PREVENTING PEDIATRIC PITFALLS PROVIDES SEVEN (7) HOURS OF CONTINUING EDUCATION CREDIT
May 10, 2018 | 8:00 AM - 4:00 PM
AGENDA
8:00 – 9:00 Gut Busters: Pediatric Abdominal Emergencies
9:00 – 10:00 When Kids are Sweet as Sugar and Sick as @#$%: Pediatric DKA
10:00 – 10:15 Break
10:15 – 11:15 Just Trying to Get a Little Gas Exchange: Pediatric and Airway Disorders
11:15 – 12:15 It’s All the Rave: Adolescent Street Drugs
12:15 – 1:45 Working Lunch - What Would Spock Do (self-care for the medical provider)
1:45 – 2:00 Break
2:00 – 3:00 Hey, Ho, Do You Know IO?
3:00 – 4:00 And You Thought Just Tampons Could Kill You! Toxic Shock Syndrome
4:00 Evaluation and Adjourn
Participants will be able to identify signs and symptoms of common pediatric abdominal emergencies. Participants will be able to recognize life threats associated with pediatric abdominal emergencies. Participants will list management therapies specific to each abdominal emergency. Finger shaped pouch Projects out from colon on R side Purpose ? Obstruction Inflamed / pus Pain at naval and down to RLQ ? Tender when pressed/sharp when released . McBurney’s sign . Rovsing’s sign Pain worsens in time and movement N / V/ D or C / Anorexia / Fever Vomiting / diarrhea
Pain
Fever / irritability
R hip complaint Ruptured Appendix
Appendiceal Abscess Exam
CBC w/ Diff, Lytes, UA
Ultrasound
CT? Removal of HOT appendix Drainage of abscess… then remove appendix TREAT PAIN
IV fluids – NPO / dehydrated
Antibiotics
Prepare patient / family Most common obstruction cause in infants Telescoping / prolapsed Mesentery is compressed / edema / obstruction Ischemia/ gangrene / perforation 6 mon-3 years
75% idiopathic
Boys > Girls Vomiting
**Red “currant” jelly stool 20%
Intermittent colicky abdominal pain
lethargic Sausage-like mass RUQ
Absence of bowel in RLQ
Fever
Peritonitis / shock Labs
Abdominal x-rays
Ultrasound (gold standard)
Air / barium enema PAIN control
IV fluid resuscitation
NGT – decompression Abnormal bulge in groin area Abdominal wall weakness Intestines and fluid “break out” Small hole + large intestines = ouch Blood supply is cut off
That usually leads to bad things….
Bowel obstruction
Bowel tissue death Vomiting / fever
Pain / fussiness
Full /round abdomen
Red / discoloration of affected tissue Exam
Most spontaneously reduce
“watchful eye”
Unable to reduce Requires surgery PAIN CONTROL!
IV fluids / NPO
Surgery Magnets
Batteries
Sharps
Laundry Pods 6 months – 3 Yrs
Intoxicated college students on a dare! 1 is ok
2 or more is very, very bad Early intervention
Risk of voltage burns- can occur within 2 hrs
direct corrosive effects
Remove if in stomach for more than 48 hrs Early intervention
Remove before passing duodenal curve Plain radiographs
Endoscopy
Exam- any symptoms?
It’s coming out! Vomiting
Obstruction
Bleeding
Pain
Fever Symptomatic? Remove
Endoscopy / Surgery
Asymptomatic? Watch
Poop patrol / x-rays Pyloric muscle connect stomach-small intestine Sphincter enlarged Blocks food / forceful projectile vomit Infants 2-8 wks of age Dehydration Insufficient nutritional needs Electrolyte disturbances Very quickly Forceful, PROJECTILE vomit after feeds The P’s report baby very hungry / eager ↓ BM, constipation, ↓wt Dehydration, lethargy, mild jaundice Exam – olive shaped lump Labs – lytes Ultrasound Contrast x-ray IV fluids Pacifier NPO Surgery –same day as diagnosis • Abdomen begins at the “nickels” • Soft, pliable rib cage • Underdeveloped abdominal muscles • Poor protection of abdominal organs • Blunt trauma • Seat belt sign
• Significant intra-abdominal injury and vertebral fracture
• (+) PV= 11.5%, (-) PV = 99.9%
• CT: solid organ injury, free fluid • Most common injury: restrained kids • 1-15% blunt trauma • Lap belt compresses intestines against spine • 50% : retroperitoneal injuries • ↑ index of suspicion, ↑ M&M • ↓ 50% with perforated intestines have peritonitis on initial exam • Free air on CT • Non-operative management • Standard of care • Failure? 5%, within 12 hr. • Exception: pancreatic injury • LOS and observation time ? • R/T: CT grade of injury • Relatively common injuries • Conservative management • PICU X 48 hrs • Spontaneous hemostatis • Conservative management (85-90%) • R/O: portal vein, hepatic vein, or suprarenal IVC disruption • Delayed bleeding 1-3% • 3 days – 6 weeks post injury • Mortality 18% • Blunt trauma • CT cannot evaluate ductal injury • Elevated serum amylase • Less likely to manage conservatively • May need surgical exploration • Incidence 1.6%, 90% blunt trauma • Abdominal trauma: 10-20% renal injury • ↓ peri-renal fat / ↓ ossified ribs • Degree of hematuria ? • Conservative management Grade I-III, Controversy: Grade IV, OR: Grade V • Mortality 3 X higher than blunt • Impaled injuries are uncommon • Type and length of weapon • GSWs • Mark with electrodes • Consider Real Estate! And you thought you had a tough job! Obstruction / Rupture Late sign Fever, diffuse tenderness, rigid abdomen Look “crappy” Late sign Infection spreads throughout abdomen VERY PAINFUL! / fever/ abd swelling No mashing – tap foot They know their children “Just not acting right” “Something’s wrong”
When Kids Are Sweet as Sugar and Sick as *&#!
Teri Campbell RN, BSN, CEN, CFRN University of Chicago: UCAN DKA
• Complex metabolic state • Emergency vs. life-threatening • Hospitalizations • Cerebral edema Objectives
• Participants will define DKA • Participants will identify precipitating factors • Participants will discuss common presentation Objectives continued • Participants will review pre-hospital vs. hospital stabilization goals • Participants will discuss treatment options • Participants will review potential complications Definition Triad • Hyperglycemia • Ketonemia • Acidemia That’s a lot of “emias”… Definition
• Blood glucose: > 250 mg/dl • PH: < 7.3 • Serum Bicarbonate: < 15 mEq/L • Urinary ketone: > = 3+ • Serum Ketone: positive at 1:2 dilutions • Serum osmolality: Variable All the stats…
• Incidence / frequency
• Race
• Mortality Precipitating factors
• New diagnosis • Infections • Non-compliance • Endocrine changes • Caregiver lack of compliance • Pump failure What a story… History • Polydipsia, Polyuria • Fatigue • Malaise • N / V • Weight loss • Fever History
Abdominal pain Pathology
Decreased Insulin
Increase of “stress hormones” • catecholamines • glucagon • growth hormone • cortisol Pathology Lots and lots of sugar to no avail…
• Proteolysis • Ketones • Lipolysis • Lactic acids Presentation Soooo… How do they LOOK?
• mental status changes • tachycardia • kussmaul • B/P • delayed cap refill • possibly febrile Hyperglycemia • High serum glucose
• Big sponge Dehydration and thirst
• Intra-cellular dehydration • Extra-cellular fluid expansion • Hyponatremia • Polyuria • H20 losses exceed NaCl losses • Decrease renal blood flow Acidosis 2 main culprits
Ketones : Proteolysis
Lactic acid: Lipolysis Tissue hypoperfusion Hyperosmolality
• Directly related to hyperglycemia • Increased serum osmols • Increased cerebral osmols Electrolyte disturbances • NA: low, normal or high
• Increased K+
• Decreased K+
Treat hypokalemia first or…ZAP! Labs • Glucose
• K+
• ABG’s
• Electrolytes: CL, HCo3, BUN, Cr, Phos Labs
• CBC • blood / urine culture • UA • serum osmolality • EKG: hyperK+ = peaked T waves
SHOCK hyperkalemia? ______Pre-hospital • A: mental status changes
• B: O2, BVM, Sellicks
• C: Isotonic fluids • 20 cc/kg X ONE… • What size IV? Pre-hospital
• D: Altered mentation? • History? Long transport? Global goals
• Restore perfusion
• Give insulin
• Correct electrolyte disturbances
• Avoid complications Where are we going? And why am I in this Hand basket? Fluid therapy
• 1st 1-2 hours of therapy • Isotonic 20cc/kg • 0.9 NS vs. 0.45 NS • 1.5 – 2.0 X maintenance • BSA: 1200cc/M2/day Fluid therapy
• 4-2-1 Rule • 1st 10 kg : 40 cc • 2nd 10 kg : 20 cc • 1cc for every kg over (20kg)
37 kg child: 1st 10 kg: 40cc 2nd 10 kg: 20 cc all the other kg (1cc/kg): 17 cc 77 cc/hr Potassium supplement
• Profound hypoK+: oral vs. IV • Treat before insulin • K+ > 5.5: No K+ to IVFs • KCL vs K phosphate
Slowwwww lab? Insulin
• Bolus controversy • timing controversy • 0.1 units/kg/hr • 0.05 units/kg/hr • clear ketones • Regular insulin 1:1 Bicarbonate
• Rarely indicated • Evidence? • PH < 7.0 • Adverse hemodynamic effects
• Hypokalemia, hyperNA, alkalemia • Never give IV push Glucose
• Blood sugar @ 250 mg/dL • D5, D10 • Ketones, prevent hypoglycemia • serum glucose: 100-150 mg/dL 150-250 mg/dL • Fall: 50-70 mg/dL / first hour Closing the “GAP”
•Related to electrolyte imbalance •+ anions (-) - anions •NA – (HCo3 + CL) •6-14 WNL (<11) •Q 1 hr BS and Q 2 hr labs Serum Osmolality
• Normal range • > 320 risk for cerebral edema • > 320 correct volume over 36 hours • > 340 correct volume over 48 hours Complications Cerebral edema
• More common kids / adol. • Incidence: 0.3-1.0% • Mortality: 70% • Risk factors • Presentation Pathology
• Hyperglycemia = high serum osmols • High serum osmols = high cerebral osmols • Rapid correction: volume or sugar • Gradient: intracerebral & serum osmols • Free H20 into brain Treatment
Initial CT
Mannitol
3% NS ARDS
• Rare
• Potentially fatal
• Lots of crystalloids
• Normal cardiac function In conclusion…
Keep it slow….. It took them weeks to get here…
It will take days to fix them…. Any Questions? When Kids Are Sweet as Sugar and Sick as *&#!
Teri Campbell RN, BSN, CEN, CFRN University of Chicago: UCAN [email protected] 312-720-0835 JUST TRYING TO GET A LITTLE GAS EXCHANGE PEDIATRIC AIRWAY AND RESPIRATORY DISORDERS
Teri Campbell RN, BSN, CEN, CFRN University of Chicago UCAN Objectives
. Participants will list acute chronic pediatric respiratory disorders
. Participants will review upper and lower airway pediatric disorders
. Participants will discuss peds assessment and care considerations Peds Respiratory Physiology Differences . Metabolism O2 consumption
. Airway resistance Upper airway resistance Nose breathers Large tongue Small airway size Collapsibility Resp Physiology Differences
. Lower airway resistance Smaller airway size / collapsible Poor elastic recoil . Lung volumes # of alveoli Poor collateral ventilation . Muscles Weak diaphragm rib cage compliance Adjuncts
. SPo2 . % of bound Hgb
. ETCo2 . “Gold standard” . Measures gas exchange (35-45) ABG (KISS principle)
. Not an intubation determinate Care considerations
. BVM / mask
Mask to the chest Congenital airway malformation
. Tracheomalacia . Laryngomalacia . Pierre Robin . Choanal atresia Chronic respiratory d/o’s
. TB . Asthma . BPD . CF . Lung transplants Tuberculosis
. Chronic bacterial infection . Mycobacterium tuberculosis . Airborne disease (sneeze / cough) . Infected vs. illness What kids are at risk?
. Live with others that have TB . Medically underserved populations . Visit or live in countries w/ prevalent TB . Homeless . Abuse ETOH, drugs, HIV+ . Elderly . Parents in jail 3 Stages
. Exposure: (-) skin test, CXR, and no S&Sx . TB infection: (+) skin test, (-) CXR, no S&Sx . TB disease: (+) skin test, (+) CXR, (+) S&Sx Symptoms
. May be age dependant
Child Adolescent Fever, chills Fever Night sweats Night sweats Weight loss Weight loss, anorexia Cough Productive cough (↑ 3 wks) Enlarged lymph nodes Bloody sputum Fatigue Chest pain Treatment
. Short term hospitalization (?) . Isoniazid, Rifampin, Pyrazinamide, Streptomycin . Up to 6 months . Must complete antibiotics (non-compliance) . Not contagious once treatment started Asthma . Chronic hyper-responsive inflammatory response . Airways sensitive to allergens . Most common chronic disease of childhood Don’t Make Me Hold My Breath
. Epidemiology data . Increasing global health problem . 3 identified factors Early allergen sensitization Frequent reoccurrence of viral infections Increased survival of premis with BPD Who’s at Risk?
. Atopic sensitization < 2 y/o Irrelevant in kids > 5 y/o . More than 2 episodes of RSV or Rhinovirus or a single lower resp tract infection More than a Hypothesis?
. Epigenetic mechanisms Predisposition to produce IgE r/t environmental stimuli
Genetic and environmental factors
Likely begins in utero May influence the onset and expression of certain diseases Hygiene Hypothesis
. Environmental factors . Air = rich or poor in bacterial endotoxins . Mucus membrane colonize pathogenic and non pathogenic species of endotoxins *MOST important r/t inducing immune response “imprinting” of the immune system (good/bad) Rural kids / farm exposure / non pathogenic stimuli Offspring of vaccinated moms = better gut colonization Breast feeding = anti-inflammatory / microbiota growth Who Can Be Diagnosed?
. Typically not diagnosed before 5 Reactive airway disease (RAD)
. GINA Guidelines Paucity of dx tests Symptom severity and frequency Response to treatments Family history suggestive of atopy Quick patho . Trigger→histamine→inflammation of lining of airways→airway muscles tighten →mucus production . Immediate: swelling and narrow of airway . Later: (4-8 hrs) ↑ inflammation of airway and obstruction of outflow Triggers
. Allergens (cockroach poop) . Irritants . Exercise . Smoke . URI, sinusitis . Sensitivity to meds . GERD . Emotional anxiety / stress Possible therapies
. SABA Albuterol, Atrovent, Xopenex pMDI* . *Oral corticosteroids Prednisolone / Prednisone . Magnesium sulfate . SQ epinephrine (?) . Terbutaline . HeliOx (70% 02, 30% Helium) Shout Out to Corticosteroids
. Most frequently Rx’d . Prevent or suppress inflammation . IV = PO (efficacy) / PO: liquid > pills / inhaled . Adverse: n/v; disturbed sleep; * growth (?) . No withdrawal complications . Chronic treatment Adrenal insufficiency Acute hypoadrenal crisis Test pearls…
. Don’t trust them EVER! . Watch high airway pressures (20-25 wnl) . High risk for chest tubes . Changes in LOC vs true fatigue . Combative behavior is never good . Silent chest Admit / Transfer… Or Not? Broncopulmonary dysplasia
. BPD or CLD (Chronic lung disease) . Scarring to fragile lung tissue . Premature babies . ↓ alveoli, ↓ surfactant . Mechanical ventilation / O2 requirements Practice pearls…
. ↑ risk for respiratory infections . May have trach and vent . Check obstruction! Large and small airways . Follow parental leads Cystic Fibrosis
. Autosomal recessive disease . Chronic, progressive, fatal . Mid 30’s . Infants : within the first year . Kids : may have later expression . (only discussing respiratory issues) Patho… real quick
. Abnormal function of CF transmembrane regulators (CFTR) . CFTR control the flow of NA and H2o . Mucus become thick and sticky . ↑ lung infections . Nasal polyps . ↑ Sinus infections Treatments of CF
. CPT . Bronchodilators . Anti-inflammatory . Antibiotics . Lung transplant PH/ED symptoms
. Hemoptysis . Spontaneous pneumothorax . Cardiomegaly . Nasal polyps . Sinusitis . Hyponatremia Upper airway disorders
. Sinusitis
. Croup
. Epiglottitis
. Pharyngitis / Tonsillitis
. Whooping cough (pertussis) Sinusitis, Pharyngitis, tonsillitis
. Usual causes . Unusual: trauma, FB, tooth infection, cleft . R/O migraine HA . Antibiotics (?) . Rare: ↓ 2 y/o to develop Group A Step throat . Antibiotics required (TSS) Croup / laryngotracheitis
. Infection in the glottis and subglottic region Inflammation/edema airway diameter and airway resistance and WOB Inspiration: subglottic space are sucked together Stridor / Seal bark . Viral: (parainfluenza and RSV most common) . 6 months – 5 years, peak is 2 y/o Boys > girls Croup: History / Diagnosis
. Usually preceded by a URI . Onset is abrupt and at night! Serum cortisol: Peak 8 am; trough 11 pm . *Usually self limited and resolved in 48 hr
. History . No labs / rare CXR . Steeple sign Westly Croup Score Croup: Management
. Humidified air / ABX ? Nut Uh… . Racimic Epi and oral cortiscosteroids Epiglottitis
. Inflammation of the epiglottitis . Acute, life threatening, bacterial . HIB(*) and Group A B-hemolytic strep . Usually 2-8 years of age . Not seasonal Symptoms
. URI, very sore throat, fever . Muffled voice or can’t talk . No cough . Drooling . Sits forward . Open mouth Treatment Pearls
. Antibiotics, steroids . Rifampin for family members . Rapid loss of airway . Answer: Keep them quiet and with mom! Whooping cough (Pertussis)
. Bordetella pertussis (droplets) . DTaP vaccine . Swelling of airways and ↑ mucus production . Paroxysms (dry and harsh) . 1-4 weeks to incubate . Hospital: antibiotics, O2 . Family antibiotic therapy Lower airway disorders
. Bronchitis . Bronchiolitis . Pneumonia Bronchitis . Inflammation of the bronchi (large airway) . ↑ mucus production . Acute (kids), Chronic (adults) . *Viral, bacterial, allergens, asthma, URI . Usually no antibiotics . Avoid antihistamines Bronchiolitis
. Infection/inflammation of the bronchioles (lower airways) . Leading cause of hospitalization . Usually viral (*RSV, parainfluenza, HRV) 30-60 days = RSV . Peak incidence Nov-April . 3-6 months of age . Risks: premie, male, low socio, smoking, bottle Clincial Presentation . Tachypnea (or) *apnea . Inspiratory crackles / expiratory wheezes . Desaturation . Dehydration . WOB Nasal flaring, retractions, grunting How Do We Make This Better?
. Synagis or RSV-IGIV vaccine . O2 and hydration (D10) . NO EVIDENCE Rac epi, ABX, bronchodilators, antivirals, systemic or inhaled corticosteroids Pneumonia
. Infection or inflammation of lungs and alveoli . Lobar pneumonia . Bronchial pneumonia . Winter / Spring Bacterial
. Streptococcus pneumonia (most common) . GBS (most common in newborns) . Staph aureus . Group A strep (most common in kids over 5)
. Usually acute onset of symptoms Respiratory Failure
. Type I Hypoxemia without hypercarbia Usually altered ventilation/perfusion
. Type II Hypoxia with hypercarbia Usually airway flow resistance and surface for gas exchange 2 Miracles
. CPAP Prevents alveolar collapse / recruits lung surface WOB / relaxes airway muscles Heated/humidified: helps secretion clearance Usually between 5-12 cm H20 . HFNC Heated/humidified mix of air and O2 Flow rates higher than inspiratory flow WOB In conclusion
. Clinician reciprocal respiratory rate . Babies and kids that cannot breath are SCARY! . Fall back on your basics Water the flower Give the flower fresh air
. Practice BVM!
. Consider early transfer for kids that don’t turn around JUST TRYING TO GET A LITTLE GAS EXCHANGE PEDIATRIC AIRWAY AND RESPIRATORY DISORDERS Teri Campbell RN, BSN, CEN, CFRN University of Chicago: UCAN [email protected] 312-720-0835 bib
. Cutrera, R, Baraldi, E. et. al. Management of acute respiratory diseases in the pediatric populations: the role of oral corticosteroids. Italian Journal of Pediatrics. March 23, 2017 It’s All the Rave Adolescent Street Drugs
Teri Campbell RN, BSN, CEN, CFRN UCAN Flight Nurse Objectives and Stuff
• Participants will briefly review commonly abused street drugs
• Participants will discuss “need to know” care pearls for the drug altered patient.
• Participants will list care treatment priorities for the drug altered patient Disclaimer
• No illicit drugs were used in the creation of this PPT
• I “cannot recall” if ETOH was involved….
5/10/2018 Free Template from 3 www.brainybetty.com Latin for Drug Abusers
• Body packers
• Body stuffers
• Free basing
• Plug it The Teen-aged Brain
• Brain development: teen-mid 20’s
• Develop back to front
• Immediate satisfaction vs reasoning and impulse control What? My Kid?
• Poor: emotional control, planning/judgment • Risky behavior + poor impulse + no consequences = developing brain risks • Dopamine This Is YOUR Brain… Cocaine / Crack
• Big C, blow, coke, nose candy, rock, snow
• Potent brain stimulant
• Cocaine: snorted or injected / Crack: smoked Cocaine / Crack
• ST: euphoric, energy / mental clarity • Sympathetic response
• LT: paranoia, aggressive behavior; pulmonary, renal, GI injury
• NTK: Coke crash Bath Salts
• Bliss, blue silk, cloud 9, meow2, (white) dove, knight, lightening. *flakka
• Synthetic concentrated cathinones (designer) • α and β adrenergic stimulation
• *Sniff/snort; PO, smoked, IV • Lasts 3-30 hours Bath Salts
• ST: severe paranoia, combative/violent, hallucinations/psychosis, HR, BP, CP,T • Excessive dopa and serotonin • LT: unknown • NTK: psychotic symptoms: single dose, may persist for days to weeks. • Avoid Ketamine • BENZOS! Ecstasy
• Adam, E, Molly, Roll, X, XTC, Adam
• MDMA, synthetic amphetamine-like & hallucinogenic psychogenic drug Ecstasy
• ST: energy, desire to touch: teeth clenching, n/v, blurred vision, chills/sweat, tachy, HTN, seizures all possible
• LT: damages serotonin producing cells, sleep disturbances, impaired memory
• NTK: dry/T: rhabdo/liver/CV failure – Herbal ecstasy • Fentanyl
• 2-3 mg of Fentanyl: induce respiratory depression/failure
• 2-3 mg = 5-7 grains (of salt) worth of fentanyl
• OD: Narcan: q 2-3 minutes Fentanyl
• NTK: Accidental exposure to HCPs and first responders (PPE/N-95) Police dogs too • Do NOT use hand sanitizer: contains ETOH and increases absorption of opioids through the skin • Don’t try to collect drug samples • Can come in innocuous devices such as nasal spray, eye drops Carfentanil
• Drop dead; serial killer • Synthetic opioid – Elephant tranquilizer • Inexpensive to make • $800-$2500 per gram: heroin $90-120/gm Carfentanil
• 10K times stronger than Morphine • 5K times stronger than Heroin • 100 times stronger than Fentanyl • Powder, pills or blotter paper • 200 mcg can be fatal (few grains of salt) Carfentanil NTK
• HCP clue: Carfentanil vs. other opioids – Requires MULTIPLE doses of Narcan • HCP exposure – inhalation; mucus membranes; ingestion, needle sticks; absorbed through the skin Carfentanil
• NTK • 2002 Moscow hostage crisis • EMS Unaware – Military instructed to bring Narcan – Too little, too late – Hundreds died Weapon of Mass Destruction
• China • Legal until 3/2017 • Canada • Seized 1 kg of drug • Concern for use as chemical weapon • Knocking out troops • Killing civilian in closed spaces Methamphetamine
• Chalk, crank, crystal, meth, tweak, ice, tina
• Sympathomimetic: stimulant, anorexiant, euphoric, hallucinogenic • Neurotransmitter inhibitor
• Oral, IV,IM, rectal, vaginal, snorted, smoked Methamphetamine
• ST: rush/flash vs high, awake, HR/RR/T • ED presentation: tachy, paranoid, agitation
• LT: tolerance, paranoia, hallucinations, “crank bugs”, aggressive/violent, teeth
• NTK:Benzos, cooling, restraints, Succs, B blockers Meth Head K2 Synthetic Marijuana
• Spice, black mamba, bliss, bombay, genie
• Synthetic cannabinoid, 2-800x potent • Onset 3-5 minutes, lasts up to several days
• Smoked, may be consumed in tea K2
• ST: agitation, n/v, ataxia, dysphagia, delusions, hallucination, HTN/tachy, red eyes, appetite, severe paranoia/hallucinations, seizures • * N/V: showers
• LT: assoc with stroke , SAH, ARF, AMI
• NTK: drug screen, benzos, cooling, RSI, psych Gamma Hydroxybutyrate GHB
• G, Georgia home boy, grievous bodily harm, scoop, X
• CNS depressant • GABA GHB
• ST: euphoria, tranquility, sex drive, hallucinations, amnesia, LOC (69%)
• LT: severe withdrawal; seizures
• NTK: body builders; date rape drug; home labs, highest reported users Heroin
• Big H, black tar, brown sugar, smack, china white, skag, hair-on • * Hot drugs
• CNS depressant, derived from MsO4
• IM, IV, snorted, smoked Heroin
• ST: “rush”, users go “on the nod”, N/V • LT: tolerance/addiction, CV/pulm infections, HIV, hepatitis, *69 y/o NH pt • Withdrawal: peak 24-48 hours • NTK: “cold turkey”; “kick the habit”; 248% • MVC Hash Oil
• Hashish oil, Honey, Wax, Dab
• THC (50-99%) • Crappy crops?
• Smoking, ingestion or vaporization (dab) Hash Oil
• ST: reported as a hallucinogenic high • LT: explosions, lung injury: (cuticle wax /pesticides) • NTK: lethal dose 30mg/kg – Toxic dose: 15mg/kg – Lowers cholesterol! – No acetaminophen – Very lipophilic Inhalents
• Huffing, sniffing, bagging, whippits, poppers
• Highly lipid soluble intoxicants, CNS depressant Inhalents
• ST:euphoria followed by lethargy, impaired judgment and coordination
• LT: neurocognitive impairment, cerebellar dysfx, loss of brain mass and white matter
• NTK: Sudden sniffing death; sniffer rash • Parklands? Ketamine
• Kit kat, special K, Vitamin K, super K
• Dissociative anesthetic (date rape)
• Snorted, oral, IM, IV Ketamine
• ST: dreamlike state, hallucinations, tachy, amnesia, HTN, depression, resp failure, • LT: Flashbacks, agitation, depression, cognitive dysfx • NTK: “K-hole”; emergence reaction; caffeine; treatment of depression • Laryngospasm / salvation in kids Rohypnol
• Roofies, R2, roach, forget me, ruffles, date rape
• Intermediate acting benzodiazepine
• Oral, snorting, IV Rohypnol
• ST: drowsy, dizzy, loss of motor,**drunk feeling, confusion, resp depression, • Lasts 2-8 hours; cocaine, heroin
• LT: addictive, impairs cognitive and psychomotor function
• NTK: No FDA use/manufacture in US; blue dye Hallucinogens
• LSD (acid, blotter, dots) • PCP (angel dust, embalming fluid) • Mescaline (peyote) • Mushrooms (caps, shrooms, magic) • DMT (businessman’s trip, fantasia) Performance Enhancing Substance (PES) • Enhance athletic ability, body appearance or fight obesity • Methamphetamines, steroids, diet aids • Prevalence (?) • Associated: feelings sad/hopeless, perceived overweight, sexually active, cigarette and ETOH use, geography, availability at school PES
• **Offered/sold/given at schools: 17-39% • 1.1 million teen: bought PES in retail stores and the intranet – WHO: 50% counterfeit • Demographics – 74%: 15-17 y/o – 60% white; 15% black In the Medicine Cabinet
• OxyContin: Opiod • Ritalin: amphetamine for ADHD • Dextromethorphan: cough suppressant • Camphor: Vicks vapor rub • OTC cold medicines: phenylephrine, pseudoephedrine, ETOH, acetaminophen Basic Drug Test
• DOA: Drugs of Abuse • Drug Free Workplace 1988 – Amphetamine: 1-3 d – Cocaine: 1-3 d – Marijuana: days to months – Opiods: 1-3 d – PCP or Benzo: 1-7 d • Controversy: prego; teens Subverted DOA screens
• Dilution with water • Ingestion of masking agents • Adulterants added to urine • “Oil change” General Treatment Guidelines
• SCENE SAFETY • Supportive / call Poison Control / drug screen
• Blood sugar, EKG, BMP
• Alpha adrenergic: No beta blockers
• Benzos, benzos, benzos! Lots More
• Avoid physical restraint
• No antipyretics
• Succinylcholine contraindication
• Ketamine caution In Conclusion
• Adolescent drug abuse, epidemiology is varied depending on the drug • Prevalent! • Partnership for Drug-Free Kids • Talk to your kids and patients!
• www.dea.gove • www.deadiversion.usdoj.gov • www.cdc.gov • www.drugabuse.gov
• U.S. Department of Justice: Drug Enforcement Administration: A briefing Guide for First Responders It’s All the Rave Adolescent Street Drugs
Teri Campbell RN, BSN, CEN, CFRN UCAN Flight Nurse • Arnold, T., Ryan, M. (2014). Acute amphetamine and synthetic cathinone (“bath salt”) intoxication. Retrieved from http://www.uptodate.com/contents/acute-amphetamine-and-synthetic-cathinone-bath-salt- intoxication?source=machineLearning&search=amphetamine+overdose+treatment&selectedTitle=1%7E150§ionRank= 5&anchor=H350266331 • Baum, C. (2014). Ethanol intoxication in children: Clinical features, evaluation, and management. Retrieved from http://www.uptodate.com/contents/ethanol-intoxication-in-children-clinical-features-evaluation-and-management • • Becker, W., Starrels, J. (2015). Prescription drug misuse: Epidemiology, prevention, identification, and management. Retrieved from https://www.uptodate.com/contents/prescription-drug-misuse-epidemiology-prevention-identification-and- management?source=search_result&search=risk+management&selectedTitle=4%7E150 • Delgado, J. (2014). Intoxication from LSD and other common hallucinogens. Retrieved from http://www.uptodate.com/contents/intoxication-from-lsd-and-other-common-hallucinogens • DMT – Partnership for Drug-Free Kids. (n.d). Retrieved April 12, 2016, from http://www.drugfree.org/drug-guide/dmt/ • Drug Guide for Parents: Learn the facts to keep your teen safe – Partnership for Drug-Free Kids. 2014. • DXM – Partnership for Drug-Free Kids. (n.d). Retrieved April 12, 2016, from http://www.drugfree.org/drug-guide/dxm/ • Gamma-Hydroxybutyrate (GHB): Effects, Hazards & Methods of Abuse - Drugs.com. (n.d.). Retrieved January 31, 2016, from https://www.drugs.com/illicit/ghb.html • GHB – Partnership for Drug-Free Kids. (n.d). Retrieved April 12, 2016, from http://www.drugfree.org/drug-guide/GHB/ • Hashoil – Partnership for Drug-Free Kids. (n.d). Retrieved April 12, 2016, from http://www.drugfree.org/drug-guide/hashoil/ • Hoffman, R. (2015). Ketamine Poisoning. Retrieved from https://www.uptodate.com/contents/ketamine-poisoning • Hoffman, R. (2015). Testing for drugs of abuse (DOA). Retrieved from http://www.uptodate.com/contents/testing-for-drugs-of- abuse-doa • K2 - Spice (synthetic marijuana) - Partnership for Drug-Free Kids. (n.d.). Retrieved April 12, 2016, from http://www.drugfree.org/drug-guide/k2-spice/ • Levine, M. (2015). Phencyclidine (PCP) intoxication in children and adolescents. Retrieved from http://www.uptodate.com/contents/phencyclidine-pcp-intoxication-in-children-and-adolescents • LSD – Partnership for Drug-Free Kids. (n.d). Retrieved April 12, 2016, from http://www.drugfree.org/drug-guide/LSD/ • Mushrooms – Partnership for Drug-Free Kids. (n.d). Retrieved April 12, 2016, from http://www.drugfree.org/drug- guide/mushrooms/ • OxyContin – Partnership for Drug-Free Kids. (n.d). Retrieved April 12, 2016, from http://www.drugfree.org/drug- guide/oxycontin/ • PCP – Partnership for Drug-Free Kids. (n.d). Retrieved April 12, 2016, from • PCP – Partnership for Drug-Free Kids. (n.d). Retrieved April 12, 2016, from http://www.drugfree.org/drug-guide/PCP/ • Perry, H. (2014). Inhalant Abuse in children and adolescents. Retrieved from http://www.uptodate.com/contents/inhalant- abuse-in-children-and-adolescents/ • Peyote – Partnership for Drug-Free Kids. (n.d). Retrieved April 12, 2016, from http://www.drugfree.org/drug-guide/peyote/ • Ritalin – Partnership for Drug-Free Kids. (n.d). Retrieved April 12, 2016, from http://www.drugfree.org/drug-guide/ritalin/ • Rohypnol: Effects, Hazards & Methods of Abuse - Drugs.com. (n.d.). Retrieved January 31, 2016, from https://www.drugs.com/illicit/rohypnol.html • Wang, G. (2015). Synthetic cannabinoids: Acute Intoxication. Retrieved from http://www.uptodate.com/contents/synthetic- cannabinoids-acute-intoxication • Wiegand, T. (2014). Clinical manifestations and evaluation of mushroom poisoning. Retrieved from http://www.uptodate.com/contents/clinical-manifestations-and-evaluation-of-mushroom-poisoning • Yin, S. (2014). Over-the-counter cough and cold preparations: Approach to pediatric poisoning. Retrieved from http://www.uptodate.com/contents/over-the-counter-cough-and-cold-preparations-approach-to-pediatric- poisoning?source=machineLearning&search=anti+histamines&selectedTitle=2%7E150§ionRank=1&anchor=H1988040 6 • Yin, S. (2014). Phenylephrine and related decongestants: Pediatric poisoning. Retrieved from http://www.uptodate.com/contents/phenylephrine-and-related-decongestants-pediatric-poisoning • National Institute on Drug Abuse NIH. Commonly Abused Drug Charts. July 2017. https://www.drugabuse.gv/drugs-abuse/commonly-abused-drugs-charts • Thorlton, Janet R. PhD; McElmurry, Beverely EdD; Park, Chang PhD; Hughes, Tonda PhD. Adolescent Performance Enhancing Substance Use: Regional Differences in the US. May 2012, p. 97-111. Journal of Addiction Nursing. Vol 23(2) • The National Center on Addiction and Substance . April 2017. Commonly Used Illegal Drugs. https://www.centeron addiction.org/addiction/commonly-used-illegal-drugs What Would Spock Do?
Teri Campbell RN, BSN, CEN, CFRN University of Chicago Flight Nurse UCAN Disclaimer WWSD?
• We are human
• We are flawed
• 90% medical/aviation errors: Human factor
• Aspire to be Bones?
• Aspire to be Spock Objectives
• The participants will STOP being human
• The participants will have a sense of humor
• Participants will list transport / hospital related safety risks
• Participants will identify personal safety risks YOUR Instructions
• Intent of this lecture
• Put the pen down I Didn’t Know…
• …What I didn’t know • First flight job • Director of Flight Operations • Line pilot • Confirmation bias Complacency
• I care about safety but I have “professional ADD”
• Does this sound like anyone you know? Complacency
• Complacency vs DISTRACTIONS
• Easily distracted…. SQUIRREL!
• Do tasks outweigh safety? Complacency
• Eyes see what they expect to see
• Stop talking during the walk around
• Police each other
• Check lists Complacency
• I am safe most of the time
• I checked it earlier…
• I am in a rush….
• I trust the person I relieved…
• I am gonna close my eyes just for a minute… Communication
• Crew communication is critical
• Closed loop communication
• Aviation challenge and response Communication
• Incomplete communication I’m Sorry, What?
• Speak: 145-160 wpm
• Hear: 400-450 wpm
• 75% time differential
• Wander / retort / shut down Word Up
• Delivering the message
• Spoken words: 30-35% of meaning
• Non-verbal communication / auditory clues
• Troublesome texting? Suffer From CRS?
• Can’t remember sh$%?
• Evening news: 17.2%
• Conversational task / asked to remember
– 2.9% of items remembered Steel Trap? You Weren’t Listening to Me
• 10 minute oral presentation
• 50 % retained
• 48 hours later: 25% retained Affect MY Safety?
• Orientation
• Feet on the street
• Please STOP TALKING Affect PATIENT Safety?
• Program differences
• Divide tasks?
• “Listening” deficits
• Re-cap before departure One brain between the 2 of us Affect TRANSPORT Safety?
• Aviation challenge responses in our own vehicle?
• Combat complacency
• Habla Latin?
– D elta I ndia C harlie K ilo
• Too much communication? Identify Other Barriers
• Speed reading / speed listening
• Verbal orders
• AWAY versus “I weigh”
• All Female jury… So What Can We Do? • Combat complacency… never ends
• Deliver the mail to the right address
• Task overload = inability to listen What Else?
• Non verbal communication
• Practice active listening LISTEN
• L Look Interested • I Inquire • S Stay on target • T Test understanding • E Evaluate the message • N Neutralize your feeling Multi-task vs Task Overload
• If you want something done give it a busy person • Professional pride • Start believing our own Press Safety Snafu Set-up
• Difficult to ask for help
• Perception becomes reality
• Dishonorable delegation?
• Slow your roll, sista
I Can Clearly SEE my Error
• Scene: single victim motorcycle • No helmet / massive head injury • Trauma center report: pupils NR • Technically not incorrect….. Is This You? Burnt to a Crisp
• Emotional burden r/t: see / do / experience
• Q day we experience their WORST day
• Accumulative Billy Bad Ass • Compartmentalize
• We EAT stress…for breakfast
• Simple physics… pressure cooker
• Coping techniques Coping Techniques
• Healthy
– Exercise / Yoga / sex / debriefing
• Not so much
– ETOH/drugs / dangerous liaisons / kick the dog Burn Out
• Failed job expectations
• Pressure to live up to the flight suit/scrubs/turn- out gear
• Our dumb questions?
• SHOULD know / USED to know / NEED to know Physical Needs and Safety
• Hangry? AKA stupid hungry
• Dehydration AKA stupid thirsty When Q One Else is Too Tired
• Fatigue AKA stupid tired
• Contributing factors
• Pre-shift sleep
• On duty rest Common Sense? Knowledge deficits r/t Safety
• Our own deficits
– Phone a friend?
• Customer deficits
• Unsafe care practices
• Call out versus calling patterns
– Compliment sandwich Laziness Affecting Safety
• Don’t be lazy, ALL will DESPISE you Laziness
• Crew that makes you PANIC?
• Crew that gives you CONFIDENCE?
• Work first: play / sleep later
• Wards off evil spirits Laziness and Homicidal Ideations
• Laziness leads to safety issues for OTHERS
• Carrots and sticks to change behavior Big , Bad and Ugly Personalities
• The “know it all”
• “I got this”
• The “I eat my young” Big Personalities and Safety
• The “Samsonite collection of emotional baggage”
• The “Dr. Jekyll and Mr. Hyde” Situational Awareness
• Cannot prevent all bad situations
• Mitigate risks
• 85% of all aviation/medical accidents r/t loss of situational awareness Spidey Sense
• Gestalt • Minimum of 4 safety chinks/ accident (ave is 7) • Barriers – Fatigue – Tunnel vision – Physical / emotional distractions A Tale of an EPIC Miss
• Minding my own business…
• Triage mass casualty Debrief to Promote Safety
• Helps to prevent burnout
• EVERY transport / shift
• Entire team (formal) Debrief
• True QA/ QI
• Non-judgmental
• Compliment sandwich Self Flagellation
• Our harshest critique • Scene prayer • Chew our cud • Family / SO issues – Exhausting to translate Latin – Sympathy but not empathy – Sugar lips Short Term Relationships
• Make them count!
• Customer encounters
• Patient / family encounters
• Grief reduction
• Reduce legal risk In Conclusion ? This Cannot Be Our Conclusion
• We cannot let bad judgment be our guide
• Our patients, our crew and our families are counting on to use GOOD judgment
• Accept our humanness and mitigate our risks This is OUR Conclusion
• Quiet reflection
• Identify YOUR safety challenges
• Find your inspiration to be more safe
• And remember… WWSD? What Would Spock Do?
Teri Campbell RN, BSN, CEN, CFRN University of Chicago: UCAN [email protected] 312-720-0835 DO YOU KNOW IO? LET’S GO!
Teri Campbell RN, BSN, CEN, CFRN Flight Nurse University of Chicago A lesson in history
• WWI
• WW II
• Vietnam Military use now Transition into civilian use
• EMS systems established
• Current EMS use
• Current hospital use
• Flight program use “My Kingdom for an intravenous line” • Pediatrics
• Orlowski
• PALS
• Distal femur What about big people?
• Historical options • DLABOOH • “Multiple stab wounds” • Central lines It Always Comes Down to A&P
• Medullary space Who is Volkman and Haversian? A Picture is Worth a Thousand Words Who Knew it was that Fast? How Fast is Fast?
• Humeral / sternum: ~ 1-2 seconds / heart • Tibia: ~ 4 seconds / heart • Beating heart Push it back, push it back, wayyyyy back
• Thick fibrin network • Vigorous flush • Displaces bone marrow • No risk of emboli Volumes
• Approximately 1-6 liters/hr • Landmark dependant • Contrast studies (?) • Patient variances • Level 1 infuser Everything but the Kitchen Sink
• All medications approved for IV use • No “new math” • Not approved for chemo • Long term hypertonic saline Landmarks
• Product dependant • Proximal and distal tibia • Proximal humerus • Distal femur • Sternal (?) Welcome to my Laboratory
• 2-10 cc waste (2-3cc and 6 cc study) • T&S, cultures, H/H, Chemistries • Platelets, PT, PTT and WBC count may be elevated. (bone marrow) • “lab dictator” • Porcine studies IO compared to Central line
• Drs Hoskins and Kramer UTMB • Proximal humerus IO delivery of epinephrine improves arterial pressure at least as much as central venous delivery.
• Results: Proximal humerus IO = Sternal IO = CVL
Dr. George Kramer, University of Texas Medical Branch, Galveston, Texas CPR Studies, IO Drug delivery
• Study Objective:
• To compare - IO bolus vs IV bolus for vascular delivery of drugs during experimental CPR
• Subjects: Ten swine (25–30 kg), anesthetized, instrumented & subjected to cardiac arrest and CPR. But Does it Compare? Contraindications
• Fracture in targeted bone • Known infection - Osteo - Cellulitis Contraindications continued
• Previous orthopedic event • Cannot identify landmarks Not just for dead kids anymore
• Historical indications
• Immediate vascular access is needed • Unable to establish PIV • Central access: Not needed or inopportune I can ALWAYS get a line…
• You tell me… • Arrest • “C” before “A”? • Trauma But We’re Really Good at IVs
• Chemo patients • Obese • Alligator skin Well, MOST of the time we’re good
• Renal patients • Diabetics • Hypertensives • LOL / LOM ACLS/PALS AHA
• When venous access cannot be rapidly achieved, Intraosseous (IO) access can serve as a rapid, safe and reliable route for the administration of drugs, crystalloids, colloids, and blood
• IO cannulation provides access to a non-collapsible venous plexus in the bone marrow and can often be achieved in 30-60 second
• This vascular access technique is suitable for all age groups - from pre-term neonates through adulthood Join the Club!
• AHA, ERC, ILCOR, NAEMSP, ENA, AACN, INS • IO should be considered early in vascular access emergencies • Adults - 2 peripheral IV attempts Progress to IO • Pediatrics - 1st line of choice Maybe “drowning” will help?
• ET tube is no longer recommended for drug
delivery
• Central lines are discouraged
• ~ 5 million CVL insertions/year/US
• CVL: unnecessary delay in drug delivery
• CDC reports: 9% CVL infection rates (14%) Potential Complications • Infections • 20+ year retrospective study of manual IO left in for ≥ 72 hours • Incidence of ALL complications : 0.6% • Current practice : 24 hours Rare Complications
• Extravasation • Compartment syndrome • Bone / soft tissue damage Oh Yeah, and Then There is US!
• Operator error • Old technique • 50-80% • New technique • 95-100% Adult vs. Pediatric Considerations • Manufacturer considerations • Growth plate concerns • Landmark development • PMH: osteoporosis, brittle bone, etc Now That’s Gotta hurt
• Not if your dead • Awake and alert • Able to perceive pain • Coming back from the dead (post-resuscitation) It’s Better Than a Sharp Stick to the Eye!
• Insertion pain • Infusion pain • Non expandable cavity But I Don’t Want to Hurt Them…
• 2 words for you… • Foley • NGT Clinical Practice Changes
• CMS
Medicare will no longer pay the extra costs of treating preventable errors, injuries, infections, a move they say could save lives and millions of dollars1
Medicare will not pay hospitals for the cost of treating certain “conditions that could have reasonably been prevented”. Among the conditions that will be affected are infections resulting from prolonged use of catheters in blood vessels
Pear, Robert. Medicare Says It Won’t Cover Hospital Errors. New York Times. 8-19-2007 Splash of betadine and stab
• Central venous catheter-related infection in a prospective and observational study of 2,595 catheters Critical Care 2005, 9:R631-R635 • ICU study of 2,018 patients in Spain.
Insertion Site CRLI CRBSI
Femoral 15.83 8.34 Internal Jugular 7.65 2.99
Subclavian 1.57 0.97 In conclusion… Modern IO
• Fast, reliable vascular access • Flow rates similar to PIV or central line • Many level clinicians • Few complications • Historically low infection rate • What do clinicians say about IO? DO YOU KNOW IO? LET’S GO!
Teri Campbell RN, BSN, CEN, CFRN Flight Nurse University of Chicago TOXIC SHOCK And you thought just tampons could kill you
Teri Campbell RN, BSN, CEN, CFRN University of Chicago: UCAN • Participants will define Toxic Shock Syndrome (TSS) • Participants will review the pathology associated with TSS • Participants will list at-risk pediatric patient groups for developing TSS • Participants will describe pediatric presentation of TSS • Participants will discuss treatment priorites for the pediatric TSS patient It was another day in paradise…
Minding my own business 3 y/o boy with respiratory c/o + Strep A pharyngitis Fine, coarse, red rash on trunk extending to limbs COOL! Scarlet fever Case # 1
H/O: Fever X 2 days, rash today PTA: Xopenex and Atrovent neb, Ceftriaxone, Azithromycin, IVF bolus X 1 CXR: LLL infiltrate T. 100.4, HR 177, RR 60, B/P 77/51 O2 sat 91- 99% Alert, quiet w/ dad Appropriate response to us Case # 1
Non-toxic look VS: 108/64, HR 169 RR 50, O2 sat 99% Slight ≤ WOB, flaring, retractions Rapid packaging and depart the bedside GCS 15 Transport initiated (15 min) Case # 1 Hospital course
Continued IVF, O2, Ceftriaxone Combative pulling off O2, sats 88% on RA PICU RN Case # 1 PICU Tachypnea, tachycardia worsening sats 88% RA Central line difficulty Grand Mal Seizure Ativan Case #1 OH CRAP… Apneic and asystolic Compressions, ETT Norepinephrine and Dobutamine Asystolic again… more PALS Case #1, Over night…
IVIG and Clindamycin Abdomen distended Bilateral calves are rigid OR for fasciotomy of bilateral calves Decompression of the abdomen Thrombi found in femoral and peritoneal veins Case #1 OR continued Peritoneal dialysis catheter Fluid and bowel were evaluated: WNL Dialysis initiated DIC Large amount of blood products Case # 1 How is this possible?
3 ½ days after admission Negative EEG Clinical exam of brain death 1650: withdraw of life support by family But…he had STREP THROAT
Group A Strep Toxic Shock Syndrome with necrotizing fascitits It used to be…
This is what we feared related to TSS History
First described in 1978 “80’s epidemic”
Bacterial link Neonates Kids Men Women CDC definition
Staphylococcal TSS: - Fever, hypotension, and rash - 3 or more organ systems - Absence of Rocky Mountain spotted fever, VDRL, leptopirosis, mealses, ANA, *meningococcemia* CDC Definition
Streptococcal TSS - Isolation of group A strep - (Sterile): CSF, blood, surgical wound - (Non-sterile): Throat
-Hypotension - 2 or more organ systems • S. Aureus is “virulent and obiquitous” pathogen • 30-50% of healthy adults and kids colonize • follicultis – skin abscess – bacteremia – endocarditis • 3 syndrome: food poisoning, scalded skin syndrome; TSS Pathology Toxin mediated Production of Super-antigens! Tumor necrosis factor
Over whelms the immune system Endotoxins
STAPH: Exotoxin toxin shock syndrome tonin-1 (TSST-1)
STREP: Exotoxin A (SPEA) and Exotoxin B (SPEB) • Activate large # of “T” cells • Massive cytokine production • Interlukin (IL) • Tumor necrosis factor (TNF) • Interferon (IFN) • 70-80% of teenagers have antibody to TSST-1
• 90-95% of adults in their 40s have the antibody
• Patients with TSS lack antibody to TSST-1
• Susceptible to relapse
• Genetic influences Just the facts ma’am…
Frequency Staph: (estimated) 10-20 cases / 100k population Strep: not well known Menstruating: 59% overall / decreasing incidence Non menstrual : increasing incidence Consumer education More fun facts… Race Sex Staph TSS: higher in women Strep TSS: = between sexes
Age Staph TSS: 15-35 y/o Strep TSS: 20-50 y/o At risk groups
Post-op wound infections Nasal packing Post-partum Diabetes HIV or related infections Super absorbent tampons Who’d da thunk? Chronic cardiac and/or pulmonary disease Common bacterial infections Viral infections with influenza A or varicella History
Similar for Staph and Strep TSS Vague (flu-like) Pharyngitis Confusion (staph) Pain at infection site (strep) Profuse watery diarrhea So you’ve got the flu… It’s not like your gonna die. Unless you don’t stop whining…
I’m forced to KILL you • Healthy folks • Menstruation: day 2-3 • Post surgical: 2 days but as late as 65 Physical exam Fever (102°) Hypotension Decreased systemic vascular resistance Non-hydrostatic leaking from intra-vascular space
Unresponsive to large amount of volume Diffuse rash - Erythroderma (sunburn) - Post operative TSS - desquamation usually 1-2 wks later - trunk » arms and legs » palms and soles Multi-organ involvement
Ventricular arrhythmias Myocytosis Renal and hepatic failure ARF; coagulopathy GI symptoms ARDS Fluid shifts Altered LOC (CNS ) Ick… Mucosal inflammation
Pharyngitis
Conjunctivitis
Vaginitis Double Ick…
Necrotizing fasciitis and/or myositis Welcome to my laboratory… CBC - leukocytosis, bandemia, thrombocytopenia
Wacked electrolytes - HYPO: na+, k+, ca+, mg+, phosphate, albumin
Coagulation studies - Elevated: PTT, FSP - WNL: PT and fibrinogen More labs Liver function tests - hyperbilirubinemia (2x) - elevated SGOT/SGPT
Creatine kinase : Rhabdomyolysis (63%)
ABG: metabolic acidosis (hypotension/hypoxia)
Cultures: Strep (50% + culture) Pre-hospital goals ABC’s Airway Oxygen Aggressive fluids Transport / Hospital goals SUPPORTIVE
Fluid resuscitation - 10-20 L/day! - Colloids ? Cardiac monitoring Pressers Remove packing materials / tampons Goals continued IVIG immunoglobulin Binds with super antigens; strep > staph Correct hypoxia / acidosis Cardiac monitoring: TSS cardiomyopathy & myocytolysis Remove tampons or surgical packing Antibiotics Strep and Staph (YES); TSS: (?) Adequate coverage for both (initially) Requires pencillinase-resistant antibiotics Resistance of strep to Penicillin G Clindamycin Nafcillin Erythromycin Prognosis
Streptococcal TSS Mortality up to 70% Re-occurrence 40-50% of patients Usually within 2 months of initial episode Usually less severe • Death usually occurs within 2-3 days • arrhythmias, cardiomyopathy, coagulopathy, irreversible respiratory failure • Menstrual: 1.8% • Non-menstrual: 6% • Pediatric: 3-5% Case # 2 14 y/o girl Menstruating Presents to the ED with fever and rash
Diagnosis: TSS • Flight crew p/u patient • Stable VS, “walking and talking” • 12 minute flight to hospital • Literally on landing…. • Apneic and pulseless • Full PALS • Transport to PICU (full CPR) • Supportive care • D/C to rehab for minimal “CVA-like” residual • TSS is the result toxin mediated pathogens • Super antigens overwhelm the immune system • Deterioration is sudden and profound • Care is primarily supportive • Affects all ages and both genders TOXIC SHOCK And you thought just tampons could kill you
Teri Campbell RN, BSN, CEN, CFRN University of Chicago: UCAN [email protected] 312-720-0835