Conference Note 7-12-2017

Yappo         Review of 2016 AAP Practice Guideline for BRUE

BRUE= Brief <1 min, Resolved, Unexplained, Event in an infant less than 1 year old. The event needs to have 1 or more of the following: apnea, pallor, change in breathing, change in tone, or decreased responsiveness.  By the time the child is in the ED the exam must be normal to be a BRUE.

You can do a quick evaluation of an infant's growth by looking for a previous ED visit. If the patient was in the ED for a prior visit you can get their weight at that time.   You then plot out that weight and the weight from the current visit to see if the child is appropriately gaining weight.   You can also just check the child's current weight against expected weights on the growth curve.  If a child is significantly below the growth curve in the setting of BRUE, you may need to consider abuse, neglect, or metabolic problems. An under-weight infant would take the patient out of the low-risk BRUE category.   Additionally, head circumference larger than normal on the growth curve may be a marker of non-accidental head trauma.

For BRUE, the apnea described by caregivers should not just be peripheral cyanosis.  For BRUE criteria, cyanosis should be central cyanosis. 

Central Cyanosis

Central Cyanosis

Low Risk BRUE: Born after 32 weeks, >60days of age, no CPR required by a medically trained provider, event lasted less than 1 minute.

High Risk BRUE: Prior BRUE, history of congenital heart disease or inborn error of metabolism, family history of BRUE or sudden death, bruising or other signs of trauma, abnormal growth, abnormal vital signs.

Management of BRUE.  If you are going to do some tests on low-risk BRUE patients, consider an EKG, it has good negative predictive value if normal.  Pertussis testing is another consideration based on immunization status and seasonal prevalence.  Infants with pertussis may have gasping or apnea prior to cough or other respiratory symptoms.   Monitor the child for 4 hours in the ED with pulse ox and document repeated exams.  No need to search for occult infection unless the child is less than 2 months or appears ill.  Same with inborn errors. No need to look for inborn errors unless child is <2months, ill-appearing, or has family history of BRUE or sudden death.

Management of BRUE.  If you are going to do some tests on low-risk BRUE patients, consider an EKG, it has good negative predictive value if normal.  Pertussis testing is another consideration based on immunization status and seasonal prevalence.  Infants with pertussis may have gasping or apnea prior to cough or other respiratory symptoms.   Monitor the child for 4 hours in the ED with pulse ox and document repeated exams.  No need to search for occult infection unless the child is less than 2 months or appears ill.  Same with inborn errors. No need to look for inborn errors unless child is <2months, ill-appearing, or has family history of BRUE or sudden death.

Editors note: BRUE reminds me of the practice guideline for bronchiolitis.  The goal is to minimize treatment and interventions unless history and physical exam indicate a need to evaluate or manage further. 

Elise comment: Identifying the low-risk BRUE is challenging. You can't do this off the top of your head in the ED.  You need to pull up the guideline and go step by step through it in real time to be sure you are not mischaracterizing a high-risk child into the low-risk group. 

Marshalla   EKG Basics

A quick way to determine the rate is to divide 300 by the number of big boxes in the RR interval.

A quick way to determine the rate is to divide 300 by the number of big boxes in the RR interval.

Normal Intervals

Normal Intervals

Quick way to determine axis based on QRS orientation in leads 1 and AVL.

Quick way to determine axis based on QRS orientation in leads 1 and AVL.

Lambert   U/S Basics   Image Acquistion & Instrumentation

The brighter an object appears on the screen the more reflective it is to sound waves.

Sound waves travel slowly through air compared to the speed of sound through tissue.  Air causes significant image degradation due to the slow speed of sound in air.   Examples:  bowel gas will make it difficult to image the aorta.  The lung will hinder imaging of the heart.

 

Anatomic Planes and Axes

Anatomic Planes and Axes

Imaging planes

Imaging planes

Low frequency sound waves travel deeper into the tissue than high frequency sound waves.  You can adjust the frequency of the probe to optimize your image in relation to the patient's BMI.  There is an easy button our ultrasound machines with pictures of a thin man and a thick man.  Click on the picture that most closely represents your patient. That will optimize the frequency for the patient's body habitus.

Lambert     Bedside Echo

The main 3 views you will use at the bedside are the subcostal, parasternal, and apical views.

U/S Images from the 4 basic views

U/S Images from the 4 basic views

Subcostal 4 chamber view is the best view for identifying pericardial effusion.

Mike said that if you see fluid between the liver and the heart on the subcostal view, it is always abnormal.

Mike said that if you see fluid between the liver and the heart on the subcostal view, it is always abnormal.

When evaluating for PE with echo, you basically are looking for a big RV.

Big RV on Left side image.  Normal RV on Right side image

Big RV on Left side image.  Normal RV on Right side image

Lambert        Central Venous Access

Most operators use a transverse view to image the vessel. Standing at the head of the bed with the screen facing you, the operator, make sure your probe indicator is matched up with the indicator on the screen. They should both be directed to the left.

You want to approach the vessel at a 45 degree angle. So puncture the skin at the same distance from the center of the probe as the depth of the vessel to the probe. It is important to identify the tip of the needle to know where you are at. 

A has to equal B to make the 45 degree angle with the needle approach.

A has to equal B to make the 45 degree angle with the needle approach.

You can move the probe proximally and distally from the puncture site to identify the needle tip. Once you have identified the needle tip tenting the IJ vessel, make a small jab with the needle to puncture through the vessel wall and obtain blood return.   Once you pass the guidewire, use the probe in a longitduinal orientation to verify that the guidewire is in the IJ.   If you verify the quidewire is in the IJ, then you can confidently use the central line right away before obtaining a CXR.

Ultrasound Lab    Lambert and Team Ultrasound