Little Big Med

On this episode, host Jason Woods speaks with Dr. Austin Larson, a specialist in pediatric inherited metabolic disorders (and also someone way smarter than I), about what do do with the crashing neonate if there are concerns for a metabolic disorder. We review the diagnostic approach, emergent treatment, and what resources are available to read/consult in this situation.

Important points

* If an ill neonate presents and there is any concern for inherited metabolic disorder, starting D10 fluids at 1.5 x maintenance is generally the recommendation, unless there is a reason why glucose/fluids will otherwise harm the patient.

* If there are concerns for inherited metabolic disorder, in addition to glucose, checking ketones (urine or serum, though serum preferred), ammonia, and lactate can be very helpful.

* If the ammonia level is >200 micromols/L and rising, dialysis will likely be needed and you need to start making plans for this.

* Neonates generally can not generate a significant ketosis, even if fasting or ill, without an inherited metabolic disorder.

* Other labs to consider obtaining in an ill child with hypoglycemia or concern for metabolic disorder

* Cortisol

* Serum Amino Acids

* Urine Organic Acids

* Serum ketones

* Free fatty acids

* Growth Hormone

* Insulin

* Acylcarnitine profile

Point of Care Resources

* New England Consortium for treatment protocols

* Vademecum Metabolicum handbook in book form

* App version of Vademecum Metabolicum – eVM

Guests

Austin Larson, MD – Assistant Professor of Pediatrics and Metabolic and Clinical Genetics, University of Colorado School of Medicine and Children’s Hospital Colorado

On this episode we discuss the rates and risks of post-resuscitation hypotension after cardiac arrest. Host Jason Woods MD talks with Dr. Alexis Topjian, a critical care doc from Children’s Hospital of Philadelphia with special interests in neuro-critical care and post-arrest care, about her recent article on post arrest hypotension. This article was published in JAMA in 2018 (see references below) and evaluated outcomes based on presence of hypotension, and hypotensive burden, after out-of-hospital cardiac.

Guests

Alexis Topjian MD, Associate Professor of Anesthesia and Critical Care Medicine, University of Pennsylvania School of Medicine, Children’s Hospital of Philadelphia

References

* Topjian AA, Telford R, Holubkov R, et al. Association of Early Postresuscitation Hypotension With Survival to Discharge After Targeted Temperature Management for Pediatric Out-of-Hospital Cardiac Arrest. JAMA Pediatr. 2018;172(2):143–11. doi:10.1001/jamapediatrics.2017.4043.

* Topjian AA, French B, Sutton RM, et al. Early Postresuscitation Hypotension Is Associated With Increased Mortality Following Pediatric Cardiac Arrest*. Critical Care Medicine. 2014;42(6):1518-1523. doi:10.1097/CCM.0000000000000216.

* Bhanji F, Topjian AA, Nadkarni VM, et al. Survival Rates Following Pediatric In-Hospital Cardiac Arrests During Nights and Weekends. JAMA Pediatr. 2017;171(1):39–7. doi:10.1001/jamapediatrics.2016.2535.

* Moler FW, Silverstein FS, Holubkov R, et al. Therapeutic Hypothermia after In-Hospital Cardiac Arrest in Children. N Engl J Med. 2017;376(4):318-329. doi:10.1056/NEJMoa1610493.

 

The last in our current series on firearm violence looks at suicide prevention and the relation of firearms to suicide. Host Jason Woods MD talks with Dr. Emmy Betz, a researcher in suicide prevention, about what is currently know, strategies for harm reduction, and her efforts as the co-founder of the Colorado Coalition for Firearm Safety, which works to bring the medical community together with firearm owners, gun shops, and shooting ranges to improve safety.

Guests

Emmy Betz MD, MPH – Assistant Professor, Department of Emergency Medicine, University of Colorado School of Medicine.

Resources 

* National Suicide Prevention Lifeline – 1-800-273-8255

* Dr. Betz’s TED Talk

* Colorado Firearm Safety Coalition

* Giffords Law Center – access state by state listing of firearm laws

* Joint program between the American Society for Suicide Prevention and the National Shooting Sports Foundation

References

* Betz ME, Kautzman M, Segal DL, et al. Frequency of lethal means assessment among emergency department patients with a positive suicide risk screen. Psychiatry Research 2018;260:30–5.

* Betz ME, Wintersteen M, emergency EBAO, 2016. Reducing suicide risk: challenges and opportunities in the emergency department. annemergmedcom

* Pierpoint LA, Tung GJ, Brooks-Russell A, Brandspigel S, Betz M, Runyan CW. Gun retailers as storage partners for suicide prevention: what barriers need to be overcome? Inj Prev 2018;:injuryprev–2017–042700–5.

* McCourt AD, Vernick JS, Betz ME, Brandspigel S, Runyan CW. Temporary Transfer of Firearms From the Home to Prevent Suicide. JAMA Intern Med 2017;177(1):96–6.

* Wintemute GJ, Betz ME, Ranney ML. Yes, You Can: Physicians, Patients, and Firearms. Ann Intern Med 2016;165(3):205–10.

We continue our look at firearm and violent injury in the youth population by examing the issue outside of the United States. Host Jason Woods MD gathered Canadian physicians Carolyn Snider and Natasha Saunders, both researchers on violent injury (and specifically firearm-related injury), to discuss the scope of violent youth injury in Canada, ED-based intervention programs, risk factors, and the rising rates of injury due to air guns and BB guns.

Guests

Carolyn Snider MD, MPH – Associate Professor, Department of Emergency Medicine, University of Toronto, Staff Physician Winnipeg Health Sciences Center, founder of the Emergency Department Violent Injury Prevention program (EDVIP)

Natasha Saunders MD – Assitant Professor Department of Pediatrics University of Toronto, Staff Physician Hospital for Sick Children, Adjunct Scientist Institute for Clinical Evaluative Sciences

Resources

National Network of Hospital-based Violence Intervention Programs – http://nnhvip.org/

* Saunders NR, Lee H, Macpherson A, Guan J, Guttmann A. Risk of firearm injuries among children and youth of immigrant families. CMAJ. 2017;189(12):E452-E458.

* Snider CE, Ovens H, Drummond A, Kapur AK. CAEP Position Statement on Gun Control. Canadian Journal of Emergency Medicine. 2009;11(1):64-72

* Snider CE, Brownell M, Dufault B, Barrett N, Prior H, Cochrane C. A multilevel analysis of risk and protective factors for Canadian youth injured or killed by interpersonal violence. Inj Prev. July 2017:injuryprev–2016–042235–7

* Snider C, Woodward H, Mordoch E, et al. Development of an Emergency Department Violence Intervention Program for Youth: An Integrated Knowledge Translation Approach. Progress in Community Health Partnerships. 2016;10(2):285-291

Violent injury, particularly related to firearms, has been at the forefront of national discussion recently. Pediatric victims and survivors have begun to enter into the public discussion via a strong social media presence, and as clinicians who treat these patients’ injuries, we are also obligated to participate in prevention. This is the first in a series of episodes to address what we know about firearm violence, what interventions have been tried, and how we can reframe the discussion to focus less on political beliefs and more on harm reduction.

Host Jason Woods MD gathered national firearm violence experts Megan Ranney MD MPH, Patrick Carter MD, and Stephen Hargarten MD MPH to introduce where the research, policy, and political climate sits currently and to give some ideas on how to think and speak about this issue with patients and families.

Guests

Megan Ranney MD MPH- Associate Professor of Emergency Medicine at Brown University, violence prevention researcher, past chair of ACEP Trauma and Injury Prevention Section

Stephen Hargarten MD MPH – Professor and chair of Emergency Medicine of Medical College of Wiscone, Director of MCW Comprehensive Injury Center

Patrick Carter MD – Assistant Professor of Emergency medicine, and Assistant Director of the Injury Prevention Center at the University of Michigan

Resources

Videos from University of Michigan  “Open Michigan” site on how to talk to patients and families about firearms

Articles

* McCourt AD, Vernick JS, Betz ME, Brandspigel S, Runyan CW. Temporary Transfer of Firearms From the Home to Prevent Suicide. JAMA Intern Med 2017;177(1):96–6.

* Wintemute GJ, Betz ME, Ranney ML. Yes, You Can: Physicians, Patients, and Firearms. Ann Intern Med 2016;165(3):205–10.

* MPH MLRM, MD JF, MPH HAM, et al. A Consensus-Driven Agenda for Emergency Medicine Firearm Injury Prevention Research. YMEM 2017;69(2):227–40.

* Parikh K, Silver A, Patel SJ, Iqbal SF, Goyal M. Pediatric Firearm-Related Injuries in the United States. Hospital Pediatrics 2017;:hpeds.2016–0146–12.

* Hargarten S. Firearm Injury in the United States: Effective Management Must Address Biophysical and Biopsychosocial Factors. Ann Intern Med 2016;165(12):882–2.

* Carter PM, Cook LJ, Macy ML, et al. Individual and Neighborhood Characteristics of Children Seeking Emergency Department Care for Firearm Injuries Within the PECARN Network. Acad Emerg Med 2017;24(7):803–13.

* Goldstick JE, Carter PM, Walton MA, et al. Development of the SaFETy Score: A Clinical Screening Tool for Predicting Future Firearm Violence Risk. Ann Intern Med 2017;166(10):707–15.

* Carter PM, Walton MA, Goldstick J, et al. Violent firearm-related conflicts among high-risk youth: An event-level and daily calendar analysis. Preventive Medicine 2017;102(C):112–9.

Host Jason Woods MD chats with Dan Lindberg MD, national expert in Child Abuse evaluation, on what role the ED plays in the evaluation of child abuse, and addresses the things that scare the ED doc the most. How do I avoid going to court? What and how should I document? What can I do so that I don’t screw up the case for the lawyers?

Host Jason Woods MD chats with Brad Sobolewski MD, on how he established his own brand as a medical educator, with advice for new medical educators just starting on this path.

Host Jason Woods MD chats with Joe Grubenhoff MD, on what role the ED plays in concussion evaluation, the updated concussion guidelines, and where the pendulum will come to rest on rest versus activity in the post-concussion time period.

Host Jason Woods MD talks with Lalit Bajaj MD on the use of home oxygen dispensed from the emergency room in the treatment of bronchiolitis. Dr. Bajaj is an emergency medicine physician at the University of Colorado and Children’s Hospital Colorado and was one of the early participants in their home oxygen protocol initiation and evaluation.

Hot on the heels of our previous recording, new guidelines were published on the care of pediatric sepsis by the American College of Critical Care Medicine/Society of Critical Care Medicine. Host Jason Woods MD and Halden Scott MD evaluate how these new guidelines change our previous discussion on the use of lactate measurement in the treatment of pediatric sepsis in the emergency department.