Conference 04/13

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  • Pediatric Respiratory Distress (Dr. Poteh)
    • Bronchiolitis
      • <2 years (>2 years is referred to as WARI)
      • Leading cause of hospitalization in infants in the US
      • Symptoms often worsen on day 3-5 of illness and worse at night
      • Hypoxemia occurs from V/Q mismatch from mucus plugging
      • Pathophysiology à infection causes inflammation of the bronchiolar epithelium
      • Commonly causes by RSV, but also caused by other viruses and bacterial infections
      • Exam tricks:
        • Expose trunk
        • Count RR yourself for at least 30 seconds
        • Note signs of respiratory distress
        • Assess activity level (playful, fatigue, lethargic)
        • Assess hydration status (tears, saliva, capillary refill, wet diapers in 24 hours)
        • Check the ears (occasionally have coinfections)
        • Always do an abdominal examination to assess for hepatosplenomegaly
      • Management:
        • Suction! Suction! Suction!
        • CXR unnecessary unless concern for superinfection or clinical picture not consistent with typical bronchiolitis (prolonged symptoms, high fevers, persistent hypoxia) à atelectasis and peribronchial cuffing on CXR if obtained
        • Viral testing is not always necessary (exception: influenza, COVID-19, RSV <1 month causes apnea)
        • Respiratory support
        • Dexamethasone in patients <1yo with no history of wheezing did not demonstrate benefit
        • Albuterol has not been shown to benefit patients
      • Bronchiolitis Score is helpful with risk stratification
      • Discharge Criteria
        • O2 saturation >90% while awake
        • Adequate PO intake
        • Mild/moderate work of breathing
        • Reliable caretaker
        • Timely pediatrician follow-up in 1-2 days
      • Admission Criteria
        • Hypoxemia
        • Severe respiratory distress
        • Apnea
        • High-risk patients
        • Poor oral intake
        • Parents uncomfortable with discharge
      • Consider intubation if…
        • Recurrent apnea
        • Declining mental status
        • Not improving with respiratory support
    • Asthma Exacerbation    
      • Antibody binds antigen à release of histamine/leukotrienes à inflammation à bronchospasm
      • Pediatric Respiratory Assessment Measure (PRAM) is helpful for risk stratification
      • Timing of medications is key!
      • CXR is not required unless concern for complicating factors
      • Management:
        • Beta-2 agonists 
          • Albuterol à MDI vs. nebulizer
            • Always use a spacer!
            • Short vs. 1-hour long vs. continuous albuterol nebulizer
            • Discharge à take 4 puffs every 4 hours for the next 48 hours, then as needed after that
            • Remember to write for MDI with spacer if discharging with albuterol prescription
          • Terbutaline à IV vs. SQ
        • Corticosteroids à mainstay of treatment considering the pathophysiology
          • Dexamethasone
          • Prednisone/prednisolone
          • Methylprednisolone
        • Ipratropium nebulizer
          • Anticholinergic
          • Often used in conjunction with albuterol nebulizer
        • Magnesium sulfate
          • Smooth-muscle relaxer
          • Can cause smooth-muscle relaxation in the vasculature à hypotension (consider IVF bolus)
        • Epinephrine à anaphylaxis dosing
      • Admission Criteria
        • Requiring >1 1-hour long albuterol
        • Respiratory distress
        • Hypoxemia (O2 <92%)
        • Dehydration
    • Croup (laryngotracheobronchitis à upper airway)
      • Acute subglottic inflammation
        • Morbidity is greatest in 1st year of life due to narrower subglottic airway
      • Affects children aged 6-36 months
      • Classically caused by parainfluenza virus, but also caused by many other viruses
      • Clinical presentation:
        • Barky cough
        • Inspiratory stridor (more concerning if occurring at rest)
        • Tachypnea
        • Suprasternal retractions (hypoxia, intercostal retractions, abnormal breath sounds, subcostal retractions are uncommon à croup is a disease of the upper airway, if hypoxia is present and lungs are clear to auscultation there should be high concern for impending upper airway compromise)
        • Low-grade fever
      • Management
        • Dexamethasone
        • Racemic epinephrine for resting stridor or respiratory distress (can repeat every 15-20 minutes)
        • Monitor for 3-4 hours prior to discharge if administering racemic epinephrine à admit for refractory stridor or if repeat dosing of racemic epinephrine is required
        • Consider Heliox for severe respiratory distress as it decreases turbulent flow
  • Documentation Lecture (Ashley Chesman)
    • Critical Care Documentation
      • 7.2% of all ED visits reported to Medicare in 2019 were reported as critical care
      • Time at bedside, but also time spent engaged in work directly related to the patient’s care:
        • Reviewing test results and imaging studies
        • Consulting services
        • Placing orders
      • Procedures billed separately
      • Billings starts at 30 minutes à critical care time requests <30 minutes may not be compensated  
      • E/M and Critical Care Same Date of Service
        • Can now bill for E/M and Critical Care on the same date/visit
        • Documentation must support decompensation to a state requiring critical care
      • Remember to document critical care time beginning in residency!
  • Subclavian Central Venous Lines (Drs. Nichols and Leavitt)
    • Contraindications
      • Overlying infection
      • Anatomic obstruction
      • Fracture of ipsilateral clavicle
      • Relative à coagulopathy (harder to compress and apply pressure to the subclavian site)
    • Complications
      • Arterial injury
      • Pneumothorax
      • Air embolism
      • Cardiac dysrhythmia
      • Infection
      • Bleeding
    • Supra- vs. Infraclavicular Subclavian Access
      • Infraclavicular
        • Utilizes short-axis ultrasound
        • Index finger on the sternal notch and thumb at the midpoint of the clavicle at the angle
        • Make contact with the clavicle and “walk-down” and pass under the clavicle vs. insert needle further laterally to avoid having to “walk-down” the clavicle
        • Ultrasound assisted technique utilizes short-axis
      • Supraclavicular
        • Well-defined landmarks (claviculo-SCM angle)
          • 1 cm superior and 1 cm lateral to the claviculo-SCM angle
          • 5-15 degrees above the coronal plane
          • Don’t advance past 3 cm
          • Ultrasound assisted technique utilizes long-axis as opposed to the short-axes
        • Shorter distance from skin to vein
        • Larger target area
        • Straighter path to the SVC
        • Less proximity to the lung
        • Fewer complications compared to infraclavicular
        • Found to be non-inferior to the infraclavicular approach

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