Sepsis Update, Marianne Kreuger

• RN can initiate triage-initiated sepsis alert if patient has 2+ SIRS criteria and suspected/confirmed infection with or without organ dysfunction
  • Patient can flag for sepsis while in waiting room- time zero is triage
• Multiple sepsis power plans exist
• Three hour bundle and six hour bundle have different requirements.
  • 3h: IV abx, fluid bolus, lactic with reflex
  • 6h: repeat lactic if initial was >2, vasopressors if not responsive to IV fluids, tissue perfusion reassessment (echo, cap refill, periph pulses eval, etc)
• 30cc/kg bolus required when patient has two or more hypotensive episodes or lactic >4
  • If withholding full sepsis fluids, please document reason why
• .sepsisreassessment is helpful dot phrase in cerner
• Effort is being made to track patients in the waiting room to help meet compliance and goals
• Also: new hyperkalemia power plan exists specifically for insulin/dextrose treatment
  • Protocol for repeat poc glucose afterward for 6 hours, BMP Q1h x4

Pediatric Trauma, Dr. Klensch:

• Trauma Stat (generally more severe) vs Trauma Alert
• Trauma Role assignments: team leader, airway, assessor, procedure physicians
  • Specific roles prior to arrival and then after arrival
• Airway considerations:
  • Small mouth, larger tongue, large adenoid, floppy epiglottis
  • Larynx more cephalad and anterior
  • Increased vagal response, use atropine PRN
  • ET Tube: (age/4)+4
  • Depth: ETT x3
• Breathing:
  • Compliant ribcage makes fracture less likely
  • Pulm contusion is most common ped thoracic injury
  • Mobile mediastinum: less aortic disruption, more tracheobronchial injuries, earlier compromise from tension ptx
• Circulation
  • Long bone fracture generally won’t have as much blood loss as adults
    • Ex: if hypotensive with femur fx, should look into chest, abdomen, etc for other causes
  • ICH with open fontanelle can contain large amount of blood
  • No sternal IO in kids <12yo
  • Hypotension: 70 + (2x age)
  • Pay close attention to mentation in evaluating shock
• Disability:
  • Modified GCS exists for infants and children
  • Prevent secondary injury in TBI: avoid hypoxia, hypercapnia, hyperthermia, hyponatremia
  • Linear skull fracture are typically benign unless depression exists, overlying vascular channel, a diastatic fracture, or over area of MMA
  • Closed head injury: PECARN <2
• Exposure:
  • Expose entirely to eval for other injuries
  • At risk for hypothermia, keep exposure time brief
    • Due to large BSA, thin skin, minimal fat
• NAT:
  • KY has highest child abuse rate in the country
    • ~20/1000 kids in the state
  • IN has highest child abuse death rate nation wide
  • Up to 25% of severe child abuse cases have previous sentinel injuries
  • Red flags:
    • No hx of trauma, mechanism does not fit, history inconsistent with age/development, history changes, delay in seeking care
  • Use TEN-4-FACESp for bruising clinical decision rule for children <4
• Cervical Spine:
  • Generally uncommon, 1-2% of all trauma admissions
  • High risk: Down Syndrome, Ehlers Danlos, NAT
  • Most common site of fracture varies with age
  • Why not CT?
    • More expensive, more radiation
    • Less likely to define injury in infants and small children with only ligamentous injury
  • Ok to clear clinically in low risk (no distracting injury, normal neuro exam, etc), also make sure to examine for tenderness/ROM
  • Conscious, not meeting low risk criteria: okay to get plain XR, CT if XR unclear or high suspicion for injury
  • Unconscious or obtunded, obtain CT head and c spine
  • SCIWORA: neuro deficits or symptoms that may be transient w/ normal imaging, get MRI and NES consult, admit, can be delayed up to 30min-4days
• FAST
  • Data mixed
  • Several studies demonstrate lower sensitivity than for adults

Clinical Pathway- Complicated Delivery, Drs. Boland and Hill-Norby:

• ED deliveries higher risk than those on labor floor
  • Often little or no prenatal care
  • Higher perinatal mortality
  • Need to expect the unexpected
• Shoulder dystocia:
  • Clinical diagnosis when gentle traction is insufficient to deliver shoulders after delivery of head
  • General Mgmt: stop pushing, align buttocks flush with edge of bed to provide optimal access, cath bladder for decompression, suprapubic pressure
  • HELPERR (Ob, empty bladder, legs flexed (McRoberts), pressure to suprapubic area, enter vagina (Rubin or Woods), remove posterior arm (Barnum), roll to all 4s (Gaskin))
    • Pressure should be applied just above pubic symphysis, not fundal
    • Rubin, Woods, and Barnum generally all require adequate anesthesia, making their use more challenging in ED deliveries
  • Maneuvers of last resort:
    • Fracture of fetal clavicle
    • Zavanelli maneuver requires immediate availability of surgeon and anesthesiologist: push fetal head back up into pelvis and c/s performed
  • Breech presentation
    • 4% of live births
    • Prone to problems with cervical dilation and umbilical cord prolapse
    • Frank, complete, incomplete breech
    • Call for help, if fetus not yet emerged, tell mom not to push
    • Consider uterine relaxants
    • Allow spontaneous delivery, support fetus but do not apply traction
    • Fetus should be delivered within 10 min as cord will be compressed causing acidosis
    • Mauriceau-Smellie-Veit maneuver
  • Umbilical Cord Prolapse
    • 50% are associated with malpresentations
    • OB should be called, prep for c/s but if delivery is imminent facilitate as possible
    • Cord manipulation can induce vasospasm and hypoxia
    • Position mom in knee chest position
    • Any presenting parts should be manually elevated with provider’s hand to reduce pressure
  • CODE GREEN: imminent delivery
  • *** See Clinical Pathway Section for Malpositions Complicating Precipitous Delivery Flowchart***

The Clench Test, Dr. Martinez:

• Nerve innervations and why the clench test is useless in assessing for true spinal cord injury
• Glutes are innervated by L5-S2 where ankle flexion is innervated by S1-2 meaning if they can plantar flex, their buttcheeks can squeeze
• S3-4 control bowel and bladder function
• Pudendal nerve supports rectal tone, urethral and anal sphincters, made up of nerve fibers from S2-S4
• Trauma neuro exam
  • GCS/pupils/mentation, gross sensory, gross motor (PF and DF ankles), digital rectal exam
• Isolated damage to S1-5 can happen with sacral fractures depending on location, more medial fractures are higher risk for neurologic injury mostly involving bowel, bladder, and sexual dysfunction
• Reasons to do a proper DRE in trauma: clued in early to severe sacral fractures, blood, high riding prostate
• Always make sure to notify patient prior to DRE

Postpartum Hemorrhage, Dr. Shaw:

• Definition: >1000cc of blood loss or any blood loss with systemic signs of hypovolemia
  • Up to 24h postpartum
• Leading cause of maternal death worldwide, 1-5% of US deliveries
• Uterine atony most likely cause also laceration, retained POC
• DDx: tone, trauma, tissue, thrombin
  • Use physical exam to differentiate
    • Fundus should be below umbilicus
    • Inspect perineum for lacs
    • Uterine sweep for retained tissue, use ultrasound, look at placenta to verify that it appears intact
    • Coagulopathy: CBC, CMP, PT, PTT< fibrinogen, dimer, type/screen
• Bimanual uterine massage: one hand compresses fundus, one hand intravaginally compressing body of uterus
• Oxytocin first line
  • 10U IM, or 10-40U per 500-1000cc bag of saline as continuous infusion wide open
• Misoprostol: PO sublingual, rectal
• Uterine inversion:
  • Risks/causes: excessive cord traction, short umbilical cord, uterine relaxants during labor, previous inversion, placental attachment
  • Management: requires reduction of uterus
    • Provide adequate analgesia, likely procedural sedation
    • Nitroglycerine is potent uterine relaxant, onset 30 seconds, dose 50-100mcg bolus over 1-2 min, half life 2.5 minutes
• Retained Products of Conception
  • Eval with ultrasound for normal endometria stripe, inspect placenta, manual removal
  • Hemorrhagic shock: blood products ASAP
    • 1g bolus TXA = decreased risk of death by bleeding, evidence based practice
  • Tamponade with uterine packing, or Bakari balloon if available
    • Other options: Blakemore, condom cath