• Shyam Murali

Grand Rounds Review: 11/6/19

Board Review Pearls - Paul de Saint Victor, MD

  • MI with LBBB or paced rhythm, use Sgarbossa Criteria

  • Tox Scents - Wintergreen --> Methylsalicylate - Garlic --> Organophosphates - Freshly mown hay --> Phosgene - Rotten eggs --> Sulfur - Bitter Almonds --> Cyanide

  • Pediatric Foreign bodies - Most common cause of in-home death in <6y/o - Right mainstem bronchus is most common site - Complete airway obstruction in <1 y/o - 5 back blows and 5 chest compressions - >1yo - 5 back blows and 5 abdominal thrusts - Most are not radio-opaque (eg. food, peanuts)

  • Cholinergic vs Anticholinergic - Cholinergic - SLUDGE, DUMBBELLS mnemonics; KILLERS ARE BRONCHORRHEA, BRONCHOSPASM, AND BRADYCARDIA - Anticholinergic




Croup - Tucker Carlson, DO

Subglottic airway inflammation causing respiratory illness
  • Viral illness, generally caused by parainfluenza virus

  • Usually presents in fall and early winter, 2nd year of life, ED visits at nighttime hours

  • 1-3 day prodrome

  • "Steeple sign" - narrowing of the subglottic airway

  • Workup: clinical diagnosis - labs and imaging are not helpful overall. Can get respiratory viral panel to give parents an answer, if needed.

  • Westley Croup score can be used to help determine the severity of illness

  • Treatment - ABCs - Don't agitate the child - Dexamethasone 0.6mg/kg for all croup - Racemic epinephrine (0.05mL/kg of 2.25% solution) for moderate-severe croup. Have a 3 hour observation period to ensure that you don't have rebound symptoms (very rare according to our attending physicians). Decreases admission and need for intubation.

  • Ineffective treatments: humidified air, heliox, B-agonists (may actually worsen symptoms)

  • Indications for admission: persistent stridor at rest, tachypnea, retractions, Hypoxia, need for more than two epi treatments

  • Discharge Criteria: No stridor at rest, normal pulse ox on room air, good air exchange, normal color, normal level of consciousness, able to tolerate PO intake

  • Intubate if needed for refractory respiratory distress, Call anesthesia for backup, use smaller ETT


Influenza - Heidi Hutchison, MD

  • Significant social and financial burdens; high mortality rates

  • 2017-18 deadliest season since 1976 due to highly mutagenic strain and hurrican's effects on limited fluids and antivirals

  • Transmission via respiratory secretions

Infects epithelial cells of upper respiratory tract and alveolar cells of lower respiratory tract
  • Clinical presentation

  • Complications - Pneumonia - caused by influenza itself or secondary bacterial infections - Acute bronchitis - Otitis media - common coinfection in children - Exacerbation of cardiopulmonary disease in elderly - most common cause of death - Rare: aseptic meningitis, pericarditis, post-infectious neuritis

  • High Risk Populations - Very young and very old - Pregnant - Immunocompromised - Chronic pulm or CV disease - Children receiving ASA or salicylate-containing meds - Nursing home or LTAC residents - Native Americans/Alaska Natives - Extremely obese (BMI>40)

  • Diagnosis - Viral culture and RT-PCR - gold standard for diagnosis but not clinically useful or practical - Sensitivity of rapid flu test is extremely variable - More sensitive in pediatric patients and during first 48hrs of illness - Positive and negative predictive values change based on prevalence of influenza in the community

  • Prevention and Treatment - Flu Vaccine for everyone >6mo, with a few contraindications - Discuss importance of vaccination with your patients; it can reduce incidence and severity of disease - Vitamin C does not work

  • Check out the CDC resources to help educate patients

  • ED Management - Avoid aspirin - Antivirals - within 48 hours for anyone with suspected flu who is hospitalized, has severe/complicated/progressive illness, or is high risk. Reduces rate of flu-related complications. > Oseltamivir (Tamiflu) - Shortens course of disease by 29-36 hours if started within first 48 hours of illness - Decreases virus shedding - Approved for any age for treatment - Side effects: nausea, vomiting, headache, rarely skin reactions, neuropsychiatric effects - Expensive medication

  • Consider chemoprophylaxis with Oseltamivir in certain circumstances (eg. post-exposure in unvaccinated high-risk patients or in immunosuppressed patients)


Pediatric Fever QA Project - Ben Wurst, DO

Dr. Wurst performed his senior QA project on pediatric fever, focusing on 2mo to 2yo children. He used metrics established by physician groups and insurance companies to come up with the ideal documentation process for pediatric fever. He then reviewed a few of our own pediatric fever charts to critique them and provide constructive feedback.

  • Important documentation for history and physical


  • MDM should reflect why you chose your workup - Document a chart review if you looked at old records - Include interpretation of results and conversations with consultants - Summarize the complaint, plan, and the reason for that plan - Paint a picture of how sick or not sick the patient is; consider the medical comorbidities of the patient

  • Reevaluate the patient and document serial exams

  • Discharge instructions - schedule follow up in the ED or with PCP in 24 hours or sooner

  • He gave a shoutout to ALiEM for their documentation pearls


Respiratory Syncytial Virus - Max Buchwalder, DO

  • Most common cause of bronchiolitis

  • Peak in January and February

  • Significant mucous production

  • Leading cause of hospitalization in children under 1y/o

  • Primarily a clinical diagnosis; can use respiratory viral panel to give parents an answer

  • Presentation:

  • There is a higher concurrence of UTI with bronchiolitis in younger children

  • Management - Supportive care - nasal suctioning, oxygen to maintain saturation >90% (HFNC, CPAP), fluids/nutrition - AAP Guidelines recommend against using systemic corticosteroids, bronchodilators, and epinephrine. Nebulized hypertonic saline should not be used in the ED. - EBMedicine algorithm



Also check out the Children's Hospital of Philadelphia Bronchiolitis pathway

  • Indications for admission



The Brady Bunch: Toxicology Grand Rounds - James Krueger, MD


Dr. Krueger is a St. Vincent's EM residency alumnus from 2015, who then went on to pursue a toxicology fellowship at Einstein Medical Center, Philadelphia, PA. His passion for toxicology was definitely evident and infectious! He graciously came back to give a talk about cardioactive drugs and his experience during fellowship.

  • Cardioactive steroids, specifically digoxin - Narrow therapeutic window - Ancient Egyptians discovered uses for Foxglove (source of digoxin) - 18th century scientists continued to use it for various medical purposes (namely dropsy, aka edema) - Renal excretion - Large volume of distribution - Direct inhibitor of Na/K ATPase --> indirectly affects Na/Ca cotransporter. Causes increased intracellular Na and Ca. Increased Ca can cause increased muscle depolarization and contraction.

  • Digoxin (pharmacologic, shorter half life) vs Digitoxin (naturally found, longer half life)

  • Absorption takes about 6 hours

  • Risk factors for Digoxin Toxicity - Age - elderly will likely have decreased renal function - Kidney injury - Electrolyte imbalance (hypokalemia, hypernatremia, hypomagnesemia) - increases sensitivity to digoxin effects - Fluid status - fluid loss or poor floor intake can lead to electrolyte imbalance and AKI (decreased renal blood flow)

  • Significant drug-drug interactions - Glycoprotein P interactions, renal clearance-altering medications, macrolides kill gut bacteria which can cause increased bioavailability and concentration of digoxin (gut bacteria can break down digoxin)

  • Diagnosis - High level of clinical suspicion - EKG - Electrolytes - History and physical

  • Acute vs Chronic digoxin overdoses - Acute: most may be initially asymptomatic, followed by GI symptoms. CNS effects are common (AMS, confusion, and weakness). Cardiac effects are related to SA/AV nodal depression and electrolyte conduction delays (eg bradycardia, heart block, ectopy, several types of arrhythmias). K+ IS KEY, potassium is a marker for toxicity; in acute overdoses, most patients with [K+]>5.5 will die, all patients with [K+]<5 will survive. - Chronic: often difficult to diagnose due to insidious onset. GI findings, neuropsychiatric disorders (delirium, confusion, drowsiness, headache, hallucinations, and rarely seizures), visual disturbances (blurry, various colors)

  • EKG findings - PVCs - Salvadore Dali moustache - Digoxin EFFECT, not toxicity - Bidirectional Ventricular Tachycardia - Digoxin toxicity (only one other thing can cause this: Aconite/Monkshood) - Absolutely cannot have SVT with digoxin toxicity, because it affects the AV node

  • Antidote Therapy - Ovine (sheep) derived antigen binding fragment (Fab) - DigiBind is an option outside of the USA - Ultimately will need to be renally excreted - Expensive medication - Calculate the dosing (for known amount of ingested digoxin or known concentration of digoxin) - Each vial of DigiFab will bind 0.5mg of digoxin

  • Pro Tips - For acute ingestions, give 10 vials - For plant-derived CAS, DigiFab will likely not work - Chronic toxicity rarely if ever needs Fab fragments - What happens if you give Fab fragments and the patient stops urinating? Dissociation occurs at 140-200 hours. Will not dialyze out. May need to redose the DigiFab if patient is symptomatic. - Be judicious with number of vials in chronic toxicity, go slow with DigiFab. - Do not recheck digoxin level after patient receives DigiFab (typically measures total digoxin level, which can be falsely elevated due to DigiFab)

  • Adjunctive Therapies - Activated charcoal - Calcium will not kill the patient (not indicated for digoxin toxicity, but "Stone Heart" caused by calcium is a myth)

Beta-Blockers/Calcium Channel Blockers

  • Beta Blocker overdose (Propranolol is most commonly used and overdosed on) - Hypotension - Bradycardia/Blocks - QRS prolongation - Hypoglycemia - Coma/Seizures - Bronchospasm - Can unmask Brugada - AMS/seizures - QRS prolongation - Most lipid soluble - can cross BBB

  • Calcium Channel Blocker overdose (Verapamil, Diltiazem) - Inhibit SA and AV nodes - More dangerous than B-Blocker overdose - Symptoms: hypotension, bradycardia, tachycardia, pulmonary edema, respiratory depression, nausea, vomiting, hyperglycemia, hypokalemia, lethargy, coma, seizures

  • Treatments that might work - BB overdose > Glucagon > IV Fluids > Epinephrine - CCB overdose > Calcium > IV Fluids > Epinephrine

  • What else might work? - High-dose Insulin Euglycemia Therapy > Start insulin at 1U/kg/hr, some patients may require doses of up to 20U/kg/hr > Significant debate among toxicologists about whether this works

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