Pediatric EM Morsels http://pedemmorsels.com Pediatric Emergency Medicine Education Mon, 29 Sep 2014 17:56:04 +0000 en-US hourly 1 http://wordpress.org/?v=4.0 Neonatal Leukemia http://pedemmorsels.com/neonatal-leukemia/ http://pedemmorsels.com/neonatal-leukemia/#comments Fri, 26 Sep 2014 11:00:15 +0000 http://pedemmorsels.com/?p=2996 We have discussed numerous common neonatal issues (ex, Analgesia, Umbilical Granuloma, Neonatal Tooth, Hyperbilirubinemia).  Many of us have learned that neonates are challenging and demand respect.  Even the most proficient practitioner...

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Neonatal Leukemia

We have discussed numerous common neonatal issues (ex, Analgesia, Umbilical Granuloma, Neonatal Tooth, Hyperbilirubinemia).  Many of us have learned that neonates are challenging and demand respect.  Even the most proficient practitioner will be apprehensive of the sick neonate, given that there are so many conditions to consider with so few clinical clues to help sort through them (ex, ALTE, Omphalitis, PGE1, Neonatal Resuscitation, Hypothermia).

While severe infections, congenital anomalies, and unusual metabolic conditions need to be pondered, it seems completely unfair that you should also have to consider cancer in neonates!!

Neonatal Leukemia - because life is not fair.

 

Neonatal Leukemia – Basics

  • Neonatal Leukemia is, fortunately, rare!
    •  Estimates of 1-5 per MILLION live births.
      • While rare, it does occur (our group just diagnosed a neonate with a WBC >900,000).
    • <1% of all childhood leukemia is diagnosed during the neonatal period.
  • Neonatal leukemia is not the same as childhood leukemia.
    • Neonatal leukemia is more likely to present with poor prognostic factors.
    • Neonatal ALL has a disease-free survival rate of ~10% compared to >70% in older children.
    • Neonatal leukemia is the leading cause of death in neonate due to neoplastic disease.
  • Trisomy 21 (Down Syndrome) and 11q23 translocation are the most common chromosomal aberrations associated with neonatal leukemia.
  • Timing of Presentation:
    • Some show signs at birth.
    • Some within a few days of birth.
    • Others present between the 3rd and 6th week of life.
      • This group may present in a more vague manner with failure to thrive, pallor, fever, and lethargy.

 

Neonatal Leukemia – Signs and Symptoms

  • Hyperleukocytosis

    • Present in the majority of ALL cases (85%), but only 49% of AML cases.
    • WBC > 50 x 10^9/L
    • Complications due to Hyperleukocytosis:
      • Leukostasis Syndrome
        • White Cells plug up the micro-circulation.
        • Heart Failure
        • Respiratory Failure (hypoxia, pulmonary infiltrates, tachypnea)
        • Neurologic insults (somnolence, coma, retinal hemorrhage)
  • Hepatosplenomegaly

    • Seen in about 80% of the cases.
    • Liver is more often enlarged than the spleen.
    • Other Lymphadenopathy is seen in only ~25% of cases.
  • Leukemia Cutis

    • Seen in about 60% of cases.
    • Caused by cutaneous leukemic infiltrates.
    • A firm blue, red, or purple nodular eruption.
    • Blueberry muffin baby.” – similar to what is seen with congenital infections.
    • Reported to be the INITIAL presenting sign in about 50% of cases!
      • Keep this on your list of items to look for in the neonate!
      • May precede the other signs by as much as 4 months!
  • Additional Findings

    • Bone Marrow Suppression (due to infiltrative disease)
      • Anemia
      • Thrombocytopenia
      • Neutropenia
    • CNS Infiltration
      • Seizures
      • Cranial Nerve Palsies
      • Bulging Fontanelle
      • Intracranial Hemorrhage
      • Infarction
    • Respiratory
      • Pulmonary Hemorrhage
      • Pneumonia
    • Sepsis

 

Neonatal Leukemia – on the Differential

  • Leukemoid Reaction
    • Causes elevated WBC counts and Hepatomegaly.
    • May also have BlueBerry Muffin Baby appearance.
    • Seen with Congenital Infections.
      • TOxoplasmosis, Rubella, CMV, HErpes, Syphilis, Listeria.
      • Also with Sepsis.
      • Typically have Intrauterine growth retardation and/or microcephaly.
  • Other Congenital Neoplasms (Neuroblastoma)
  • Hemolytic Disease of the Newborn
  • Congenital HIV Infection

 

Neonatal Leukemia – Initial Work-up

  • The definitive diagnosis will not be made in the ED, but your suspicion for it should lead you to obtain:
    • CBC with Differential
    • Peripheral Smear
    • Work up for Congenital Infections!
  • During the admission, the child will have Bone Marrow Aspirate performed to help make definitive diagnosis.

 

References

Orbach D1, Sarnacki S, Brisse HJ, Gauthier-Villars M, Jarreau PH, Tsatsaris V, Baruchel A, Zerah M, Seigneur E, Peuchmaur M, Doz F. Neonatal cancer. Lancet Oncol. 2013 Dec;14(13):e609-20. PMID: 24275134. [PubMed] [Read by QxMD]

van der Linden MH1, Creemers S, Pieters R. Diagnosis and management of neonatal leukaemia. Semin Fetal Neonatal Med. 2012 Aug;17(4):192-5. PMID: 22510298. [PubMed] [Read by QxMD]

Isaacs H Jr. Fetal and neonatal leukemia. J Pediatr Hematol Oncol. 2003 May;25(5):348-61. PMID: 12759620. [PubMed] [Read by QxMD]

Sande JE1, Arceci RJ, Lampkin BC. Congenital and neonatal leukemia. Semin Perinatol. 1999 Aug;23(4):274-85. PMID: 10475541. [PubMed] [Read by QxMD]

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Optimize Chest Compressions http://pedemmorsels.com/optimize-chest-compressions/ http://pedemmorsels.com/optimize-chest-compressions/#comments Fri, 19 Sep 2014 12:00:49 +0000 http://pedemmorsels.com/?p=2973   On occasion, I get the honor of being to “asked” to help with my daughter’s homework. It isn’t common, fortunately, as I don’t recall middle school algebra that well, but...

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Chest Compressions Basics

 

On occasion, I get the honor of being to “asked” to help with my daughter’s homework. It isn’t common, fortunately, as I don’t recall middle school algebra that well, but recently I was emphasizing the fact that you cannot expect excellent results from complicated systems (equations) if you fail to do the basics correctly.

Often we get distracted with “advanced” strategies and techniques. While advanced procedures can be effective, suboptimal performance of the basics will undermine the entire project.  This concept, I think, is easily reflected when we are involved in resuscitations.  Focusing on the choice between lidocaine, procainamide, and amiodarone is fruitless if the team is not performing the basics optimally.  Without question, The Basics are the Best!

We all know that the American Heart Association has emphasized the focus on the basics, and we recently discussed the need to de-emphasize pulse checks, but let us now look at how to optimize our chest compressions!

 

What are Quality Chest Compressions

  • For pediatrics patients quality chest compressions require:
    • Rate of 100 compressions per min
    • Compression Depth of 1/3 AP diameter
    • Compressions that allow for complete recoil of the chest!
      • This is just as vital as the depth and the rate, but often under appreciated!
      • It is during recoil phase that the heart chambers fill with blood and the coronary arteries have blood flow.

 

Quality Chest Compressions Matter

  • Goal of delivering CPR is Return of Spontaneous Circulation (ROSC) and Maintaining Cerebral Perfusion.
    • Obvious ROSC is important, but survival with good neurologic outcome is the real goal.
  • Quality chest compressions can generate good MAP.
    • This is integral to having a chance to provide cerebral perfusion!
    • Sutton et al. showed that quality chest compressions can generate systolic BP >80 and diastolic BP >30!
  • Quality chest compressions can lead to improved survival.
    • When compared to suboptimal chest compressions, quality chest compressions have been associated with improved survival in the first 24 hours.
    • Obviously, this does mean overall survival, but you have to start somewhere.

 

Optimize Chest Compressions

  • Since chest compressions are so important, one of the most important roles a team leader has is to ensure they are being optimized.
    • Use a BackBoard!
      • Even with adults this is important, but particularly true in children.
      • Often the compression of the gurney’s mattress will significantly diminish the actual AP compression of the patient!
      • The backboard can be easily overlooked and if not present, all of the efforts are being undermined!!
    • Get the timing down! Use a Metronome!
      • Often it is recommended to do compressions to the beat of a song…
        • But even if we all sing the same song, the tempo of that song can easily be misjudged.
      • Take the guess work out of it… is an automatic timing system.
        • Use a metronome to help define what 100/min is.
        • There is “an app for that.”  Some apps will use your smartphone’s flash to signal that rate… which give nice visual cues to the compressor.
        • There are also “fancy” commercial products available that can give cues to the timing and depth of compressions, but they aren’t free.
    • Use End-Tidal CO2 to provide feedback.
      • Studies show that EtCO2 can be a surrogate maker of blood flow produced during compressions in both adult and pediatric patients.
        • CPR is a low flow state, and as such, EtCO2 becomes less dependent upon CO2 production and ventilation and is more related to Cardiac Output.
        • Since pediatric arrests are usually due to respiratory (or infectious) etiology, do not rely on the initial EtCO2 value.
        • The value is more reliable after 1 min of compressions.
      • Goal EtCO2 of between 10-15 during chest compressions.
        • Can be used as a feedback device… as it indicates quality compressions are being done.
        • If EtCO2 <10, ROSC is unlikely. Double check your quality characteristics!
      • If EtCO2 increases substantially during chest compressions, this likely indicates ROSC.
        • Using this method can help decrease interruptions in chest compressions for “pulse checks.”
        • Just seeing an increase would not lead me to stopping compressions… I’d likely complete that 2 min cycle before checking for pulse.
    • Mandate the Rotate!
      • While we work with many true heroes, this is not a time to allow someone’s self-sacrifice to interfere with quality chest compressions.
        • Even the strongest and biggest person will get tired.
        • The power to do quality chest compressions is similar to that of running or swimming.
        • While the compressor may be a physically fit individual, he/she will not sprint at the same rate the entire time.
      • Studies show there is a measurable and significant decrement in quality of chest compressions at 2 minutes for both adult and pediatric patients!
        • Interestingly, the rate and depth often stays the same, but the compressor begins to lean on the chest.
        • This decreases the chest recoil!!  We cannot have that.
      • Do not ask if the compressor is “ok.”
        • Tell him or her that it is time to rotate rapidly and have the next person prepped and ready to take over without interruption!
        • Even if it is Superman, tell him it is time to rotate for the sake of optimizing your chest compressions!

References

Hamrick JL1, Hamrick JT, Lee JK, Lee BH, Koehler RC, Shaffner DH. Efficacy of chest compressions directed by end-tidal CO2 feedback in a pediatric resuscitation model of basic life support. J Am Heart Assoc. 2014 Apr 14;3(2):e000450. PMID: 24732917. [PubMed] [Read by QxMD]

Sutton RM1, French B2, Niles DE3, Donoghue A3, Topjian AA3, Nishisaki A3, Leffelman J3, Wolfe H3, Berg RA3, Nadkarni VM3, Meaney PA3. 2010 American Heart Association recommended compression depths during pediatric in-hospital resuscitations are associated with survival. Resuscitation. 2014 Sep;85(9):1179-84. PMID: 24842846. [PubMed] [Read by QxMD]

Badaki-Makun O1, Nadel F, Donoghue A, McBride M, Niles D, Seacrist T, Maltese M, Zhang X, Paridon S, Nadkarni VM. Chest compression quality over time in pediatric resuscitations. Pediatrics. 2013 Mar;131(3):e797-804. PMID: 23439892. [PubMed] [Read by QxMD]

Sutton RM1, French B, Nishisaki A, Niles DE, Maltese MR, Boyle L, Stavland M, Eilevstjønn J, Arbogast KB, Berg RA, Nadkarni VM. American Heart Association cardiopulmonary resuscitation quality targets are associated with improved arterial blood pressure during pediatric cardiac arrest. Resuscitation. 2013 Feb;84(2):168-72. PMID: 22960227. [PubMed] [Read by QxMD]

Tress EE1, Kochanek PM, Saladino RA, Manole MD. Cardiac arrest in children. J Emerg Trauma Shock. 2010 Jul;3(3):267-72. PMID: 20930971. [PubMed] [Read by QxMD]

Kleinman ME, de Caen AR, Chameides L, Atkins DL, Berg RA, Berg MD, Bhanji F, Biarent D, Bingham R, Coovadia AH, Hazinski MF, Hickey RW, Nadkarni VM, Reis AG, Rodriguez-Nunez A, Tibballs J, Zaritsky AL, Zideman D; Pediatric Basic and Advanced Life Support Chapter Collaborators. Part 10: Pediatric basic and advanced life support: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation. 2010 Oct 19;122(16 Suppl 2):S466-515. PMID: 20956258. [PubMed] [Read by QxMD]

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Intussusception & Altered Mental Status http://pedemmorsels.com/intussusception-altered-mental-status/ http://pedemmorsels.com/intussusception-altered-mental-status/#comments Fri, 12 Sep 2014 20:10:38 +0000 http://pedemmorsels.com/?p=2958 Evaluating the child with altered mental status can be very challenging.  As with adults, there are a myriad of potential etiologies and it can be difficult to prioritize the order...

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Intussusception Altered Mental Status

Evaluating the child with altered mental status can be very challenging.  As with adults, there are a myriad of potential etiologies and it can be difficult to prioritize the order of the evaluation.  Does this patient have an intracranial process or maybe just simple hypogylcemia?  Or maybe we need to consider serious bacterial infections and intoxicants instead?

Many of you will recall the mnemonic “TIPS AEIOU” [Trauma, Infection, Psych, Space Occupying Lesion, Alcohol, Electrolytes, Insulin, Opiates, Uremia] to help consider a number of the potential etiologies of altered mental status.  I use this often, but it is important to remember that along with “infection” and “insulin” the “I’s” also stand for “Intussusception.”

 

Intussusception Basics

  • Occurs when one segment of bowel telescopes into the adjacent segment.
  • Second most common abdominal emergency (appendicitis is #1).
  • Most often this occurs near the ileocecal valve.
  • Most are idiopathic.
  • ~5% are associated with lead points or disease

 

Intussusception Presentation

  • “Classic” presentation (Abdominal Pain, Currant Jelly Stools, and vomiting) is only seen in 20%- 33% of cases.
  • 75% without obviously bloody stools will have positive occult blood.  
    • Great reason to check heme occult for the vomiting child without diarrhea.
  • Abdominal Mass is commonly found (when looked for).
  • Fever, anorexia, diarrhea, and dehydration can be seen and can lead to misdiagnosis.
  • Many cases are missed upon initial evaluation — we must always remain vigilant!

 

Intussusception and Altered Mental Status

  • Along with the classic and common presentations, patients with intussusception may also present with altered mental status.
  • This altered mental status is often thought of as the child being inconsolable.
    • Most practitioners will have intussusception high on the DDx in the child with inconsolability and vomiting.
  • Additionally, significant somnolence and lethargy can be seen with intussusception!
    • Numerous cases have been reported that highlight this fact.
    • Cause of the lethargy is unclear.
    • Presence of lethargy does not, necessarily, portend a worse outcome (but does contribute to delayed diagnosis, which can lead to more morbidity/mortality).
  • Cases of intussusception and altered mental status often also have history of:
    • Vomiting,
    • Heme-positive stool,
    • Abdominal Pain,
    • or Abdominal Mass

 

POCUS and Altered Mental Status

  • So how can Point of Care Ultrasound (POCUS) help with the evaluation of altered mental status in a child?
  • POCUS can be used to AUGMENT the physical exam.
    • Studies have shown the POCUS can be used by emergency practitioners (in a variety of locales) to rule-in the diagnosis of intussusception.
    • The evaluation should not (yet) be used to rule-out the diagnosis; however, it’s utility can help prioritize the next most appropriate step.
      • For instance, consider the 18 month old presenting with lethargy and episodes of non-bilious emesis.  You perform POCUS:
        • If consistent with intussusception, then call your surgeon and your radiologist.
        • If not consistent with intussusception, it may still be present, but you may want to get that Head CT and give antibiotics before getting abdominal imaging.

 

Moral of the Morsel

Altered Mental Status?  Augment your exam with POCUS.  It may be intussusception.

 

References

Halm BM. Reducing the time in making the diagnosis and improving workflow with point-of-care ultrasound. Pediatr Emerg Care. 2013 Feb;29(2):218-21. PMID: 23546429. [PubMed] [Read by QxMD]

Gingrich AS1, Saul T, Lewiss RE. Point-of-care ultrasound in a resource-limited setting: diagnosing intussusception. J Emerg Med. 2013 Sep;45(3):e67-70. PMID: 23777777. [PubMed] [Read by QxMD]

Stolz LA1, Kizza H, Little K, Kasekende J. Intussusception detected with ultrasound in a resource-limited setting. Lancet. 2013 Jun 8;381(9882):2054. PMID: 23746905. [PubMed] [Read by QxMD]
Raymond-Dufresne É1, Ghanayem H. Towards evidence-based emergency medicine: best BETs from the Manchester Royal Infirmary. BET 2: Can emergency physicians safely rule in or rule out paediatric intussusception in the emergency department using bedside ultrasound? Emerg Med J. 2012 Oct;29(10):854-5. PMID: 23038721. [PubMed] [Read by QxMD]

Birkhahn R1, Fiorini M, Gaeta TJ. Painless intussusception and altered mental status. Am J Emerg Med. 1999 Jul;17(4):345-7. PMID: 10452429. [PubMed] [Read by QxMD]

Hickey RW1, Sodhi SK, Johnson WR. Two children with lethargy and intussusception. Ann Emerg Med. 1990 Apr;19(4):390-2. PMID: 2321825. [PubMed] [Read by QxMD]

Heldrich FJ. Lethargy as a presenting symptom in patients with intussusception. Clin Pediatr (Phila). 1986 Jul;25(7):363-5. PMID: 3709021. [PubMed] [Read by QxMD]

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Intranasal Analgesia http://pedemmorsels.com/intranasal-analgesia/ http://pedemmorsels.com/intranasal-analgesia/#comments Fri, 05 Sep 2014 12:00:00 +0000 http://pedemmorsels.com/?p=2939 Being flexible and creative are important traits to have while working the ED.  It is also vital to always keep the end result in mind.  Pain control is always an important...

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Intranasal

Being flexible and creative are important traits to have while working the ED.  It is also vital to always keep the end result in mind.  Pain control is always an important endpoint for us to constantly consider.  While most of us would say that we strive alleviate our patients’ pain, there is evidence that we are not great at it.

 

It’s Complicated

  • Why would we not alleviate pain optimally?  Well, like many things, it is more complicated than us just cruel and sadistic.
  • Certainly, there used to be a perception that pain in kids (especially neonates) was not as important since they wouldn’t remember it. – WRONG.
  • Additionally, there are times when our consultants have “requested” that we didn’t give pain medications (ex, Morphine for Appendicitis). – A MYTH.
  • Of course, we need to always remain optimally educated on the subject (THANKS FOR READING THE PEDEM MORSELS!).
  • But even with a highly educated and compassionate provider, delivering appropriate analgesics in a timely fashion is not easy:
    • You have to evaluate the patient, then write the orders.
    • Often these orders include Intravenous Analgesics (ex, IV Morphine).
    • This, in turn, requires an IV.
      • Now, in a busy ED, a nurse may not be able to promptly jump in that room an place the IV.
      • Placing an IV is also not always an easy task.
    • All of these steps and possible obstructions can easily lead to delayed analgesic administration.
    • Now, despite how compassionate you are… you appear to be cruel!

 

Intranasal Route – No Need for an IV

  • We all know that the blood supply to the nose is quite robust.
    • Anyone who has bonked their nose knows.
    • Our patients who snort heroine or cocaine also know.
  • The venous drainage from the nose conveniently ends up in the SVC, avoiding the liver (and 1st pass metabolism).
  • The anterior potion of the nose (the Vestibule) is the main site for drug absorption as it has a relatively large surface area and has a good blood supply.
  • Volumes of 0.3 mL are easily tolerated.
    • This requires concentrated solutions of the administered medications.
    • If you need to use larger volumes, you can divide the dose in half and use each nostril.
    • If the volume is still too large, you can administer in separate aliquots separated by 10-15 minutes… or use another strategy (nothing is perfect).

 

Intranasal Fentanyl to the Rescue

  • Fentanyl is a great example of a medication that works well when given via the intranasal route.
    • It has a low molecular weight.
    • It is lipophilic.
    • It has concentrated versions (50 microgr/mL – 150 microgr/mL).
  • Fentanyl (1-2 micrograms/kg) given via intranasal route has proven to be as efficacious as IV Morphine (0.1 mg/kg).
  • It has also been shown that intranasal fentanyl can be administered more rapidly than IV morphine to pediatric patients in the ED.

 

A Reasonable Approach (at least I think so)

  • Intranasal Fentanyl can be delivered before even an IV can be placed.
  • Even if you still need an IV (say for the grossly deformed forearm that you know will need procedural sedation), the intranasal fentanyl is still a faster way to get analgesics on board.
    • Yes, it might require some explanation that you are going to squirt pain meds up the kid’s nose and then still place an IV… but the focus is on delivering pain meds quickly.
    • This will likely also help the nursing team trying to get the IV, as now they have a more comfortable and cooperative patient.
    • It also helps speed up the process for getting your X-rays… now you are not waiting for the IV to give the pain meds so that you don’t feel like a sadist getting the xrays.
  • In the end, this also helps you… not feeling like a sadist is very helpful in avoiding compassion fatigue... and will help keep you happier as a physician!

 

 

 

 

References

Del Pizzo J1, Callahan JM. Intranasal medications in pediatric emergency medicine. Pediatr Emerg Care. 2014 Jul;30(7):496-501; quiz 502-4. PMID: 24987995. [PubMed] [Read by QxMD]

Dong L1, Donaldson A, Metzger R, Keenan H. Analgesic administration in the emergency department for children requiring hospitalization for long-bone fracture. Pediatr Emerg Care. 2012 Feb;28(2):109-14. PMID: 22270501. [PubMed] [Read by QxMD]

Holdgate A1, Cao A, Lo KM. The implementation of intranasal fentanyl for children in a mixed adult and pediatric emergency department reduces time to analgesic administration. Acad Emerg Med. 2010 Feb;17(2):214-7. PMID: 20070272. [PubMed] [Read by QxMD]

Borland M1, Jacobs I, King B, O’Brien D. A randomized controlled trial comparing intranasal fentanyl to intravenous morphine for managing acute pain in children in the emergency department. Ann Emerg Med. 2007 Mar;49(3):335-40. PMID: 17067720. [PubMed] [Read by QxMD]

Bauman BH1, McManus JG Jr. Pediatric pain management in the emergency department. Emerg Med Clin North Am. 2005 May;23(2):393-414, ix. PMID: 15829389. [PubMed] [Read by QxMD]

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Palpation of Pulse for Cardiac Arrest http://pedemmorsels.com/palpation-of-pulse-for/ http://pedemmorsels.com/palpation-of-pulse-for/#comments Fri, 29 Aug 2014 11:00:00 +0000 http://pedemmorsels.com/?p=2923 One of my personal goals is to make my life easier.  Yes, that is easier said than done; particularly given my proclivity for working in the Emergency Department.  The ED is...

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Pulse Check

One of my personal goals is to make my life easier.  Yes, that is easier said than done; particularly given my proclivity for working in the Emergency Department.  The ED is not an easy place to work many times, particularly when faced with truly life-altering events like a pediatric cardiac arrest.  While managing pediatric cardiac arrests is never easy (no matter how clinically skilled you are), the first task of determining whether the child actually does or does not have a pulse would seem to be the easiest.  Sadly, it is not.

 

Phases of Pediatric Cardiac Arrest

  • Pre-Arrest
    • This is where Injury Prevention has the greatest potential to save lives.
      • The Back to Sleep program, Submersion awareness, and trauma prevention are example.
    • Also where being vigilant for “covert sickness can came in handy (hopefully the Morsels help you with this part).
  • No-Flow
    • This is the Arrest part (obviously).
    • We really need to limit the time spent in this phase!
    • Factors that are known to be associated with survival with good neurologic outcomes are:
      • Having the arrest be witnessed.
        • Obviously, this impacts the time for an AED to arrive, initiation of bystander CPR, etc.
      • Having the duration of CPR be short.
      • Having an initial rhythm that is shockable (much more rare occurrence in children).
      • Younger age.
  • Low-Flow
    • This begins when CPR begins.
    • The goal is to obtain Return of Spontaneous Circulation (ROSC) as well as maintain cerebral perfusion!
    • We know that the basics of CPR (quality Chest Compressions while allowing recoil of the chest wall and minimizing interruptions) are the most important aspects of the resuscitation.
  • Post-Arrest
    • After ROSC is obtained, the body experiences multiple stressors and potential injuries.
    • Post-Cardiac Arrest Syndrome
      • Brain Injury
      • Myocardial Dysfunction
      • Systemic ischemia/reperfusion response (similar to SEPSIS)

 

Palpation of Pulse is Not Easy

  • If getting out of the No-Flow phase is imperative, then it means that detecting the No-Flow phase is important so that chest compressions can be started promptly.
  • Problem: We aren’t good at feeling pulses!
    • When medical providers were challenged to determine whether a pulse was present in patients (don’t worry, the patients were on ECMO):
      • Only 78% of doctors and nurses correctly determined presence or absence of a pulse.
      • 14% of the time the falsely identified the presence of a pulse!
    • Therefore, 14% of the time when compressions should have been initiated, they would have been delayed.
  • Problem: We need more time… that the kid doesn’t have!
    • We are supposed to detect a pulse within 10 seconds
    • The mean time for rescuers to determine a lack of a pulse was 30 seconds.
    • Interestingly, experienced doctors and nurses are quicker at deciding when a pulse is present, BUT they are not quick at deciding when a pulse is absent!!
    • Essentially, experience helps you to rule-out cardiac arrest, but not rule it in!
  • Palpation of pulse by healthcare providers to diagnose cardiac arrest in infants and children is both time-wasteful and unreliable!” (Tibballs, 2010).

 

When Should You Start Chest Compressions?

  • It is advocated that the lay-public minimize the importance of palpation of pulse.
  • Lay-person rescuers have been advised to give chest compressions to a collapsed infant/child on the basis of observation of lack of movement, unresponsiveness and inadequate breathing.
  • While skilled professionals (like us) should determine whether there is a pulse, we should also recognize that every second counts and if you are uncertain after 9 seconds, err on the side of being conservative with overcalling a lack of pulse.
    • Essentially, I would rather be wrong by starting chest compressions when the child has a weak pulse that I have not appreciated rather than not starting compressions when they are needed.
    • So make your job easier… stop trying to be perfect and err on the side of being safe… if you aren’t sure there is a pulse after 9 seconds… on the 10th second initiate compressions!!

 

 

 

References

Sandroni C1, Nolan J; European Resuscitation Council. ERC 2010 guidelines for adult and pediatric resuscitation: summary of major changes. Minerva Anestesiol. 2011 Feb;77(2):220-6. PMID: 21368728. [PubMed] [Read by QxMD]

Tibballs J1, Weeranatna C. The influence of time on the accuracy of healthcare personnel to diagnose paediatric cardiac arrest by pulse palpation. Resuscitation. 2010 Jun;81(6):671-5. PMID: 20227813. [PubMed] [Read by QxMD]

Tibballs J1, Russell P. Reliability of pulse palpation by healthcare personnel to diagnose paediatric cardiac arrest. Resuscitation. 2009 Jan;80(1):61-4. PMID: 18992985. [PubMed] [Read by QxMD]

Sarti A1, Savron F, Ronfani L, Pelizzo G, Barbi E. Comparison of three sites to check the pulse and count heart rate in hypotensive infants. Paediatr Anaesth. 2006 Apr;16(4):394-8. PMID: 16618292. [PubMed] [Read by QxMD]

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Eating Disorders http://pedemmorsels.com/eating-disorders/ http://pedemmorsels.com/eating-disorders/#comments Fri, 22 Aug 2014 11:00:52 +0000 http://pedemmorsels.com/?p=2899   Most of us entered into the practice of medicine to “make a difference.”  {Having read a lot of applicants’ personal statements, I know this to be true.}  The realm...

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Eating Disorder2

Most of us entered into the practice of medicine to “make a difference.”  {Having read a lot of applicants’ personal statements, I know this to be true.}  The realm of Pediatric Emergency Medicine often places us in the most ideal arena to fulfill that calling, but we often are looking at the more dramatic presentations.  Let us not forget that our astute diagnostic skills can be extremely useful even when the presentations are less dramatic.  Patients with Eating Disorders can often present with subtle cues (see Bradycardia) and if you are vigilant, you can make a profound difference — just like you always wanted to do.

 

Eating Disorders in the ED

  • Prevalence of clinically significant eating disorders in adolescents and adults in the ED is estimated at 16%.
  • Patients with eating disorders have been found to have increased utilization of all healthcare services including the EDs.
  • Although rare in general adult population, eating disorders are one of the most prevalent chronic disorders in teens and young adults.
  • Anorexia Nervous is the third most common chronic condition in adolescent girls – behind obesity and asthma.

 

Anorexia Nervosa

  • Basics

    • Peak: women – 15-19 years; men – 10-24 years
    • Highest mortality rate of ANY Psychiatric Disorder!
      • Suicide accounts for ~20%
      • Medical causes account for the majority of mortality associated with anorexia nervosa.

 

  • Associated Conditions

    • High-Level Exercise and Athletic Competition
    • Depression or Anxiety Disorder
    • Substance Abuse
    • Early childhood eating and gastrointestinal problems
    • Perfectionism and self-esteem issues
    • History of sexual abuse
    • “High-concern parenting”

 

  • Signs and Symptoms

    • Hypotension (SBP <90 mmHg, DBP <50 mmHg)
    • Bradycardia (HR <60 bpm)
    • Brittle nails
    • Thinning hair
    • Fine lanugo hair on side of face and arms
    • Anemia, leukopenia, hypoglycemia, hypophosphatemia – usually only seen with severe disease.

 

  • Medical Complications

    • Cardiovascular
      • Decreased cardiac muscle from malnutrition leading to decreased heart function.
        • IV fluids need to be given carefully, as pulmonary edema can develop.
      • Bradycardia thought to be due to increased vagal tone.
      • Serious dysrhythmias can lead to sudden death.  Respect Syncope in this patient!
      • Mitral Valve Prolapse develops from diminished cardiac muscle mass with the valve remaining unchanged.
    • Fluid/Electrolytes
      • Serious disorders can occur with Refeeding Syndrome
        • Hypophosphatemia leading to low ATP levels.
        • This impairs muscle contractions in the heart and diaphragm –> arrest.
        • Low magnesium and low potassium also can be altered with refeeding syndrome and cause arrhythmias.
      • Even a bag of D5 Normal Saline (200 kcal) can be deleterious in the patient who only consumes 400 kcal a day.
    • Gastrointestinal
      • Delayed gastric and colonic emptying
      • High risk for gastroparesis, gastric distention, GER, constipation, and SMA syndrome.
    • Skeletal
      • Osteoporosis develops from altered hypothalamic-pituitary axis.
      • Back Pain in this patient should not be dismissed as muscle strain.

 

Bulimia Nervosa

  • Basics

    • Self-induced vomiting and abuse of diuretics and laxatives are the most common purging mechanisms.
    • Peak: women – 16-20 years
    • Bulimia is more common than anorexia.

 

  • Associated Conditions

    • Psychiatric Disorders
    • Substance Abuse
    • Childhood obesity
    • Sexual abuse
    • Poor self-esteem
    • Parental substance abuse and obesity
    • Parental expectations
    • Previous dieting

 

  • Signs and Symptoms

    • Likely have normal body weight.
    • Painless bilateral hypertrophied salivary glands.
    • Poor dentition
    • Russell sign – erosions over the dorsum of the hands from self-induced emesis.
    • Metabolic alkalosis c/w vomiting (with low potassium)

 

  • Medical Complications

    • Cardiac
      • Binge-Purge subtype is at great risk for hypokalemia and subsequent arrhythmias.
    • Fluid/Electrolytes
      • Metabolic alkalosis, hypochloremia, hypokalemia.
      • Chronic contraction alkalosis and dehydration.
    • Gastrointestinal
      • Odynophagia, hoarseness, dysphagia, heartburn, GER
      • Chronic laxative abuse leading to cathartic colon syndrome (damaged intestinal nerve cells).

 

SCOFF, but don’t DisMiss it!

  • To help you further refine your concern when your sixth-sense is alarming, you can use the screening tool SCOFF.
    1. Do you ever make yourself SICK, because you feel uncomfortably full?
    2. Do you worry you have lost CONTROL over how much you eat?
    3. Have you recently lost more than One Stone (14 pounds) in a 3 month period?
    4. Do you believe yourself to be FAT when others say you are too thin?
    5. Do thoughts and FEARS about food and weight dominate your life?
  • 2 or more “Yes” answers is suggestive of an eating disorder.

 

Disposition?

  • If the patient is medical stable, then disposition should still include social work and psychiatric consultation to provide resources.
  • Particular attention should be paid to the potential for suicidal risk (suicide is frequent with patients who have eating disorders).
  • Helping to establish to referral to a eating disorder specialist would be ideal so that all of the medical and comorbid states can be addressed.
  • Admission should be considered for those with:
    • Adolescent with bradycardia < 50 bpm (Adult < 50 bpm)
    • Syncope (potentially concerning for an arrhythmia)
    • Severe electrolyte derangement
    • Psychiatric disorder concurrent
    • Suicidal ideation

References

Trent SA1, Moreira ME, Colwell CB, Mehler PS. ED management of patients with eating disorders. Am J Emerg Med. 2013 May;31(5):859-65. PMID: 23623238. [PubMed] [Read by QxMD]

Dooley-Hash S1, Banker JD, Walton MA, Ginsburg Y, Cunningham RM. The prevalence and correlates of eating disorders among emergency department patients aged 14-20 years. Int J Eat Disord. 2012 Nov;45(7):883-90. PMID: 22570093. [PubMed] [Read by QxMD]

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Catecholaminergic Polymorphic VTach http://pedemmorsels.com/catecholaminergic-polymorphic-vtach/ http://pedemmorsels.com/catecholaminergic-polymorphic-vtach/#comments Fri, 15 Aug 2014 12:00:13 +0000 http://pedemmorsels.com/?p=2882 Honestly, one of the best aspects of writing the Ped EM Morsels weekly is that I benefit from learning (or re-learning) something each week. This week is a great example...

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PolyMorphic VTach

Honestly, one of the best aspects of writing the Ped EM Morsels weekly is that I benefit from learning (or re-learning) something each week. This week is a great example of that phenomenon. We do not often have to care for the pediatric cardiac arrest, but when we do we take comfort in our advanced training and can rely on some of the basic concepts and recommendations (AHA Resuscitation Guidelines). What happens, though, when our advanced life support training steers us in the wrong direction? Let us consider the unusual case of Catecholaminergic Polymorphic Ventricular Tachycardia.

Catecholaminergic Polymorphic VTach: Basics

  • Rare, but important cause of syncope or sudden death in kids.
    • Mortality as high as 35% by age 30 years when untreated.
    • Worse prognosis for those who present earlier in life.
  • Malignant arrhythmogenic disorder that is characterized by:
    • Structurally normal heart,
      • Unlike Hypertrophic Cardiomyopathy.
      • Unlike Arrhythmogenic Right Ventricular Dysplasia
    • Normal baseline ECG (some may have borderline long QTc),
      • Unlike Long QT Syndrome
      • Unlike Short QT Syndrome
      • Unlike Brugada Syndrome
      • Unlike Wold-Parkinson-White Syndrome
    • Polymorphic VTach induced by:
      • Exercise or
      • Emotional Stress or
      • Other cause of Increased Catecholamines (ex, illicit substances)
  • Generally presents between ages of 7 and 9 years.
  • Uncommon to present before age 2 years.

 

Catecholaminergic Polymorphic VTach: Genetics

  • Family history of exercise-related syncope, seizure, or sudden death is reported in 30% of cases.
  • Caused by gene mutations.
    • Likely several genes involved, but two are known (RyR2 and CASQ2)
    • Both encode of proteins that regulate intracellular calcium!
  • It is recommended that other family members are tested and treated if found to have the genes.

 

Catecholaminergic Polymorphic VTach: Presentation

  • Typically will present with syncope and/or “seizure.”
    • Often initially misdiagnosed as either seizure or benign cause of syncope.
    • Mean delay in correct diagnosis is ~ 2 years.
  • Resting ECG is normal.
  • There is progressive ventricular ectopy as the heart rate increases.
    • Between 100-120 beats per minute there is increasing complexity.
    • First isolated PVCs evolve to bigeminy and then runs of nonsustained VTach.
    • Eventually, sustained VTach and Polymorphic VTach are observed.

 

Catecholaminergic Polymorphic VTach: Daily Therapy

  • It is recommended that ALL phenotypically and genotypically diagnosed individuals receive therapy.
  • OPTIONS:
    •  Beta-Blockers
      • 1st line
      • Nadalol is often used
    • Implantable Cardioverter Defibrillator (ICD)
      • Used for those who fail medications or for those who present with an aborted cardiac arrest.
      • Should be used concurrently with beta-blockers to avoid electrical storm caused by the adrenergic surge from the shocks.
    • Flecainide
    • Verapamil
    • Left Cardiac Sympathetic Denervation
  • Also recommended that they avoid competitive sports or other stimulants.

Catecholaminergic Polymorphic VTach: ACUTE Therapy

  • Managing a patient with CPVT who is in VTach can be tricky.
  • The most important step is recognizing that the patient has Catecholaminergic Polymorphic VTach.
    • Family history is integral!
    • Previous history of syncope or seizure can raise suspicion for it as well.
  • Standard use of Epinephrine during the resuscitation can be counterproductive.
  • IV beta-blockers is considered first choice, similar to VTach storm of other etiologies.
  • Given that it is Polymorphic VTach, it would also be reasonable to administer Magnesium, but this would be aimed at possible Prolonged QTc.

 

Moral of the Morsel

  • This represents a significant challenge for us in the Emergency Department. It is rare and can present in a benign fashion (syncope). Even those who are thorough and obtain an ECG may be inappropriately reassured by the normal ECG.
  • The patient who has had a SYNCOPAL event deserves consideration for multiple entities (ex, Prolonged QTc, SVT) and should have a screening ECG.
  • Ask about family history!  You can’t outrun your genes.
  • Ask about prior syncopal events that were associated with exciting or stressful situations.
  • Don’t always assume wellness just because the patient is young.

 

References

Leenhardt A1, Denjoy I, Guicheney P. Catecholaminergic polymorphic ventricular tachycardia. Circ Arrhythm Electrophysiol. 2012 Oct;5(5):1044-52. PMID: 23022705. [PubMed] [Read by QxMD]
Pflaumer A1, Davis AM. Guidelines for the diagnosis and management of Catecholaminergic Polymorphic Ventricular Tachycardia. Heart Lung Circ. 2012 Feb;21(2):96-100. PMID: 22119737. [PubMed] [Read by QxMD]

Heiner JD1, Bullard-Berent JH, Inbar S. Deadly proposal: a case of catecholaminergic polymorphic ventricular tachycardia. Pediatr Emerg Care. 2011 Nov;27(11):1065-8. PMID: 22068070. [PubMed] [Read by QxMD]

van der Werf C1, Zwinderman AH, Wilde AA. Therapeutic approach for patients with catecholaminergic polymorphic ventricular tachycardia: state of the art and future developments. Europace. 2012 Feb;14(2):175-83. PMID: 21893508. [PubMed] [Read by QxMD]

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