Airway Algorithm

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  -  Jaime McCarthy MD,  UT Health Sciences Center at Houston EM Director

One of the many things that we do better than anyone in the business is obtain the emergent airway.  Unlike our colleagues in other disciplines, we do not have the luxury of planning our airway approach on the golf course the evening before; we meet patients on their worst day.  Even though we would often prefer it, we do not have the option to reschedule our intubations. 

Smashed, bloody, distorted, edematous, airways secondary to trauma, anaphylaxis and GI bleeds are the things that we deal with routinely with nary a complaint or even a hither for a better look than what were given.  We often feel lucky to get any type of view that resembles normal laryngeal anatomy.  Personally, if I knew that I would need to be intubated today, that my airway would be bloody and edematous, and there was only time for one person to take a shot at placing the tube, then I would pray to God that the last face I see before the Roc and Etomidate push me asunder is the familiar grill of one of my EM colleagues.  Who better to bet all my chips on then someone who deals with the hardest airways on the face of the planet as part of their daily routine?  The general EM provider can not only get that airway, but is so relaxed about it that they will casually check on the patient in the next bed before and after the intubation.   That’s the confidence I’m looking for when it comes to the fast paced life and death world of emergency airway.

Whether it is pediatric or adult emergency medicine, the most important thing that we do as “emergentologists and resusitologists” is control the airway.   

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Airway Algorithm

Developing a good rule to clinically clear the pediatric cervical spine would be difficult.  Very few kids suffer injuries to that region of the body making it nearly impossible to create a well-powered decision instrument.  Like with many other attempts in pediatrics you would most likely end up with a guideline that would be fairly sensitive, but horribly specific. 

Lets say we abstracted and validated a pediatric c-spine rule that was 95% sensitive and 50% specific.  With a disease that occurs at an incidence of less than 0.1% (1/1000), by employing a decision instrument that is 95% sensitive you would reduce your patient's risk of missed injury to say 0.005% (1/20,000) .  Sounds great right?  Hold on though; there's more.  If that same rule is 50% specific (which most peds clinical rules are) 50% of the kids you applied your rule to will have false positives.  Therefore 500 of every 1000 patients you employ your decision instrument for would actually be subjected to further workup and needless radiation.

Does any of that sound familiar?  It's nearly identical to the use of D-Dimer in very low risk adults (probably better stated as no risk).  If you take a low to medium pre-test probability of disease (Wells Score of low-mod = 2-16% risk) and apply a D dimer (sensitivity > 95%) that comes back as a negative result (you now have reduced your 16% chance of having disease to less than 1% because 16% reduced 95% is 0.8%).  Well done!  You are done with the work-up and you have excluded disease.  If you apply the D-Dimer to a very low risk population (1-1000 to 1/10,000 depending on who you read) then you may further reduce your risk (I'm not sure how much lower you need to go to fell comfortable 1/1000 is pretty low), but just like in the example above, you will have subjected twice as many patients to needless CTA of their chests because your D-Dimer specificity was so poor (about the same 50% as above).  

Sorry, that's a lot of stats, but here's the take-home message. Your pediatric patient doesn't need a decision instrument as much as they need a good doctor.  Any injury with extremely low prevelence will most likely end up below the test threshold of creating and validating a decision instrument that you can rely on.  It is hard to get objective data in pre-verbal children, but it is easy to play with them, earn their trust and make a good clinical decision.  NEXUS gets you to 8 years of age, but then it's up to you to make a decision based on experience. 

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 Podcast 5 - AVI Format (Larger Video Version)

Practitioners have a love-hate relationship with this procedure.  Whether you embrace it or react to its’ necessity in the same manner you would when finding out you've just been cut-out out of your wealthiest relative’s will, the words “lumbar puncture” invoke emotion.  I would like to thank Dr. David Delemos for inventing this simple recipe for success. It is one of my favorite procedures and hopefully after hearing this podcast it will be one of yours as well.  

Check out the PDA friendly companion file below.

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Pediatric LP Show Notes

Full disclosure: The author on two of the articles below is LCDR Sherry Rudinsky who is an old navy friend of mine.  We were interns together and then attended the same Naval Flight School class.  Dr. Carstairs is also an aquantaince; she was a resident when I was a Navy Surgical Intern.  I was stationed at the Naval Medical Center San Diego when they were collecting their data, but I had no part in this study.  They are simply dang good reads so check them out.

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Fever Algorithm

Fever Part 2 - MP3 Version

References:

Reardon JM, Carstairs KL, Rudinsky SL, Simon LV, Riffenburgh RH, Tanen DA. Urinalysis is not reliable to detect a urinary tract infection in febrile infants presenting to the ED. Am J Emerg Med. 2009 Oct;27(8):930-2. PubMed PMID: 19857409.

Rudinsky SL, Carstairs KL, Reardon JM, Simon LV, Riffenburgh RH, Tanen DA. Serious bacterial infections in febrile infants in the post-pneumococcal conjugate vaccine era. Acad Emerg Med. 2009 Jul;16(7):585-90. Epub 2009 Jun 15. PubMed PMID: 19538500.\

Carstairs KL, Tanen DA, Johnson AS, Kailes SB, Riffenburgh RH. Pneumococcal bacteremia in febrile infants presenting to the emergency department before and after the introduction of the heptavalent pneumococcal vaccine. Ann Emerg Med. 2007 Jun;49(6):772-7. Epub 2007 Mar 6. PubMed PMID: 17337092.

Just in time for the winter season.....

Have you seen a bunch of snot-nose kids with fever recently?  Do you want to put a needle in their back?  Better yet, do you not want to put a needle in their back, but feel really guilty about it?

I sat down with Texas Children’s very own Dr. Andrea Cruz who is triple boarded in pediatrics, pediatric emergency medicine and pediatric infectious disease to talk about fever without a source in neonates/infants and who really needs that LP.

There are so many pearls here that I am going to break  this into 2 podcasts.  Enjoy part one now and don’t forget to check out the link to my “fever without a source” algorithm link below.   

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Fever Algorithm

Fever MP3 Version

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 Undifferentiated Hypotension Slide

 RUSH Slide

 References

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