specific cxr finding). He also brought up to not forget about UTI in febrile kids with bronchiolitis.
Should we test for RSV: Sirosek-NO. It has no utility during bronchiolitis season. Dr. Butterly said test may have some risk stratification utility. Dr. Collins said it has no utility when we have single patient rooms. Dr. Roy and Dr. Collins said we should be isolating by symptoms not by RSV testing.
Summary by Dr. Barounis: Suction is mainstay of treatment. Give trial of albuterol, can try 3% saline nebs, avoid CXR, avoid Steroids, avoid testing. Racemic epi can be tried in the very nasal congested kids or sicker kids.
Patel/Katiyar Oral Boards
Case 1 Iron poisoning: Treat with IV fluids, intubation, give deferoxamine, consult poison control. Most common fatal pediatric overdose. Look for a high anion gap metabolic acidosis (It is one of the I’s in MUDPILES). Iron is caustic to gi tract/produces free radicals/disrupts ox-phos in the mitochondria. Check two Iron levels separated by 2 hours. If sustained released or enteric coating get levels several hours later as well. Treat with deferoxamine. This will give you a vin rose color of urine as complexed iron is excreted.
Case2 Herpes keratitis: Need to consult ophthalmologist. Educate patient about potential blindness. Corneal findings can be an ulcer or dendritic pattern.
Case3 Imperforate Hymen: Hymen obstructs menstrual outflow causing hematometria (blood in uterus) or hematocolpos (blood in the vagina). Presentation is adolescent with abdominal pain and amenorrhea. Can be a monthly cycle. Hymen may be bulging in exam. Treatment is surgical incision of hymen.
Lovell comment: With Tox cases, your goal is to figure out the toxin. Get info from parents/family/ems/ pmd or drug store. Always check for visual acuity on all eye cases. Visual acuity is the vital sign of the eye.
Coghlan comment: Be sure to circle back on the tests you order like accucheck. Check blood sugar prior to intubating a patient with altered mental status.
Anneken Electrolytes/Acid Base
Moderate dehydration should be treated with oral rehydration. Solution should have sodium/glucose. Not too much glucose to cause diarrhea
Kids with diarrhea may return to a regular diet as soon as tolerated. It has been shown to shorten th course of diarrhea.
Calcium gluconate is the treatment of choice for wide QRS due to hyperkalemia. It stabilizes cardiac membranes but does not decrease k+ . It is the fastest acting treatment. Insulin/glucose is the best treatment to decrease serum K level.
Severe Hyponatremia (<120) associated with severe symptoms (coma/seizures/focal neuro findings) treat with hypertonic saline. Also use for acute drops in sodium (marathon runners/ecstasy use/polydipsia). Down side to hypertonic saline use is overly rapid correction resulting in Osmotic demyelination syndrome. Harwood comment: He is not using hypertonic saline unless patient is in status epilepticus or not protecting airway. It has been recently been found that ODS can be stopped by giving water.
Sorry I missed the rest of this lecture.
Barounis Electrolyte Emergencies
5 causes of hyperkalemia: renal failure, meds (example pt is on an ace-i and you give them an NSAID), cell death like tumor lysis/ischemic gut/rhabdomyolysis.
Ekg changes due to hyperkalemia: peaked t waves, prolonged QRS, loss of p waves, bradycardia , sine wave, heart block. Elise comment: If ekg is real wide and ugly that is a classic sign of a metabolic problem/diagnosis. There is no linear stepwise change in ekg correlating with K level. However if there are EKG changes, the K level is likely over 6.5.
If giving insulin for hyperkalemia, give 1 amp of glucose for every 5 units of insulin. Example is 2 amps of glucose for 10u of insulin.
IV bicarb works well for hyperkalemia only if patient is acidotic.
If giving calcium, calcium chloride has 3 times more calcium than gluconate. If pt is unstable give calcium chloride IV. Calcium gluconate is broken down in the liver and takes more time (20-30 min) to be effective. Ca Chloride is very sclerosing and otentially tissue damaging. There was a discussion of administration of CaChloride and Cagluconate. It was generally agreed that Cagluconate should be used in patients who don’t have immediately life threatening hyperkalemia. CaChloride should be used in patients with immediately life threatening hyperkalemia.
Down-Up pattern of ST segments is a sign of hypokalemia in addition to U waves and prolonged QT. Hypokalemia can be a cause of death from V-fib. Hypokalemia=Hypomagnesiemia.
If a patient has a K of 3.0, they are whole body depleted of potassium by 300meq. You can’t replete 300meq in the ED. The best you can do is 10meq per hour via a peripheral IV. Max rate of repletion is 20meq/hour via central line. What you can do is give patients some repletion in the ED and figure out why they are losing potassium at home (diuretics). Pt’s should also eat 2 bananas/day or drink OJ every day.
Ecstasy use can result in hyponatremic seizures. More common in women.
If a baseline normal patient has hyponatremia less than 120 and is seizing (acute severe hyponatremia), give hypertonic saline 100ml over 10 minutes. Can push or give IVDrip or IV Pump. Alternative is to give 1 amp of sodium bicarb (has 50meq of sodium just like 100ml of hypertonic sodium). If patient has mild symptoms (weakness, fatigue), just do nothing except consulting nephrology. For all hypontremia patients, never correct more than 10 in a day.
Hypercalcemia: 90% are caused by parathyroid adenoma or other cancer. Treat with 200ml of saline hydration per hour. 2nd-3rd-4th line therapy is diuretics and bisphosphonates and calcitonin.
Cyanide, CO, APAP, Toluene, Mthanol, Uremia, DKA, Paradehyde, Porpylene glycol, iron, isoniazid, lactic acidosis, ethanol, ethylene glycol, salicylate.
Chastain Electrolyte Abnormality Cases
Seizing patient due to severe hyponatremia: Treat with 100ml of hypertonic saline or 1 amp of sodium bicarb over 10 min. Can repeat if needed.