Questions of the Week for 9/5/2023
Authors: Christian Gerhart, Will Freeman and Aaron Lacy
A child presents in cardiac arrest of unclear etiology. Their rhythm strip shows PEA with a narrow complex QRS. There is no suspected ingestion, and the child has no past medical history. What is the role of empiric calcium or sodium bicarbonate in this pediatric resuscitation?
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Empiric administration of both calcium and bicarbonate unless specifically indicated is associated with worse outcomes in pediatric cardiac arrest. While tempting to "do it all" for children who are in cardiac arrest, unless specifically indicated (i.e. hyperkalemia or suspected TCA overdose) the focus should be on high quality airway management (good BVM with airway adjuncts), high quality chest compressions and chest compression fraction, and team dynamics.
Empiric administration of calcium during in-hospital pediatric cardiac arrest has an adjusted odds ratio of 0.68 (95% CI 0.52-0.89; p = 0.005) for survival to hospital discharge, and an aOR of 0.75 (95% CI 0.57 - 0.98; p = 0.038) for survival with favorable neurologic outcome. (PMID 36565948)
Empiric administration of sodium bicarbonate during in-hospital pediatric cardiac arrest has an aOR of 0.70 (95%CI 0.54-0.92; p = 0.01) for survival to hospital discharge, and an aOR of 0.69 (95% CI 0.53-0.91; p = 0.007) for survival with favorable neurologic outcome. (PMID 35880872)
A child is brought into the ED after a cardiac arrest. Their rhythm is ventricular fibrillation. How would you set the defibrillator/pads prior to unsynchronized cardioversion? The patient then goes into PEA after being defibrillated. What is the code dose for epinephrine in pediatric patients?
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The initial dose for unsynchronized cardioversion is 2J/kg in children. This can be increased to 4J/kg if unsuccessful. The pads can be placed anterolateral unless they touch, in which place they should be placed anteroposterior1. The code dose for epinephrine is 0.01mg/kg IV in pediatric patients. If amiodarone is given for VT/VF, the dose is 5 mg/kg.
Briefly describe an escalating algorithm for the treatment of an uncomplicated case of epistaxis.
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First, apply firm, continuous pressure to the anterior aspect of the patient’s nose for 15-20 minutes, after applying vasoconstrictors and/or topical TXA to the affected nostril. Next re-examine the nostril and assess for the presence of prominent blood vessels that may be cauterized using silver nitrate. It can be helpful to have the patient blow the clots out if present. If this is insufficient, pack the affect nostril with non-resorbable packing (rhino rocket). If resolved, generally the patient can be discharged with ENT follow-up within 72hrs. Evidence for antibiotics in patients with packing is mixed, consider this in high-risk patients. If unresolved, consider if the other nares requires packing. If there is concern for a posterior bleed, consider posteriorly packing the nasopharynx with a posterior balloon device and transfer/escalate to consultation with ENT specialists for more definitive management. Patients with posterior or bilateral packing require admission.
You are taking care of a patient who presents with what appears to be a left MCA stroke. After discussion with neurology, you both agree that the patient should receive TNK. The patient has no contraindications apart from their blood pressure of 240/130. How would you manage this situation?
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This is a truly time sensitive situation and blood pressure control is one of the most common delays in thrombolytic administration in ischemic stroke. If the patient’s heart rate is normal, consider an IV push of 10mg of labetalol to start. At the same time, this patient should also be started on an IV infusion of a titratable blood pressure agent such as nicardipine or clevidipine. In our system, nicardipine is generally a bit easier to get quickly and can be obtained from the pixus as an override pull without an order, whereas clevidipine requires an order but is faster and easier to titrate. The standard starting dose for nicardipine at our institution is 0.5 mcg/kg/min, however you may choose to start higher in a patient with such severe hypertension. Generally, nicardipine should be titrated every five minutes, however if you are standing at the bedside with close monitoring, you may be a bit more aggressive as every minute matters in ischemic stroke.
You start blood pressure medication for the patient above. What is your goal BP in order to administer TNK? What is your goal BP after TNK?
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In order to give TNK, the patient's blood pressure must be under 185/110. After TNK the blood pressure should be kept under 180/105 for the first 24 hours. It is important to not overcorrect the blood pressure as normal or low-normal blood pressures in patients with chronic hypertension can lead to hypoperfusion and worsening stroke symptoms in some patients. If the patient arrived with extremely elevated blood pressures, consider a lower limit on your titratable infusion to avoid overcorrection of their blood pressure.
You are caring for a 77 yo female patient with a history of hypertension and atrial fibrillation in TCC who arrives with a GCS of 4 after suddenly collapsing at home. BG is normal. Her pupils are 1 mm bilaterally. She did not respond to high dose Narcan with EMS in the field. She does not have any verbal response. She extends in her bilateral upper and lower extremities to pain and does not open her eyes to painful stimuli. Her vitals are BP: 190/85, HR 84, RR: 20 (mechanically ventilated), T: 37.2, O2 sat: 98% on 40% FiO2. She is subsequently intubated for airway protection and moved emergently to the CT scanner. Her non contrast head CT is normal. What is your next step?
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This patient’s history is highly concerning for either an acute intracerebral hemorrhage or a large vessel occlusion ischemic stroke. Given her normal non-contrast head CT, a CTA of the head and neck +/- a CT perfusion study should be performed. This case would be a classic presentation for a basilar artery stroke. Remember that in patients with acute coma, ischemic stroke must be high on the differential! If you don’t see findings on the non-contrast CT have a low threshold to obtain a CTA.
Describe your structured approach to altered mental status.
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Always start with ABC + GLUCOSE. One approach for the causes of altered mental status is to break this down into five categories:
1) Vital sign abnormalities
2) Toxic/metabolic
3) Infectious
4) Structural
5) Seizure/psych
References:
1) Van de Voorde P, Turner NM, Djakow J, et al. European Resuscitation Council Guidelines 2021: Paediatric Life Support. Resuscitation. 2021;161:327-387. doi:10.1016/j.resuscitation.2021.02.015.
2) Bath PM, Song L, Silva GS, et al. Blood Pressure Management for Ischemic Stroke in the First 24 Hours. Stroke. 2022;53(4):1074-1084. doi:10.1161/STROKEAHA.121.036143.