On behalf of the Fellows form the Division of Emergency Medicine at Cincinnati Children’s I am delighted to bring you a new series that will highlight what we are learning during our ongoing didactic conferences. The main goal of the Pediatric Emergency Digest series will be to provide concise teaching points to reinforce in-person learning and to further the conversation. As always, feedback is welcome.
Special thanks to Victoria Wurster-Ovalle, Pediatric Emergency Medicine Fellow, for helping put this together.
Airway/Complex Care Conference
with Ben Kerrey, MD
Case discussion
- Example of laryngospasm in a two month old in the OR during an anesthesia rotation. Anesthetic was propofol. Laryngospasm likely occurred secondary to laryngoscopy during early stage anesthesia.
- Task fixation during laryngoscopy and failure to cognitive switch likely contributed to a delay in recognition of laryngospasm and thus delay in paralytic administration.
- Pearl from Dr. Kerrey – “if you’re failing and continuing to fail…try something else”
There was a brief discussion about preoxygenation for procedural sedation in preparation for potential apnea. Not all providers do this, there may be some evidence to support.
Lessons Learned from the Storz Video Laryngoscope
- Case 1: an example of a difficult post-arrest edematous, pale airway. Things that may have been helpful = cheek pull to increase the amount of room available, potentially a bougie if <= grade 2b view.
- While there is not a lot of evidence for pre-laryngoscopy positioning, maximizing positioning (i.e. ear to sternal notch) is helpful.
- Tongue Control: sweeping to the left versus entering the mouth midline. Little evidence supporting one over another. Either approach works, as long as it is stepwise.
- Green-Hopkins looked at this exact question in 2015 – sweep vs midline (on video laryngoscopy). Investigators found that midline and sweep had no difference in first pass success, and that sweep leads to increased mucosal injury and aspiration (aOR = 4.1, 95% CI = 1.2 to 14.5; aOR = 7.7, 95% CI = 1.5 to 39.5, respectively) as well as increased time to intubation 42 seconds vs. 31.5 seconds; p < 0.05.
Fellows Video Review
with Matt Lipshaw, MD
- Case of a 6 week old former full term infant presenting to the trauma bay for hypothermia, apnea
- History of non-bilious spit ups and failure to thrive
- Several questions arose during our discussion:
- What is the definition of hypothermia? Most sources define neonatal hypothermia as < 36˚C. Local EMS uses the WHO definition of 35.5˚C.
- What is the definition of apnea? Not breathing for 20 seconds. For this infant, it doesn’t appear that there was true apnea (at least on video or via capnography)
- For this case, rapid PIV access was an issue. There is literature (Zavorsky et al, 2007; https://www.ncbi.nlm.nih.gov/m/pubmed/16919507/) that shows capillary gases correlate just as well as venous gases do in looking at pH and pCO2.
- Given potential apneic spells, a decision was made to intubate. This was not a low-risk intubation – children under 2 years of age are at high risk of desaturation during intubation attempts.
- There was a lot of discussion around communication. Specifically, as team leader, what is the best way to communicate in order to get buy-in from your team members? Sometimes we can use time as a diagnostic tool, and discuss the reasons for watching and waiting prior to intervention. But, in the trauma bay, how much time do we really have? Our goal for sick trauma patients, for example, is to have them to CT in < 25 minutes.
- The infant was intubated, a sepsis workup was initiated, and admitted to the PICU. Imaging upon admission revealed pyloric stenosis! remember that infants with pyloric stenosis can drive their CO2 high enough that they lose respiratory drive.
Hypertrophic Pyloric Stenosis Can present with apnea
Hypercarbia leads to hypoventilation. The resultant hypoxia can progress to overt respiratory failure. It also leads to atelectasis and hypoxemia. Fortunately, apnea secondary to infantile hypertrophic pyloric stenosis is rare.
References
Practical Stats
The p-value
- Indicates how incompatible the data are with a specified statistical model
- By itself, does not provide a good measure of evidence regarding a model or hypothesis
Bonus: Choosing the Correct Statistical test in SAS, STATA, SPSS and R
