A TEMPLATE FOR DESCRIBING THE “ILL-APPEARING” INFANT

Templates do not just facilitate documentation but also can guide bedside observations. The person taking a history who uses OLD-CARTS might be reminded to ask a dimension of a symptom that otherwise would not have been elicited.

 

What does it mean to say a child is “well-appearing” or “ill-appearing?” I find the GCS (Glasgow Coma Scale) categories to be helpful:

 

Eyes – is the child attentive with the eyes

Motor – is the child appropriately active/reactive

Verbal – is the level of social interaction appropriate for age (eg comforted by the arms of the mother).

 

Using GCS can stimulate a more detailed description of what we mean when we describe an ill-appearing child.

 

TAKE HOME POINTS

-Use the categories of GCS to detail what it means for a child to be “ill-appearing.”

NONCONVULSIVE STATUS EPILEPTICUS

There are two scenarios where you might see non-convulsive status epilepticus (NCSE):

-Presentation of coma

-Failure to rouse after seemingly successful treatment of a seizure (one article said up to 20% of status epilepticus generates NCSE after resolution of the convulsion)

 

The gold standard is 48 hours of continuous EEG monitoring. Unfortunately at many EDs we rarely can get EEG monitoring at all. Thus we need to be mindful of some subtle clinical signs.

 

Clinical signs or triggers that might prompt you to consider non-convulsive status epilepticus:

-***history of epilepsy in someone in an unexplained coma***

-volatile vital signs

-dilated pupils

-twitching (disrobe patients. May especially notice this around the eyes, where it is easier to see)

 

TAKE HOME POINTS

-failure to rouse after seizure could indicate non-convulsive status epilepticus

-unexplained coma in someone with a history of epilepsy should trigger this possibility

-Disrobe the patient and look for subtle signs of twitching

-Consider autonomic signs – vital signs, pupils

AIRWAY VISUALIZATION – EXTERNAL “CEPHALIC” MANIPULATION

Here is a potential airway technique that may help with visualization: hold the laryngoscope in the left hand (the usual) but the right hand, instead of being at your side, is behind the patient’s head. You then move it around until you get the best view. Then you have an assistant hold the head in that spot.

 

A hospital in Southern California started doing that. The technique deserves some exploration. The work of Richard Levitan reminds us that the airway is most patent in the sniffing position. Extension does not really help but true sniffing position does. Sometimes you think you have enough and you need more.

 

I have not seen this technique studied but it probably deserves some attention.

 

TAKE HOME POINTS

-Consider external cephalic manipulation as an analogy to “external laryngeal manipulation” as a way of fine tuning the visualization during a tough intubation

INDIRECT LARYNGOSCOPY

A patient presents with severe sore throat. You wonder about epiglottitis. You know that using a mirror to look at the epiglottis is a great way to check this but are not confident in your skills. What do you need?

 

Dental mirror – they are cheap, have your ED stock them

 

Light – can use a headlamp, the kind that are sold in outdoor stores. Get one with a spot beam rather than a flood light. Nice to have regular AAA batteries instead of the medical ones with cords that are always getting lost or damaged

 

Relaxed patient – explain to them what you are doing and rehearse it once first

 

Anatomy – have them lean forward, chin out

 

View – wrap gauze around their tongue. Don’t pull it out but hold it so they don’t have to sustain muscle contraction to keep the tongue out

 

No gag – not sure topical anesthetics really work. Try to avoid hitting their pharynx with the mirror until you are ready to lift the uvula and look. Have the patient fix vision in the distance. Have them say “eeeeeee.” Have them do slow panting style shallow breathing.

 

No fog – hydrogen peroxide or hot water will help prevent fogging

 

You look and it is hard to see. That reminds us the final thing you need – practice!

 

TAKE HOME POINTS

-Indirect laryngoscopy is a complex hand-eye skill that you can learn

-Get the right supplies and start doing this now. It may really help you one day.

FINGER TEST FOR NECROTIZING FASCIITIS

A patient presents with a deep muscle abscess. Is this necrotizing fasciitis? All too often I see the deliberation focus on things like the laboratory score or the imaging. The role of those things are being debated but what is beyond debate is to have the bedside skills for recognizing necrotizing infections.

 

Childers in 2001 and 2002 described the finger test as a diagnostic intervention at the bedside. It does not get enough attention. The instructions are to make a 2 cm incision down to fascia. “…if the tissues dissect with minimal resistance, the finger test is positive”

 

Other signs:

-lack of bleeding

-grey necrotic tissue

-dishwater purulence

 

There is no reason ED physicians should not know this and perform it. We are already making incisions to check for abscess. Know the 4 surgical signs of necrotizing fasciitis.

 

TAKE HOME POINTS

The 4 surgical signs of necrotizing fasciitis are:

-lack of resistant to finger spread

-lack of bleeding

-grey necrotic tissue

-dishwater purulence

 

Childers BJ Necrotizing fasciitis: a fourteen-year retrospective study of 163 consecutive patients. Am Surg. 2002;68:109-16.

 

Andreasen TJ, Green SD, Childers BJ. Massive infectious soft-tissue injury: diagnosis and management of necrotizing fasciitis and purpura fulminans. Plast Reconstr Surg. 2001;107:1025-35.

BLADDER STIMULATION TECHNIQUES FOR NEWBORN CLEAN CATCH URINE COLLECTION

An infant presents with fever. The parents do not want a catheter placed in his penis. You want to check for urine infection. The resident suggests placing a bag. Are there any other options?

 

In 2013 Herreros-Fernendez described a technique of coaxing the child to urinate. She would tap the bladder at a rate of 100 taps per minute, and massage the low back. 86% of the time the child would urinate, with a median of 45 seconds. The population was strictly those less than 30 days of age, so it may not apply to older babies. The idea was inspired by bladder stimulation techniques used in adults with neurological diseases. There may be some element of a frontal lobe “release” reflex involved in the phenomenon.

 

The original study stacked the odds in their favor by feeding the babies, but follow-up studies all showed a greater than 50% success rate within 5 minutes. Thus, this technique is well worth trying in a low risk population.

 

Of note, the bladder tapping was 100 taps per minute. It is supposed to be gentle but the parents may quickly throw in the towel and ask for the catheter.

 

Take Home Points

-For the infant with a low suspicion of urinary tract infection, consider massage and bladder tapping to elicit a urination reflex

 

Herreros Fernández ML et al. A new technique for fast and safe collection of urine in newborns. Arch Dis Child. 2013;98:27-9.

LUNG AUSCULTATION: HEARING CRACKLES

You are seeing a patient with suspected pneumonia. Your attending hears crackles but you do not hear them. Later the radiograph shows pneumonia right where the attending heard crackles. What can you do to improve your pulmonary examination?

 

Sit up and take a deep breath might be bad advice?

 

Increase signal

Sensitivity for auscultation of crackles is increased in the supine position. Should you always listen supine? No. That is hard to do because anterior is less helpful and posterior requires you to squeeze the stethoscope behind their supine back. But be aware it is an option if you need to increase the sensitivity for the physical examination.

 

You can make crackles more easily discerned by varying your exam. If it sounded too quiet have them take a deeper breath.

 

Decrease noise

Should they always take a deep breath? No. That can increase other noise if they make upper respiratory noises. Have the patient take a “full and quiet” breath. That might be best for minimizing noise and maximizing signal.

 

Take Home Points:

-“Sit up and take a deep breath” is not the only way to do a lung examination

-Increase signal by auscultating the supine back

-Decrease noise by asking the patient to breathe deeply, but quietly

PNEUMONIA: CLINICAL VS RADIOGRAPHIC DIAGNOSIS

An elderly patient presents with cough and shortness of breath. The resident says the lung examination is normal and the chest x-ray is negative and wants to send the patient home. But you hear crackles posteriorly at the right base. And the oxygen saturation is 94%. And the patient looks ill. What do you do?

 

If your practice is to use chest radiograph as the gold standard for pneumonia (following IDSA guidelines – Mandell 2007) then you might be missing pneumonia. In medicine we tend (alas) to assume our reference standards are disease-defining until we compare them against something else.

 

Against CT scan, chest radiograph is probably about 75% sensitive and specific for pneumonia. Often the literature does not give exact numbers but false negatives and false positives are extensively documented. Where sensitivity is reported, it can be as low as 44%.(Self Am J Emergency Medicine 2013 – from a datebase of PE workups) A more representative finding for sensitivity is 77% (Ye PLoS One 2015). Good, but not perfect. Other studies show significant false positive rates (Clasessens Am J Resp Crit Care Med 2015). Specificity is probably also about 75% but we do not yet have a precise estimate of that. And of course there are significant differences between a supine 1 view chest radiograph in an altered patient and a 2 view standing radiograph with tidal volume inspiration.

 

Your overall accuracy is not doomed by limited tests. Your accuracy depends on how well you formulate Bayesian “prior probability” BEFORE applying results of tests. Of course, if you don’t want to do that there is always pulmonary ultrasound, with 95% sensitivity (Ye PLoS One 2015). But let’s talk bedside medicine.

 

The classical clinical signs of pneumonia are:

-fever

-tachycardia

-hypoxemia

-asymmetric breath sounds

-tachypnea

-progression of symptoms after 3-5 days

 

Steven McGee’s Evidence-Based Physical Diagnosis has an excellent chapter on this topic. It essentially supports the classical findings but reminds us of their limitations too.

 

Back to the case. You have a moderate clinical suspicion and you are aware that the gold standard is flawed. Do you order an ultrasound? CT? Do you start empiric antibiotics? Do you recommend next day follow-up? In this case you desire to admit the patient because she appears ill. But the utilization case manager and hospitalist argue that the admission does not meet Interqual criteria. They say it is impossible for a patient to have pneumonia without a positive chest x-ray and besides, the patient does not even have a fever (oral temperature).

 

You palpate the temperature at the neck with the back of your hand and leave it there for 5 seconds, and feel a tingle – this is a fever. The RN confirms the rectal temperature is 103. You perform a bedside ultrasound and find mild hepatization and a few air bronchograms in the area where you heard crackles. They do not accept the legitimacy of that test, despite the literature.

 

You order a CT scan and the radiologist confirms a moderate size consolidation, interpreted as pneumonia, at the exact area where you heard crackles hours before.

 

TAKE HOME POINTS

-Chest x-ray has limitations in sensitivity and specificity for pneumonia (probably about 75% for each)

-If you do a thorough physical examination with attention to heart rate, oxygenation, and auscultation then the CXR is probably adequate for most patients.

-When you need more information, consider pulmonary ultrasound, or CT scan of the chest.

JAW THRUST MASK GRIP

You are intubating a critically ill patient. The first intubation attempt fails and the patient experiences rapid oxygen desaturation. The respiratory therapist tries to ventilate the patient but air leaks out around the mask with each breath. The chest does not rise and the saturation is dropping.

 

What is the problem?

Sometimes the problem is an insufficient seal around the mouth but more often the problem is soft tissue obstruction. We intubate supine. The tongue occludes the airway. The air follows the path of least resistance, which is out the face, leaking around the mask.

 

What are the choices of grip?

  1. One handed grip, aka C or CE grip (generally acknowledged to be less optimal).
  2. Classic two handed grip – taking the problematic one handed grip, and doing it with the other hand too. Similar to the grip you would have if holding a soda can.
  3. Jaw thrust grip – similar to the grip you would have if lifting a gurney or plank, thumbs on top, fingers below doing the work of lifting. Or if you will, taking your soda can and dumping it out forward.

 

Some studies say CE grip or jaw thrust grip are equally effective. So why do you say jaw thrust is better?

Most of the time airway resistance (A) is lower than mask resistance (M). Anything will work in that situation. What really matters is what happens when A is greater than M. That isn’t addressed in most of these studies.

 

What happens when A is higher than M?

When airway resistance is higher than mask resistance, the operator grips harder to raise mask pressure. The fingers often compress the submandibular space. This presses the tongue against the posterior airway, and raises airway pressure further. The harder you grip, the more you close off the airway.

 

What is a better way?

JAW THRUST MASK GRIP

The best way to grip the mask is to press the mask to the face with the thumbs pointing forward. The fingers then fit over the angle of the jaw. If you want more pressure, you pull the fingers, which not only increases the seal pressure but also performs a jaw thrust maneuver. It pulls the tongue off of the palate.

 

Is there anything else that will help?

NASAL AND ORAL AIRWAYS

Place two nasal trumpets and an oral airway. Whether you have great technique or bad technique this will help. Don’t be afraid to “waste” some plastic here. I suspect that nasal trumpets also improve the effectiveness of apneic oxygenation via high flow rate nasal cannula.

 

Back to the case. You put the thumbs pointing forward on the mask and pull jaw thrust with digits 2-5. The leak is gone and the patient is re-oxygenated before your second attempt.

 

TAKE HOME POINTS

-Use the jaw thrust mask grip technique for ventilation

-Good mask ventilation is a crucial airway skill. Invest in it.

-If you are have ANY trouble, place nasal and oral airways

 

Suggested references:

Efficacy of facemask ventilation techniques in novice providers.

Gerstein NS, Carey MC, Braude DA, Tawil I, Petersen TR, Deriy L, Anderson MS.

J Clin Anesth. 2013;25:193-7

DE-ESCALATING VIOLENT PSYCHOSIS: TELL A STORY

A patient presents to the emergency department on a 5150 hold. He is yelling and straining against police restraints. Of course you will use medications but also want to try calming him down through bedside interaction.

 

The human mind, unhinged by disease and drugs and high emotions, needs simple, calm communication that is easy to understand. Talk to the patient in a story format. Introduce the characters and organize it chronologically (past, present, future). Make it very clear that they are safe, and you are on their side.

 

INTRODUCTION

Hi Mr. ____, I am Dr. ____. My job is to help people who are sick or hurt get better.”

 

PAST

“You are here because somebody called 911. They could tell something was wrong. When the police evaluated you they determined something was wrong also.”

 

PRESENT

“My job is to make you better. I am going to be talking to you and doing a physical examination.”

 

FUTURE

“When we are done we will determine the best treatments and the best place for you to continue to get better.”

 

REASSURANCE OF SAFETY

You will be safe here and you will be treated with respect.”

” Everything we do will be in your ultimate best interest.

 

DEFINE THE RULES

“Just as I promise to keep you safe and treat you with respect, I expect you to do the same for my staff.”

 

SHARE POWER WHEN POSSIBLE

To get started I would like to calm you down with a medication. That can be through a shot or a pill. If you are willing to take the pill you can choose that. The medicine will calm you and make it easier for us to talk.”

 

ANTICIPATORY GUIDANCE

“I know you will be safer if you get some medication. We are going to give you the shot and 4 people will hold you down. They will not hurt you. They are to keep you from hurting yourself and anyone else. When it is done I will talk to you some more.”

 

RESTORATION AFTER USING FORCE

Go back to being therapeutic right away so the patient is reassured.

“Are you feeling better after the shot? I want to talk to you about what to expect going forward.”

 

AGENDA SETTING

“What are you most concerned about?”

“What would you most like to see accomplished today?”

 

How does your emergency department treat the patient with psychosis? This is a stress test for genuine patient-centeredness. If you can be sincerely non-judgmental with them, it reminds everyone that we are serious about our caring culture.

 

TAKE HOME POINTS:

-Explain their care like a story. Introduce yourself and explain the past (how they got here), present (what you are doing now) and future.

-Everything you do is ultimately in their best interest (say that!)

-Reassure their safety first, and respect, and require them to abide by it also.

-Stay therapeutic before, during, and after conflict

 

References:

Verbal De-escalation of the Agitated Patient: Consensus Statement of the American Association for Emergency Psychiatry Project BETA De-escalation Workgroup.

Richmond JS, Berlin JS, Fishkind AB, Holloman GH Jr, Zeller SL, Wilson MP, Rifai MA, Ng AT. West J Emerg Med. 2012 Feb;13(1):17-25.