Miss us already? Click here for notes on AllNYC #15

by ALLNYCEM


Notes from our keynote speaker, Dr. Levitan-

1.    Engineer your practice...compartmentalize and incrementalize---one step at a time. The first steps are the most important

a.    How you hold laryngoscope, 

b.    Response to hypoxia- OOPSOxygen On, Pull mandible, Sit 'em up

c.     Rock the rhomboid to identify midline for surgical airway

2.    Pick up the laryngoscope with two fingers---uvula points to epiglottis.  Do not "intubate"---perform epiglottoscopy, then laryngoscopy, then tube delivery.

3.    Patients want to live--they position themselves upright, head forward, breathing in their nose and out their mouth for a reason. Your practice should align with this--O's up the nose, upright oxygenation, ear-to sternal notch positioning for intubation.

4.    To win with your hands, you first have to win in your head. Control your self-talk, run at your fears. You "unload" fear through insight and understanding. 

 

Dr. Sanders- “Eat Your Heart Out: Pediatric Cardiac Emergencies"

1.    Start prostaglandin early in patients less than one month of age if concerned for a ductal dependent lesion. 

2.    Congestive heart failure may present as slow or difficult feeding in infants. 

3.    "Silent tachypnea", or tachypnea without signs of upper respiratory infection, should raise concern for cardiac etiology. 

4.    Fontan surgery is the final stage of surgical palliation for univentricular cardiac patients.

5.    Pulmonary blood flow is passive, and volume and pressure dependent in Fontan patients.

 

Surles- “Crash Talkin’ Fellow- Seizure”

1.    FIRES is a rare difficult to control epilepsy syndrome in children.

2.    The Status Epilepticus pathway is different for children under two months and older than two months.

3.    Propofol causes problems, but it works. Use it if you need to.

**Seethis linkfor useful info-graphic!**

 

Nickerson- “Crash Talkin’ Fellow- Neonates”

1.    The most important part of neonatal resuscitation is airway.

2.    The first thing you do is bag with a BVM (with PEEP) whether you are worried about airway or low heart rate.

3.    HR < 100 is bad, but HR < 60 is a coding baby. If they do not respond to BVM, they should be intubated. Start chest compressions, get access, and give epinephrine

 

Dr. Chavda- “Crash Talkin’ Fellow- Asthma”

1.    Asthmatic that comes in blue, give epinephrine IM or Terbutaline SC, then standard meds.

2.    Avoid intubation as long as possible in acute severe asthma unless there is AMS, bradycardia, or silent chest.

3.    Higher peri-intubation risk of decompensation due to pre-existing acidosis, hypercapnea, hypoxia, and hyperinflation that leads to decreased venous return.

4.    Ensure using correct settings post intubation: low TV (6mg/kg IBW), low RR (6-12), low PEEP (0-5), short iTime (1:4); maintain synchrony with ventilator (sedate/paralyze as necessary).

5.    General anesthesia/ECMO are further options if all else fails.

 

Dr. Josh Rocker- “Vax Attacks! The Unvaccinated Child”

1.    The measles rash does not present until day 3- so if fever, conjunctivitis and URI make sure to look in the mouth to see if there are Koplik spots.

2.    Mortality rate from measles in the US is approximately 1 in 1000 cases.

3.    Rates of measles have skyrocketed in Europe secondary to decrease in vaccinations- in just the first half of 2018 over 41k cases with 37 deaths  (That is a 13 fold increase in 2 years!!!).

4.    An unvaccinated patient may be at risk for bacteremia from H influenza or Strep pneumoniae if they are 3m-36mo of age with a fever >39C.  Previously the recommendation (pre-vaccinations) was to perform a CBC, blood cultures and give ceftriaxone because the occult bacteremia rate was known to be approximately 2.8%.  With herd immunity we do not think the risk for occult bacteremia would be that high in an unimmunized patient but the logic exist that as long as the risk is >0.5% we would encourage following the old recommendation.

 

Dr. Rebillot- “One Pill Killers”

1.    Lomotil has both opiate and anticholinergic toxidrome effects, which both effect the pupils in opposite ways and can cause patients to complain of blurry vision. 

2.    Lomotil can display delayed opiate effects up to 24 hours after ingestion. Requires 24 hour monitoring in telemetry setting for late onset of respiratory depression. 

3.    Oil of wintergreen exhibits a salicylate toxidrome and children are able to compensate their respiratory drive very well, thus typically will see only metabolic acidosis and not respiratory alkalosis.

4.    Camphor toxicity usually seen in formulations containing 11% or higher concentrations of the drug, most common presentation is neurologic deficit in form of atonic seizures and present within 4 hours of toxic ingestion or application.

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