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11/1/2020

Necrotizing Fasciitis

▪Is a surgical diagnosis characterized by friability of the superficial fascia, Necrotizing dishwater-gray , and a notable Soft-Tissue absence of pus.

N ENGL J MED 2017;377:2253-65.

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Necrotizing fasciitis type I: Necrotizing fasciitis type II

▪ Polymicrobial involving aerobic ▪ Often associated with gas in the tissue ▪ A monomicrobial infection. and anaerobic organisms. and thus is difficult to distinguish from gas gangrene ▪ Seen in the elderly or in those with ▪ Among gram-positive organisms, group A is the underlying illnesses. ▪ Nonclostridial anaerobic and most common pathogen, followed by MRSA. synergistic necrotizing cellulitis are type ▪ Predisposed I variants. Both occur in patients with ▪ May occur in any age group and in those without underlying illness ▪ Diabetic or decubitus ulcers diabetes and typically involve the feet, ▪ with rapid extension into the leg ▪ Aeromonas hydrophila (freshwater laceration) ▪ Rectal fissures ▪ Necrotizing fasciitis should be ▪ Vibrio vulnificus (saltwater laceration, ingestion of raw oysters, ▪ Episiotomies considered in patients with systemic cirrhosis) ▪ Colonic or urologic surgery or gynecologic manifestations of , such as procedures. tachycardia, , acidosis, or ▪ Necrotizing group A streptococcal and clostridial infections are marked hyperglycemia mediated by bacterial exotoxins and the host response ▪ Ludwigs- submandibular ▪ Lemierre’s – of jugular ▪ Fournier’s-urethral breach

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Invasive Group A Streptococcal Soft-Tissue Infections Invasive Group A Streptococcal Soft-Tissue Infections (Streptococcus Continued pyogenes)

▪ Infection with a defined portal of bacterial entry: Infection that arises spontaneously in the deep tissue, without an overt or lesion:

▪ In 50% of patients with group A streptococcal necrotizing fasciitis or myonecrosis, are without a portal ▪ S. pyogenes gains entry to the deep tissues through superficial cutaneous lesions (chickenpox of entry, often at sites of nonpenetrating trauma (muscle strain or bruise). vesicles, insect bites), after breaches of skin or mucosal integrity (e.g. drug injections, surgical incisions, childbirth), or after penetrating trauma. ▪ Only fever and crescendo pain may be present. Malaise, myalgias, diarrhea, and anorexia may be present in the first 24 hours ▪ The initial lesion may appear to be only mildly erythematous, but over 24 - 72 hours, becomes extensive, the skin turns dusky and then purplish, and bullae appear. ▪ Since cutaneous manifestations are absent initially, the infection is often misdiagnosed or the correct diagnosis is delayed, and as a result, mortality is > 70%. ▪ By the time ecchymoses and bullae develop, tissue destruction is extensive, and systemic toxicity and organ ▪ Bacteremia is frequently present, and metastatic infections may occur. failure are evident. Very rapidly, the skin becomes gangrenous and undergoes extensive sloughing. At this stage, mortality is high, even with treatment ▪ Emergency surgery, including extensive debridement or multiple amputations, is often required to ensure survival

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1 11/1/2020

Nonsteroidal Anti-inflammatory Drugs Necrotizing Clostridial Infections and Group A Streptococcal Infection

▪ Proponents note that NSAIDs can suppress functions ▪ Gas gangrene (clostridial myonecrosis) is an acute invasion of and augment the production of tumor factor α, a key healthy living tissue that occurs spontaneously or as a result of mediator of septic . traumatic injury . It can recur. ▪ Others argue that NSAIDs merely mask the of ▪ Deeply penetrating injuries that compromise the blood supply developing infection, delaying diagnosis and treatment. Studies create an anaerobic environment that is ideal for spore have not resolved the issue germination and bacterial proliferation. Such trauma accounts for 70% of cases of gas gangrene ▪ Other predisposing conditions: Bowel and biliary tract surgery, IM epinephrine injection, retained placenta, prolonged rupture of the membranes, and intrauterine fetal death. ▪ Clostridium perfringens causes approximately 80%

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Diagnosis of Necrotizing Fasciitis and Other Spontaneous (nontraumatic) gas gangrene Necrotizing Infections

▪ C. septicum, which is more aerotolerant than other clostridial pathogens. ▪ Most infections occur in patients with GI portals of entry such as adenocarcinoma or in those with neutropenia. ▪ C. sordellii infections can affect women after natural childbirth, as well as after abortion or other GYN procedures. ▪ Such infections can also develop after traumatic injuries and surgical procedures or illicit-drug injection. ▪ Common sites include the skin, muscle, uterus, and perineum. ▪ Systemic signs include an absence of fever, profound , diffuse leak, hemoconcentration (HCT 50 - 80%), and a marked leukemoid reaction (WBC 50,000 - 150,000/cubic mm). ▪ Mortality is 70 - 100%, and death occurs within 2 - 4 days after hospital admission NEJM377;23 December 7, 2017 9 10

Clinical Findings Imaging Tests

▪ Classic manifestations of necrotizing fasciitis: soft-tissue ▪ Imaging studies will show soft-tissue swelling with group A ▪ (in 75% of cases) ▪ erythema (72%) streptococcal infection and will show gas in the tissues of patients ▪ severe pain (72%), ▪ tenderness (68%) with gas gangrene or necrotizing fasciitis type I. ▪ fever (60%) ▪ skin bullae or necrosis (38%). ▪ Gas in the tissues, or the presence of crepitus, should prompt ▪ In a recent study, factors that differentiated necrotizing fasciitis from cellulitis: immediate surgical consultation. Recent surgery, pain out of proportion to clinical signs, hypotension, skin necrosis, and hemorrhagic bullae. ▪ MRI may show thickening and hyperintensity of intermuscular ▪ In patients with cryptogenic group A streptococcal infection (i.e., infection with fascia, findings that are sensitive but not entirely specific for no portal of entry), the process begins deep in the tissues. Crescendo pain is the most important clinical clue, and its onset typically occurs well before shock or necrotizing fasciitis. organ dysfunction is manifested ▪ The absence of fascial enhancement on enhanced CT has been ▪ all patients presenting with a sudden onset of severe pain in an extremity, with or without an obvious portal of bacterial entry or the presence of fever, should shown to be specific for necrotizing fasciitis as opposed to other be evaluated for severe soft-tissue infection musculoskeletal infections

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Tissue Biopsy, Histologic Tests, and Gram’s Surrogate Markers for Early Diagnosis Staining of Necrotizing Fasciitis

▪ Gram’s staining of surgically obtained material is crucial for ▪ Group A streptococcal infection determining the cause of infection and guiding treatment. ▪ C-reactive protein level of more than 200 mg ▪ White-cell count with a marked left shift ▪ Group A streptococcal necrotizing infection is characterized ▪ Elevated creatinine histologically by the destruction of muscle tissue, a paucity of ▪ C. sordellii infection infiltrating , and large numbers of gram-positive cocci. ▪ Marked leukemoid reactions (50 to150,000 white cells per cubic millimeter) ▪ The findings are similar for gas gangrene, though with more ▪ profound hemoconcentration are characteristic evidence of edema, gas formation, or both. ▪ Necrotizing fasciitis I ▪ WBC > 15,400/mm3 plus ▪ serum sodium < 135 mmol/L ▪ Elevated CPK or AST suggest deep infection involving muscle or fascia (as opposed to cellulitis)

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LRINEC Treatment

Surgical Intervention Pharmacologic Treatment ▪ LRINEC scores of 5.8 or higher (on a scale of 0 to 13, with higher ▪ For patients with aggressive soft-tissue ▪ Polymicrobial Necrotizing Infections: IDSA scores indicating a greater likelihood of necrotizing soft-tissue infection or those with mild infection guidelines are Vancomycin or linezolid plus one plus evidence of systemic toxicity, of the following: piperacillin-tazobactam, a infection), prompt surgical exploration is very carbapenem, or ceftriaxone-metronidazole. ▪ the positive predictive value for necrotizing fasciitis ranged from 57 to important for 3 reasons: ▪ Group A Streptococcal Infections: Treatment 92% in three studies ,4,65,67 with negative predictive values of 86% ▪ to determine the extent of infection with penicillin plus clindamycin 10-14 days ▪ to assess the need for debridement or and 96% in two studies amputation ▪ A. hydrophila: Treated with doxycycline plus either ciprofloxacin or ceftriaxone. ▪ to obtain specimens for Gram’s staining and culture ▪ Use with caution, as the LRINEC Score has performed poorly in ▪ • V. vulnificus: Treated with doxycycline plus either ceftriaxone or cefotaxime. external validation, most recently in Neeki 2017 ▪ Survival is significantly increased among patients taken to surgery within ▪ • MRSA infections: Vancomycin, linezolid, 24 hours after admission. Survival is daptomycin, or ceftaroline. further increased with earlier surgical intervention (e.g., within 6 hours)

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Care of Critically Ill Patients Adjunctive Measures

▪ Capillary Leak Syndrome ▪ Hyperbaric Oxygen: Controversial. Surgical debridement should not ▪ Circulating bacterial and host mediators cause diffuse endothelial damage. ▪ IV fluid requirements may be extremely high (10 - 12 L of NS/day). be delayed for hyperbaric oxygen treatment ▪ Profound (0.5 - 1 g/dL) is common, and albumin may be necessary to maintain oncostatic pressure ▪ IV Immune Globulin: Rationale for use in patients with necrotizing ▪ Intravascular Hemolysis fasciitis is based on its ability to neutralize extracellular toxins that ▪ Bacterial hemolysins cause striking and rapid reductions in the HCT in the absence of DIC. mediate pathogenesis. A consensus supporting its use has not ▪ Thus, the HCT may be a better indicator of the need for transfusion than the Hgb level. been reached. ▪ Cardiomyopathy ▪ Global hypokinesia is seen in some patients with streptococcal toxic shock syndrome. ▪ Among survivors, this cardiomyopathy is reversible, fully resolving in 3 - 24 months. ▪ Management is difficult, since use of vasopressors increases afterload, resulting in decreased peripheral perfusion and reduced cardiac output. ▪ Symmetric gangrene resulting in loss of 1 -4 extremities is described. Maintenance of MAP not to exceed 65 mm Hg is prudent

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Eye Trauma

▪ Estimated 840 000 annual injuries in the United States ▪ Most pediatric eye injuries are minor and can be evaluated by qualified providers in urgent and ambulatory care settings Nonpenetratig Eye Injuries in Children

NONPENETRATING EYE INJURIES IN CHILDREN / ROOT ET AL. • VOL. 18, NO. 1

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EVALUATION Ruptures Globe

▪ manage (other) life-threatening ▪ Prior to pharmacologic dilation of the eye, ensure there is no evidence injuries of a ruptured globe ▪ ensure the structural integrity of ▪ Typical ruptured globes appear as blue, brown or black material on the the globe eye surface as the iris or choroid plugs the wound. ▪ assess vision in the injured and ▪ pupil can take on a teardrop shape ▪ Circumferential hemorrhage and bullous uninjured eye hemorrhage ▪ seek ophthalmology consultation ▪ Seidel test using fluorescein dye: In the presence of an open globe, a when further assistance is stream of aqueous humor dilutes needed the fluorescein as it streams down the eye. ▪ Protect with a eye shield

NONPENETRATING EYE INJURIES IN CHILDREN / ROOT ET AL. 21 22

CORNEAL ABRASIONS Corneal abrasions cont

▪ Contact lens- usage can result in ▪ Eye patching: ▪ No longer recommended for small, uncomplicated lesions that coalesce around a corneal abrasions (< 4 mm) central defect. ▪ Cochrane review found that patching of the affected eye does not improve pain, and can slow healing while causing temporary loss of binocular vision while ▪ Multiple vertical lines - on the wearing a patch superior cornea suggest a foreign ▪ Patching may be indicated for pain control with large corneal abrasions (>50% of the cornea) and for body under the upper lid. pediatric patients who may rub their eyes without barrier protection. Topical cycloplegics and mydriatrics ▪ ▪ Patients who wear contacts lenses may be (e.g. cyclopentolate 1%) have been colonized with and used to relax accommodation and are at risk of rapid progression to corneal provide pain relief in more severe perforation and vision loss. Therefore, they corneal abrasions, but their use has should be treated with topical antibiotics (e.g. limited benefit in uncomplicated ciprofloxacin) injuries ▪ corneal abrasions heal within 24 - 48 hours ▪ Outpatient use of topical anesthetics ▪ Follow up is reserved for patients with large abrasions (> 4 mm), contact lens-related is not typically recommended abrasions, and those with persistent symptoms after 48 hour

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OCULAR BURNS OCULAR BURNS Cont.

▪ Alkali substances are more dangerous ▪ Irrigate the eye with copious water, than acidic compounds because of they , or LR solution until the cause liquefaction necrosis of the lacrimation fluid has a normal pH, cornea and rapidly penetrate into the generally between 6.8 - 7.4. The anterior chamber and deeper surfaces unaffected eye can be used to determine the normal ocular pH. ▪ Concentrated ammonia and lye are particularly dangerous, causing ocular ▪ Many ophthalmologists recommend injury in less than 1 minute and 3 to 5 continuous irrigation for 30 minutes, minutes, respectively then every 15 - 30 minutes, until the pH returns to the normal range. The ▪ While acidic burns tend not to penetrate ocular pH should be rechecked 30 the deeper eye tissues, they can cause minutes after the eye is restored to focal tissue injury, including corrosive a normal pH. damage of the cornea. ▪ Cycloplegic eye drops are indicated ▪ Hydrofluoric acid, found in glass polish and for pain relief and prevention of iris rust removal agents, is especially dangerous. adhesion to the cornea and lens

Classification of alkali-burned eye. Courtesy of Pfister and Pfister. 25 26

TRAUMATIC HYPHEMA TRAUMATIC HYPHEMA CONTINUED

▪ Topical cycloplegic ▪ Outpatient management is preferred in lower grade injuries in ▪ 1 drop of 1% cyclopentolate or 1 drop of 1% atropine 1 to 3 times daily for up to 5 days ▪ older patients ▪ Mearusre the IOP ▪ risk factor for acute angle-closure glaucoma ▪ who can be compliant with bedrest, especially in patients at lower risk of rebleeding. ▪ The ED evaluation should include screening for risk for ▪ Topical corticosteroids are generally recommended but ▪ While strict bedrest has not been found to be beneficial, outpatient secondary hemorrhage, including sickle cell disease and trait, consult your ophthalmologist management should include elevating the head of the bed and hemophilia and von Willebrand’s disease limiting activity. ▪ Systemic antifibrinolytics (e.g. aminocaproic acid and TXA) ▪ Indications of hospitalization in the pediatric population: ▪ The head of the patients’ bed should be elevated to 30-45° to have been used to prevent rebleeding. promote settling of the blood in the anterior chamber away ▪ If there is penetrating ocular trauma ▪ A recent Cochrane review found that the effect of ACA was not from the visual axis. significant but that TXA reduced the rate of secondary hemorrhage ▪ secondary hemorrhage ▪ suspected child abuse ▪ Eye shielding should be done as soon as possible to reduce ▪ Elevated IOP (greater than 22-24 mm Hg) can be treated with ▪ hyphema > 50%, further injury, for patient comfort, and continued until the topical β-blockers; topical, oral, or intravenous carbonic hyphema resolves. anhydrase inhibitors (except In sickle hemoglobinopathies); ▪ risk of a noncompliant family and intravenous mannitol after consultation with an ▪ patients with sickle cell disease or trait ▪ NSAIDS should be avoided due to the potential for platelet ophthalmologist) inhibition and risk of rebleeding. ▪ Anti-emetics are recommended to prevent increases in IOP from ▪ Surgical management vomiting. ▪ 50% of the anterior chamber that persist for > 8-10days ▪ sickle cell trait or anemia ▪ Secondary hemorrhage, or re-bleeding into the anterior chamber, typically occurs 2 - 7 days after initial injury and ▪ IOP > 25-35 mm Hg for > 24 hours indicates a poor prognosis. ▪ corneal blood staining, significant visual deterioration and active bleeding.

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Fractures of the frontal bone and superior orbital ORBITAL FRACTURES rim:

▪ Orbital fractures are the most ▪ Common in children due to the increased common facial fracture in all ratio of the cranial vault to the facial pediatric age groups, accounting for skeleton. up to 50% of facial fractures ▪ The frontal sinus does not pneumatize until age 6, so these frontal bone fractures ▪ Floor of the orbit, also known as are actually cranial fractures and may blowout fractures, are the most have increased frequency of intracranial common orbital fracture in children injuries older than 5 years ▪ Superior orbital rim fractures may be ▪ The following findings are palpable on exam, but the diagnosis is suggestive of an orbital fracture: often difficult to make without imaging. ▪ These fractures require neurosurgical and ▪ Orbital dystopia (orbits in different planes) ophthalmologic involvement. ▪ Enophthalmos (posterior displacement of the eyeball) ▪ Frontal bone fractures are often repaired ▪ Flattening of the nasal complex VOL. 18, NO. 1 • NONPENETRATING EYE INJURIES IN CHILDREN / ROOT ET AL. to reduce contour deformities. ▪ Telecanthus (increased distance between ▪ Patients require long term follow up since brain medial canthi of eyelids). growth can push apart the fracture site and result in brain herniation requiring cranioplasty

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Traumatic iritis and traumatic uveitis

▪ CT is the gold standard for assessing ▪ Generally occur 24 - 72 hours after orbital fractures and guiding the blunt trauma to the eye need for reconstruction ▪ symptoms of dull, aching eye pain, ▪ Since many non-displaced/minimally redness, and light sensitivity a few days displaced pediatric orbital fractures are after an eye injury treated non-operatively ▪ CT should not be reflexively obtained for ▪ Slit lamp microscopy reveals all pediatric patients with facial trauma presence of WBCs and protein ▪ indications for surgical repair ▪ Discussion with an ophthalmologist ▪ entrapment of extraocular muscles for possible dilating drops and/or ▪ early enophthalmos topical steroids if the patient has ▪ persistent restrictive strabismus and significant symptoms diplopia of central gaze ▪ Children develop more ▪ Antibiotic administration is complications of uveitis and there is indicated if the patient has a history an increased tendency for of , diabetes or is corticosteroids to lead to increased immunocompromised IOP and cataracts

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SUBACUTE PRESENTATIONS OF SUBACUTE PRESENTATIONS OF OPHTHALMOLOGIC INJURY OPHTHALMOLOGIC INJURY

Retrobulbar neuritis Choroidal rupture Traumatic retinal detachment Commotio retinae ▪ Present with symptoms such as ▪ Occurs when blunt trauma to the globe ▪ A form of optic neuritis in which the optic nerve causes shock waves that travel becomes inflamed and requires urgent intervention ▪ Can occur from any type of trauma, flashes of light, floaters, curtains posteriorly into the orbit and disrupt the moving over the field of vision photoreceptors. ▪ trauma, infectious, inflammatory, allergic, and including forceps utilization during exposure etiologies delivery in neonates with or without vision loss. ▪ Fundoscopic exam there is a confluent ▪ Patients typically complain of blurry vision, central area of retinal whitening from the vision loss, dull-appearing colors, pain with eye ▪ Blunt trauma at the site of injury, or ▪ The location of the detachment movement, or eye tenderness from a location opposite to the edema and fragmentation of the and whether the macula is photoreceptor outer segments. ▪ There may be decreased pupillary response to light. injury site due to contre-coup forces, may also result in choroidal rupture. involved guides timing of surgery. ▪ Visual acuity does not always correlate ▪ Treatment includes steroids with the degree of retinal whitening. ▪ Overlying blood concealing the rupture often delays visualization of ▪ No treatment is required as the the injury until days after the trauma condition clears without therapy.

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Iridodialysis ▪ Disinsertion of the iris from the sclera ▪ Usually asymptomatic unless symptoms of glaucoma develop. CHANGES IN PROVIDER PRESCRIBING ▪ Patients should be encouraged to wear sunglasses or contact lenses with an PATTERNS AFTER IMPLEMENTATION OF artificial pupil. AN EMERGENCY DEPARTMENT ▪ Surgical correction is reserved for large iridodialysis and/or symptomatic PRESCRIPTION OPIOID POLICY patients. LLSA 2020 ▪ Patient needs to be closely monitored for development of open-angle PAZDERKA, MD FACEP glaucoma

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Washington State Department Introduction of Health

▪ The Centers for Disease Control and Prevention has classified ▪ Formed the ED Opioid Abuse Workgroup in 2009 prescription drug abuse as an epidemic. This initiative led to the draft Opioid Prescribing Guidelines by mid- ▪ >13,000 deaths nationally since 2007 ▪ 2010, designed to help curb the rapidly increasing opioid ▪ Individuals who abused prescription opioids upon entering prescribing patterns and overdose rates. methadone treatment, 13% reported obtaining their opioids from Eds ▪ The objective was to determine the effectiveness of implementing an opioid prescription policy on reducing opioid prescribing pattern ▪ Prescription opioid pain relievers are the leading cause of ▪ Compared over a 7-year period. overdose deaths in the United States, accounting for 73.8% of ▪ Number of ED visits with an opioid prescription. prescription drug overdose deaths in 2008 ▪ Dispensing quantity (number of tablets or capsules prescribed per ▪ ED visits for prescription opioid misuse or diversion account for an prescription). estimated 950,000 ED visits each year

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Prescribing Guideline

▪ One medical provider should provide all opioids to treat a patient's ▪ EDs are encouraged to share the ED visit history of patients with chronic pain. other emergency physicians who are treating the patient using an Emergency Department Information Exchange (EDIE) system. ▪ The administration of intravenous and intramuscular opioids in the ED for the relief of acute exacerbations of chronic pain is discouraged. ▪ Physicians should send patient pain agreements to local EDs and ▪ Emergency medical providers should not provide replacement work to include a plan for pain treatment in the ED. prescriptions for controlled substances that were lost, destroyed, or stolen. ▪ Prescriptions for controlled substances from the ED should state that the patient is required to provide a government-issued picture ▪ Emergency medical providers should not provide replacement doses of identification (ID) to the pharmacy filling the prescription. methadone for patients in a methadone treatment program. ▪ EDs are encouraged to photograph patients who present for pain- ▪ Long-acting or controlled-release opioids (such as OxyContin®, fentanyl related complaints without a government-issued photo ID. patches, and methadone) should not be prescribed from the ED.

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▪ EDs should coordinate the care of patients who frequently visit the ED ▪ Prescriptions for opioid pain medication from the ED for acute using an ED care coordination program. injuries, such as fractured bones, in most cases should not exceed 30 pills. ▪ EDs should maintain a list of clinics that provide primary care for patients of all payer types. ▪ ED patients should be screened for substance abuse prior to ▪ EDs should perform screening, brief interventions, and treatment prescribing opioid medication for acute pain. referrals for patients with suspected prescription opioid abuse problems. ▪ The emergency physician is required by law to evaluate an ED ▪ The administration of Demerol® (meperidine) in the ED is discouraged. patient who reports pain. The law allows the emergency physician to use their clinical judgment when treating pain and does not ▪ For exacerbations of chronic pain, the emergency medical provider require the use of opioids. should contact the patient's primary opioid prescriber or pharmacy. The emergency medical provider should only prescribe enough pills to last until the office of the patient's primary opioid prescriber opens.

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Results Discussion

▪ After the intervention, there was a 39.6% decrease in the ▪ Prescriptions for oxycodone decreased most dramatically, with proportion of ED visits resulting in a discharge opioid prescription lesser decreases in hydrocodone, now the most commonly ▪ (from 25.7% to 15.6%, absolute decrease 10.2 percentage points; 95% CI prescribed opioid and a designated Schedule III drug at the time 9.6–10.7) with a lower potential for abuse. ▪ The decrease in proportion of visits with an opioid was sustained ▪ The setting likely affected the success of the program. Our ED is for 2.5 years of follow-up. part of an institution with a long track record of focus on Lean management principles. Then institutional culture strongly ▪ The mean number of pills per prescription decreased 14.8%, from supports uniform adoption of standardized processes and use of 19.5 to 16.6 (absolute decrease 2.9; 95% CI 2.6–3.1; p < 0.001) Lean quality improvement events to effect change. ▪ The largest reduction was seen in patients aged 18–49 years (from 31.6% to 17.5% prescribed)

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Conclusion The Pediatric ▪ The study demonstrates that a formal ED policy with provider education can decrease ED opioid prescribing by nearly 40%. Airway and ▪ The policy was placed openly throughout the ED so that staff could review the policy with patients as necessary. Rapid ▪ For exacerbations of chronic pain, the emergency medical provider Sequence should contact the patient's primary opioid prescriber or pharmacy. The emergency medical provider should only prescribe Intubation in enough pills to last until the office of the patient's primary opioid prescriber opens. Trauma ▪ Prescriptions for opioid pain medication from the ED for acute TRAUMA REPORTS injuries, such as fractured bones, in most cases should not exceed NOV/DEC 2017 30 pills.

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The Pediatric Airway and Rapid Introduction Sequence Intubation in Trauma

▪ Trauma: most common cause of injury and death for 1-19 year olds. ▪ Have a high index of suspicion for C-spine injury ▪ Avoid hyperextension ▪ MVCs most common cause of death ▪ manual in-line stabilization ▪ Peds airway divided in to 3 segments: ▪ OPA useful adjunct ▪ Supraglottic (most collapsible) ▪ No gag reflex ▪ Laryngeal (includes trachea and cords) ▪ Intrathoracic ▪ The OPA is measured from the corner of the mouth to the angle of the jaw ▪ Too large: trauma and bleeding ▪ Peds airway differences: ▪ Too small: can push tongue posteriorly and cause obstruction ▪ Shorter in length, smaller in diameter ▪ Do not insert upside down and rotate as in adults ▪ More superior and anterior larynx ▪ Larger tongue ▪ NP also a useful adjunct Trauma reports VOL. 18, NO. 6 ▪ The large occiput combined with the short ▪ measured from the nares to the tragus of the ear. neck makes laryngoscopy more difficult ▪ Narrowest portion of airway (<10y): cricoid ▪ NPA should be avoided in children with suspicion of a basilar skull fracture.

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RSI Equipment

▪ Preoxygenation critical to avoid ▪ Formula for ETT size: (age/4) + 4 hypoxia and . for uncuffed tubes and (age/4) + 3.5 for cuffed tubes ▪ Without it, 30% of children desaturate. ▪ ETT cuffs should be inflated to no ▪ Within the pediatric population, more than 20-25 cm H2O. the most common indications for ▪ SOAPME intubation are trauma and ▪ Suction primary respiratory failure. ▪ Oxygen ▪ Airway equipment ▪ Pharmacy ▪ Monitors ▪ Extra

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Access for a difficult airway RSI drugs

▪ Assess for difficult airway ▪ Sedatives ▪ Etomidate ▪ Midazolam ▪ Head, face or neck trauma ▪ very minimal effect on heart rate and blood ▪ anticonvulsant effect pressure, neuroprotective properties ▪ lends itself to usefulness as a sedative ▪ Blood, vomit ▪ cerebral perfusion pressure is maintained ▪ for RSI for patients in status epilepticus Facial abnormalities (micrognathia, suppression of adrenal cortical function by ▪ decreases systemic vascular resistance, resulting ▪ inhibiting 11-β-hydroxylase in hypotension buck teeth) ▪ Ketamine ▪ Fentanyl ▪ both analgesic and amnestic properties ▪ analgesic properties ▪ Monitoring ▪ sympathomimetic effects of ketamine on the cardiovascular and respiratory systems result in ▪ Paralytic Pulse oximetry increased heart rate, , and ▪ bronchodilation ▪ Succinylcholine, Rocuronium ▪ Wave form capnography ▪ airway protective reflexes, such as coughing, sneezing, and swallowing, are maintained ▪ Propofol ▪ hypnotic anesthetic agent that causes sedation by direct suppression of brain activity ▪ Doesn’t provide any analgesia. ▪ Causes both vasodilation and myocardial suppression

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Complications

▪ First pass success rate:77-90% ▪ The pediatric airway differs greatly from the adult airway: It is ▪ Be ready for a failed attempt, have a shorter and more anterior. This can lead to a challenging direct backup plan visualization. ▪ Want to avoid multiple attempts ▪ Hypoxia is a precursor to cardiac arrest in children. Preoxygenation ▪ Mainstem intubation: common is necessary prior to securing an airway. (30%) technical complication ▪ ETT should be advanced as little ▪ Nondepolarizing paralytic agents, such as rocuronium, are increasing in popularity in pediatric emergency medicine because as 2.5 cm in neonates, as the distance between the glottis and the carina can of their shorter half-life and more favorable safety profile. be as little as 5 cm.

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