Conference Notes 7-26-2017

Carlson           Pediatric Toxicology Problems

Top 5 Pediatric Exposures in Frequency

1. Cosmetics and personal care products

2. Household cleaning products

3. Analgesics

4. Foreign bodies, toys

5. Topical preparations

Poison control centers are able to manage a large number of patients at home so they don't need to present to an ED.  There has never been a case in the last 15 years of a patient managed at home by the poison center who had a bad outcome.  They are very conservative in their management and will send the patient to the ED if any doubt.   So.....Support your local Poison Control Center!

Most common causes of pediatric deaths due to toxin exposure 2015:  (N=66) 1. Analgesics (ASA, APAP), 2. Button batteries, 3. Fumes, 4. Stimulants, 5. CardioVascular drugs.

How are products tested to determine if they are child-resistant?

Panels of 50 children (42-51 months) are tested sequentially following division into three age categories (42-44 months; 45-48 months; 49-51 months). The testing period is 10 minutes and children are instructed on how to open the package and that they may use their teeth.  If test results are inconclusive, additional testing involving one or more groups of 50 children each is required. A maximum of 200 children may be tested. (Consumer Healthcare Products Assoc)

Biggest EM Toxicology Concerns for Kids: Calcium Channel Blockers, Camphor, Clonidine, TCA's, Opioids, Lomotil, Methylsalicylate, Sulfonylureas, and Toxic alcohols.

Latest thinking on management of carfentanil (100 times more potent than fentanyl)is that it is very similar to the management of heroin.  Patients don't necessarily need huge doses of narcan.  They likely will respond to normal doses of narcan.  

Carfentanil:    "The drug was never intended to be consumed by humans. But it has been used to kill and immobilize humans — reportedly, in assassination attempts and by Russian Special Forces in 2002. They apparently used it in aerosol form as a knockout gas to end a hostage situation. Tragically, the gas ended up killing more than 100 hostages.

Boos is the section chief for the Diversion Control Division, of the DEA's Drug and Chemical Evaluation section. He says the only legitimate use of the drug is as a tranquilizer for very large animals, like elephants or hippos. So there's no medical literature to consult for its effects on humans. That knowledge is being gained the hard way, by first responders."  (NPR Reference)

For button batteries in the esophogus, ear or nose, get them out in 2-4 hours.  If it is in the stomach or GI tract it can be managed expectantly with serial abdominal xrays.

Really worry about these toxins: diltiaem/verapamil, methadone, methanol, hydroflouric acid, colchicine, paraquat, amanita mushrooms, cyanide.

Worry about these toxins: beta blockers, clonidine, TCA's, MAOI's, atropine, ethylene glycol, sulfonylureas, theophylline, carbamazepine, causits, salicylates

Dont worry about these toxins: brodifacum, Chlorox bleach(3% sodium hypochlorite), ACEI, ARB, diuretics, cholesterol medications, antibiotics, OTC camphor products, Ibuprofen, H2 blockers, Actos/Avandia.

It is always OK to not give activated charcoal.   There is a 1 hour window from the time of ingestion of toxin to give the charcoal.  Outside of the 1 hour window it has little effect. It is tolerated best when mixed with chocolate syrup and drinken with a straw from a closed cup.   Never place an NG tube to give charcoal.  Never force-feed charcoal to a child.  The risk of aspiration of charcoal is significant.

Traylor     Code STEMI

Start with IV access, consider O2 (some question of benefit), place patient on a monitor, give po ASA, give IV Heparin 4000U bolus followed by 12U/kg/hr drip.   Give Plavix vs Brilenta based on Cardiolgoy preference.

PAIL is a nice mnemonic to remember reciprocal changes.  The letter following the prior letter is where the reciprocal changes will be.  Posterior MI -Anterior depression, Anterior MI -Inferior depression, etc.  

With Inferior MI's, if the ST elevation in lead 3 is greater than lead 2 you are more likely to have an RCA occlusion.

 EKG suggestive of RCA occlusion.   Editor note:  A mnemonic I just made up is 3-2-1. ST elevation in 3>2 and ST depression in Lead 1.

EKG suggestive of RCA occlusion.   Editor note:  A mnemonic I just made up is 3-2-1. ST elevation in 3>2 and ST depression in Lead 1.

 EKG suggestive of Circumflex Occlusion.  Editor note: My next mnemonic is 2-3-none.  ST elevation is 2 and 3 are equal with no ST depression in Lead 1.    So, 3-2-1 and 2-3-none are mnemonics you can use to differentiate a RCA and Circumflex occlusion.

EKG suggestive of Circumflex Occlusion.  Editor note: My next mnemonic is 2-3-none.  ST elevation is 2 and 3 are equal with no ST depression in Lead 1.    So, 3-2-1 and 2-3-none are mnemonics you can use to differentiate a RCA and Circumflex occlusion.

 Wellen's syndrome is a sign of critical LAD stenosis. These patients are at high risk for Anterior MI and should not be given stress testing.  They need a cath.

Wellen's syndrome is a sign of critical LAD stenosis. These patients are at high risk for Anterior MI and should not be given stress testing.  They need a cath.

 De Winter EKG changes are considered an Anterior STEMI equivalent

De Winter EKG changes are considered an Anterior STEMI equivalent

Lovell    Occupational Wellness

The work culture and the system you work in is the largest factors contributing to burnout.  Factors in the work environment that are detrimental to wellness include loss of autonomy, and feeling undervalued by leadership or administration. 

Ways to battle burn out: 

1. Find Compassion role-models.  Try to model your behavior on people who are genuinely caring toward others.  These people can be uplifting to you in your work.   Make a connection with each human being you care for.

2. Your patients are not your enemies.  Patients are just looking for help.  They may have low health literacy.  Be their ally.  That mind frame is much more positive and better for your own wellness.

3. Foster social resilience.   You and your co-workers are really a tribe .  Being able to rely on others in your tribe is a big factor in your personal wellness as well as in your fellow tribe members.

4. Coping with medical error.    Acknowledge your own imperfection, learn and teach about mistakes, and most importantly forgive yourself.

5. Develop a growth mindset.   Your learning and knowledge evolve over time.  Learn to value feedback and even look for feedback.  Support other people's successes.     Avoid the fixed mindset where you feel your knowledge is fixed and you see other's successes are a threat.

6. Read about Medical Humanism

7. Mitigate your Unconscious Bias    You can go to Implicit.Harvard.edu and measure your implicit bias.  Try to take the perspective of people different from you.  Read a the article "How to be a real EP; Advice to new Graduates"  Roberts.  Editor note: Great article and pops up with a quick google search.

Excerpt:

Always put the patient's well-being and the family's expectations first and foremost. Everyone thinks you know far more than you actually do, so take advantage of that lovely yet secret scam, and step up and portray the Godsend they expect and want to believe you are.

Above all, always, always, always be nice. Remember, patients and family rarely remember exactly what you said, but they always remember exactly how you made them feel. There is only one time to make that first impression, a great opportunity to brand yourself as a hero and angel of mercy or a complete jerk. Be nice to the cleaning lady, security guard, cafeteria worker, and x-ray tech. And learn their names; they know yours.

In the end be kind to everyone you meet for they are all fighting a hard battle.  Ian Maclaren

Sklar    Safely Discharging ED Patients

The ED discharge process is high risk.  However, many physicians find the discharge process time consuming and not all that important. We need to re-cnsider our approach to discharging patients from the ED. 

We overestimate the patients' understanding of discharge instructions.  Only 22% of the time do we confirm that the patient understands our instructions.   Only 16% of the time do we ask if the patient has any questions.

Patients who do not understand their diagnosis and treatment plan are more likely to be non-compliant, bounce back to the ED, have increased morbidity/mortality, lower satisfaction, and increased risk of pursuing malpractice litigation.

Poor discharge planning and instruction is the #2 cause of malpractice litigation in EM. 

Factors increasing discharge risk: incomplete or misunderstood instructions, overly-fast discharge due to production pressure, discharge without reconciliation of symptoms and test results.

Discharge is really a Hand-Off to the patient's self care.  Treat discharge time similar to how you sign out patients to another physician.  Take the time and care to discuss with the patient and their family what they need to do at home to get better.

The majority of malpractice cases involve a patient who was discharged home. The emergency physician should have a template or checklist for safely discharging patients.

mnemonic WTF DR DC:

What we found, Treatments, Follow up plan, Drugs, Restrictions, Diagnosis, Come back if.....

 mnemonic as a Discharge TemplateWTF DR DC?

mnemonic as a Discharge TemplateWTF DR DC?

 AMA is a high risk ED discharge situation.  The above points are all very important.

AMA is a high risk ED discharge situation.  The above points are all very important.

 Great summary of using the discharge time period to make one last re-evaluation of the patient, their vitals, and their diagnostic testing results.

Great summary of using the discharge time period to make one last re-evaluation of the patient, their vitals, and their diagnostic testing results.

 

Walesa      Infection Control Update

Bottom line: Wash your Hands. It is the #1 way to prevent the spread of infections.   Minimize your use of urinary catheters. 

Hospital acquired infections are common (75,000 patients per year), potentially deadly, and very costly.

There are more bacteria in your mouth than there are people on the earth.

A handshake transfers 124 million bacteria between the two people.

Fingernails, thumbs, and webspaces are the spots most commonly missed when washing hands.

Hand sanitizer kills bacteria better than soap and water, except norovirus and c-diff.

When placing a central line, the chlorhexadine prep needs to dry to kill the bacteria.