On behalf of the Fellows from 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.

Shock in adults

Courtesy of Tim. Murphy, MD

It is possible that an adult sized/aged patient will present in shock in the Pediatric Emergency Department. Some high yield pearls were discussed during the recent University of Cincinnati and Cincinnati Children’s Emergency Medicine combined conference.

Hemorrhagic Shock in Adults 

Hemorrhagic shock is seen in both the pediatric and the adult emergency department.  Early recognition and appropriate management are crucial for morbidity and mortality. Important considerations include:

• Pediatric total blood volume: 80-90ml/kg 
• #1 Goal is source control: STOP the bleeding 
• Management of hemorrhagic shock can vary based on the location of the bleeding 
• There are areas where bleeding is not obvious but can lead to significant blood loss  – Head, Chest, Abdomen, Retroperitoneal, Long bones

Management specific to individual locations

• The scalp is a very vascularized area and heavy bleeding can occur
• Quick methods to stop the bleeding include placing staples, packing with combat gauze, or suturing the wound. 
• Long bone and open fractures can lead to vascular injury and increased bleeding. 
• Placing a tourniquet can provide temporary control of the bleeding. Be sure to record the time the tourniquet was placed The tourniquet should be placed as close as possible to the injury to achieve hemostasis (~2-3in above wound).
• Pelvic fractures can present without obvious external signs of injury. 
  When placing a pelvic binder, be sure to place with center around greater trochanters.  They are commonly placed too high which can lead to worsening of the injury  

Balanced Resuscitation and the PROPPR Trial – Holcomb et al.

• The idea of giving equal parts Plasma, Platelets(Plts) and Packed Red Blood Cells 
• PROPPR – Pragmatic, Randomized Optimal Platelet and Plasma Ratios (PROPPR) – giving equal parts Plasma, Platelets(Plts) and Packed Red Blood Cells
• Main goal of the study: Determine the effectiveness and safety of transfusing patients with a ratio 1:1:1 vs 1:1:2(PRBC) in the setting of severe trauma with major bleeding
  
• Primary Outcomes: 24hr and 30-day mortality
  
• Methods: Randomized clinical trial 

Results

• No statistically significant difference in mortality at 24hrs or 30 days (Powered to detect 10% difference) 
• More patients achieved hemostasis (86% 1:1:1 vs 78% 1:1:2, p=0.006) and had significantly decreased exsanguination (9.2% 1:1:1 vs 14% 1:1:2, p=0.03)in 1:1:1 group.

Impact

• They were unable to detect a statistical difference in mortality at 24hrs and 30 days but did find that 1:1:1 Plasma:Plt:PRBC likely leads to faster hemostasis and decrease in death by exsanguination at 24hrs.

TXA

The use of TXA in patients with hemorrhagic shock has good supporting evidence. Let’s take a look at the CRASH 2 Trial by Shakur et al.

• Main goal of study: To test if TXA given within 8 hours of injury to patients at significant risk of bleeding reduces death within 4 weeks of the injury. 
• Primary Outcome: Death within 4 weeks of injury
• Methods: Randomized double-blinded controlled trial  

Results

• A decrease in all-cause mortality with TXA vs placebo group (16% vs 14.5% p=0.0035)
• Absolute risk reduction: 1.5%
• NNT: 68 for death

Impact

• TXA reduces 1mo mortality by 1.5% if used in the first 8 hours and is a safe and effective treatment for trauma patients with a high risk of bleeding. 
• Calcium: blood products contain citrate which binds to calcium in the blood leading to hypocalcemia.
• Adult treatment is 1g calcium for every 2U of blood products

Cardiogenic Shock in Adults

Cardiogenic shock is much more common in the adult population than the pediatric population with myocardial infarctions being the #1.  Other causes include pulmonary embolism, cardiomyopathies, valvular disease, tamponade, myocardial contusions.

The evaluation of an adult with concern for cardiogenic shock at a minimum includes a EKG, CXR, and laboratory analysis.  Ultrasound use is increasing and provides a slew of critical information. You should look for:

• Pulmonary Edema
• Global function
• Valves 
• Other signs (D-sign, bowing of septum)

General management concepts:

• Treat underlying cause 
• Early vasopressor use 
• Norepinephrine is first line agent and best for undifferentiated shock

Septic Shock

The adult literature is constantly updating on the best practices in management sepsis. The identification of sepsis is not an easy task and there has been a push to update the tools we used to identify patients. 

• SEPSIS-3 2016[3]
• SOFA Score
• Goal to find a better score than SIRS criteria for identifying sepsis
• Original SOFA score involves multiple laboratory and hemodynamic variables (PaO2, Plt count, Cr level, bilirubin, MAP, GCS, RR) 
• Changing definition for sepsis = life-threatening organ dysfunction caused by a dysregulated host response to infection
• Septic Shock: a need for vasopressors AND lactate >2mmol/L
• No more Severe Sepsis 
• qSofa useful tool to help assess the need for further lab evaluation

The Quick SOFA

AKA the qSOFA – A more efficient to screen for patients who may need more evaluation.

Anaphylactic Shock

The management of anaphylaxis does not significantly differ with age.  

• Diagnostic criteria vary

• Skin finding and upper and lower airway symptoms are the most common
• Other symptoms include: GI symptoms (vomiting, abdominal pain), cardiovascular, and CNS (confusion, tunnel vision, behavioral change)
• Time to hypotension differs based on exposure
  • ~5min: Iatrogenic
  • ~15min: Insect 
  • ~30min: Ingested 

Treatment and biphasic reactions

• 2 EPIPEN and then move to Epi drip
• Adjunct therapies (Mixed to poor data for use)
• Ranitidine, Steroids, Benadryl 
• Biphasic Reactions are when symptoms recur following initial treatment – Can occur from hours to days after exposure
• No clear rule for observation period after exposure

References

Holcomb JB, Tilley BC, Baraniuk S, Fox EE, Wade CE, et al. Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma: the PROPPR randomized clinical trial. JAMA. 2015 Feb 3;313(5):471-82. doi: 10.1001/jama.2015.12. PMID: 25647203 

Shakur H, Roberts I, Bautista R, Caballero J, Coats T, Dewan Y, et al. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial. Lancet. 2010;376(9734):23–32. PMID: 20554319 

Singer M et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016; 315(8):801–10. PMID: 26903338

Seymour C et al. Assessment of Clinical Criteria for Sepsis. For the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) JAMA. 2016;315(8):762-774. doi:10.1001/jama.2016.0288 PMID: 26903335

PEM/PICU Combined Conference

With Drs. Kopp and Stark

This month’s PEM/PICU Combined Conference was about a 13-year-old autistic male who initially presented with a fever to 101 C, decreased oral intake, slow response.  EMS had obtained a blood glucose which was 167.  In triage he was sleepy and not responding appropriately so was taken to the trauma bay.  Exam highlights included an ill-appearing male who was intermittently moving spontaneously.  He had sluggish pupils R slightly larger than the left but no signs of trauma to head or body.  His GCS was 8 (1:2:5).  

The team was initially concerned about meningitis, intracranial abscess, encephalitis, or toxic ingestion.  Labs were obtained and a STAT Head CT showed diffuse cerebral edema.  He was subsequently transferred to the PICU for continued management. 

Key Discussion Points

Methods of decreasing increased intracranial pressure and resuscitative management 

Airway/Intubation 

• RSI Drug choice is important (Ketamine or Fentanyl are good first choices) 
• Make sure to preoxygenate adequately prior to the attempt
• Lidocaine has mixed literature as a pre-medication for intubation 

EtCO2

• Maintain a goal of normal end-tidal CO2 
• Hyperventilation temporarily decreases ICP and is transient 
• Minimize space occupying components and stress to the brain 

Other management pearls

• Hypertonic saline/mannitol to decrease fluid status in brain
• Adequate sedation is important to prevent transient rises in ICP from pain
• Anti-epileptic therapy for prophylaxis for seizure 
• Craniotomy 
• Decreasing venous drainage 
• Keep head midline and elevate in reverse Trendelenburg to about 30 degrees to increase drainage from the head 
•  CSF drainage / Placement of an EVD