VLVids: Room for Improvement!

This real-life videolaryngoscopy example (RSI of a patient with a head injury for craniectomy) shows some commom errors, and room for improvement. Three major areas that could be better to spot here:

  1. Less-than-ideal positioning of the VL blade. The tip is too deep (over the epiglottis, rather than in the vallecula), which reduces the available space to manipulate both VL and ETT, the field of vision, and the ability to perceive the approach of the ETT.
  2. Quick suctioning of the secretions/saliva/mucus would reduce the risk of losing the view or the patient aspirating.
  3. An introducer (stylet/bougie) would greatly assist passage of the ETT through the cords.

Enoxaparin And anti-Xa Levels: Who Cares? Part 1.5

Oops, I’ve got to backtrack a little. I just ran across a newly published study from the authors mentioned in Part 1 of this series a few days back. I pointed out some of the issues that surfaced as they tried to “hit the numbers” for factor anti-Xa levels in patients from their hospital. Here’s a breakdown of the new study.

First, I love the beginning of the title:

“If some is good, more is better”

Really?

Recognizing that 30% of patients had low anti-Xa trough levels when given the standard 30mg bid dosing regimen for enoxaparin, the authors engaged in some fancy predictive and statistical models to come up with a new one. A good portion of the methods section of the paper is devoted to explaining the machinations of exactly how they did this.

They used a patient dataset that was a little fresher than from Part 1. Three years of data from 2011 to 2014 were reviewed, and 275 patients were used to generate the new models. They selected one of seven candidates, based on a combination of simplicity and fewer supranormal levels of anti-Xa. They used this model to guide dosing to the next 145 patients. Here is the new regimen:

Weight Dose (q 12 hrs)
50-60 kg 30 mg
61-99 kg 40 mg
> 100 kg 50 mg

And here are the factoids:

  • Of the 275 patients used to create the model, 70% were subtherapeutic. (This is exactly the same number as in the first paper, but a different number of patients. Hmm.)
  • With the new dosing regimen in place, only 21% were subtherapeutic
  • Patients with supratherapeutic anti-Xa levels increased from 2 to 5% using the new routine
  • VTE was the same, at about 3-4%
  • Four patients developed VTE on the new regimen, and 3 of them had therapeutic anti-Xa levels (!)

Bottom line: A lot of modeling and statistical work went into the production of this paper. I still wonder why the number of patients included over 3 years is so low for such a busy center. But the authors certainly showed that they could improve the rate at which they “hit the number.” But how important is this, really?

The concluding sentence of the abstract reads, “further studies are needed to determine whether such dosing decreases venous thromboembolism rates.” Perhaps we should figure that out before continuing to spend lots of time playing with dosing changes and blood tests.

Reference: If some is good, more is better: an enoxaparin dosing strategy to improve pharmacologic venous thromboembolism prophylaxis. J Trauma 81(6):1095-1100, 2016.

Source: http://thetraumapro.com/2016/12/23/enoxaparin-and-anti-xa-levels-who-cares-part-1-5/

VLVids: Use an introducer!

A classic example of good videolaryngoscopy technique being thwarted by not always using an introducer (stylet or bougie).  Note the clinician performing the intubation gets perfect, optimised VL view (Rule of 3), but then struggles to pass the ETT anteriorly enough, losing time.  Although this was no problem for the well-oxygenated patient in this case (and the intubation is still under 45 seconds duration), in a critical case it can lead to desaturation, frustration, and possible intubation trauma.

AAP Top 10 2016 #10: RNA biosignatures and SBI

Association of RNA Biosignatures With Bacterial Infections in Febrile Infants Aged 60 Days or Younger

Mahajan P, Kuppermann N, Mejias A, Suarez N, Chaussabel D, Casper TC, Smith B, Alpern ER, Anders J, Atabaki SM, Bennett JE, Blumberg S, Bonsu B, Borgialli D, Brayer A, Browne L, Cohen DM, Crain EF, Cruz AT, Dayan PS, Gattu R, Greenberg R, Hoyle JD Jr, Jaffe DM, Levine DA, Lillis K, Linakis JG, Muenzer J, Nigrovic LE, Powell EC, Rogers AJ, Roosevelt G, Ruddy RM, Saunders M, Tunik MG, Tzimenatos L, Vitale M, Dean JM, Ramilo O; Pediatric Emergency Care Applied Research Network (PECARN)

JAMA, 2016

Links   PubMed   JAMA   pdf

The Bottom Line

RNA biosignatures have the potential to help us distinguish which febrile infants under 60 days have serious bacterial infection

What They Did

  • The authors collected RNA biosignatures from 279 randomly selected infants out of a pool of 1883 total patients
  • They identified 66 genes that helped distinguish SBI vs not – with a sensitivity of 87% (95% CI, 73%-95%) and a specificity of 89% (95% CI, 81%-93%)
  • Ten “classifier” genes distinguished infants with bacteremia from those without bacterial infections 94% (95% CI, 70%-100%) sensitivity and 95% (95% CI, 88%-98%) specificity

What You Can Do

  • Know that this is an emerging area of research – Obviously these arrays are technically complex and not widely available… yet.
  • Cultures are still the gold standard for identifying SBI – and with blood culture false positive rates as high as 10% in some reports new methods that are easier to obtain and are more accurate hold promise

Hyphema

Traumatic HyphemaInjuries to the face are commonly encountered when caring for children. We have previously reviewed several facial injury topics (see, Mandibular FracturesDental Trauma, Tongue Lacerations, and Eyelid Lacerations).  Eye injuries can sometimes be under appreciated, especially when there are other associated injuries. One simple finding that we should pay particular attention to is the presence of a Hyphema.

 

Traumatic Hyphema: Basics

  • Ocular trauma is a leading cause of non-congenital, monocular blindness in children worldwide. [Yildiz, 2016; SooHoo, 2013]
  • Hyphema = blood in the anterior chamber of the eye. [Trief, 2013]
    • Deformity of the globe leads to displacement of the lens and iris, possibly tearing the ciliary body and/or iris vessels.
    • Bleeding will increase the intraocular pressure, which assists tamponading the bleeding along with clot formation.
    • Clot integrity is best 4-7 days after the injury.
  • Traumatic hyphema is more common in children than in adults. [SooHoo, 2013; Tries, 2013]
  • Most commonly occurs from blunt injury (~75%). [Trief, 2013]
    • Projectiles (like airsoft/BB guns, paintball guns) [Shazly, 2012]
    • Sports
    • Airbags deployed during MVC [Motlery, 2003]
    • Assault, Non-accidental Trauma [Calzada, 2003]
    • Miscellaneous items (hanger, towel, rubber toy snake) [SooHoo, 2013]

 

Traumatic Hyphema: Complications

  • Rebleed / second hemorrhage
    • Associated with a worse prognosis.
    • Typically occurs within first 4 days after injury.
  • Corneal staining (~5% of cases)
    • Can lead to amblyopia.
    • May require surgery to resolve.
  • Increased intraocular pressure
  • Synechiae
  • Glaucoma
  • Amblyopia
  • Visual Impairment [Yildiz, 2016]

 

Traumatic Hyphema: Evaluation

  • Don’t get distracted!
    • Evaluate for other associated traumatic injuries.
    • Evaluate for Open Globe Injuries!
      • The presence of a hyphema should heighten the concern for open globe injury.
      • History of lacerating injuries, small projectiles, or sharp objects also warrants greater concern for open globe injuries.
      • Look specifically for anisocoria and afferent pupillary defect.
      • A portable slit-lamp is a very useful tool!!  Ultrasound, used carefully, can also help evaluate globe integrity.
  • Check intraocular pressure
    • Only do this if confident that there is not open globe injury.
    • This can be challenging in children, but is very important.
  • Characterizing the hyphema can help communicate to consultants and helps to determine potential risk for complications.  [Trief, 2013]
    • Having patient sit upright will allow hyphema to settle.
    • Hyphemas can be characterized as Microscopic or Macroscopic.
    • Macroscopic hyphemas are graded by the height of the blood in the anterior chamber (AC).
      • Grade 1: Less than 1/3 of the AC; Best prognosis
      • Grade 2: 1/3 to 1/2 of the AC
      • Grade 3: 1/2 to nearly the entire AC
      • Grade 4: Fills the entire AC; Worse prognosis
  • Finish the complete eye exam.
    • Fundoscopic exam should be used to look for vitreous hemorrhage. [Trief, 2013]
    • Ultrasound can help characterize the posterior chamber, especially if there is a Grade 3 or 4 hyphema.
    • Visual acuity should also be documented.
  • History of Sickle Cell DiseaseSickle Cell Trait or other Bleeding Disorders (Hemophilia, Von Willebrands) should be considered.
    • Patients with sickle cell disease and trait are at risk for developing hyphema, even spontaneously.
    • It is important to inquire about possible sickle cell disease/trait in the family. [Trief, 2013]
    • Patients have been diagnosed with sickle cell disease/trait following traumatic hyphema. [SooHoo, 2013]

 

Traumatic Hyphema: Treatment

  • Outpatient care is most often successful. [SooHoo, 2013]
  • Basic care consists of:
    • Head of Bed 30-45 degrees.
    • Relative rest / limited activity
    • Avoiding Aspirin or NSAIDS.
    • Refraining from reading (or watching electronic devices up close) as accommodation can stress the injured vessels. [Trief, 2013]
    • Protective eye shield recommended by some.
    • Close Ophthalmology follow-up (sometimes daily).
  • Medication strategies include: [Trief, 2013]
    • Suppress aqueous production
      • Topical Beta Blockers
      • Carbonic anhydrase inhibitors (avoid if Sickle Cell Disease present)
    • Cycloplegics
      • Helps with comfort.
      • May reduced secondary hemorrhage risk.
      • Topical atropine, cyclopentolate, or scopolamine.
    • Steroids
      • Topical or systemic have been used.
      • Help to reduced inflammation and stabilize clot.
      • Avoid long-term use as it will increase risk of cataracts and glaucoma.
    • Antifibrinolytics
      • Decreases rates of secondary bleeding.
      • Aminocaproic acid is commonly used.
      • TXA has been found to be safe, although has less literature to show its benefits. [Albiani, 2008]
  • Inpatient care should be considered for patients with:
    • Sickle cell anemia/trait
    • Grade 3 or Grade 4 Hyphema
    • Penetrating ocular trauma
    • Secondary bleed
    • History concerning for abuse
    • Poor ability to adhere to the medical plan.
  • Surgery may be required in those who have:
    • Corneal staining
    • Uncontrolled increased intraocular pressures
    • Grade 4 hyphema that persists for >5 days
    • Large clots persisting > 10days

 

References

Yildiz M1, Kıvanç SA1, Akova-Budak B1, Ozmen AT1, Çevik SG2. An Important Cause of Blindness in Children: Open Globe Injuries. J Ophthalmol. 2016;2016:7173515. PMID: 27247799. [PubMed] [Read by QxMD]

Trief D, Adebona OT, Turalba AV, Shah AS. The pediatric traumatic hyphema. Int Ophthalmol Clin. 2013 Fall;53(4):43-57. PMID: 24088932. [PubMed] [Read by QxMD]
SooHoo JR1, Davies BW, Braverman RS, Enzenauer RW, McCourt EA. Pediatric traumatic hyphema: a review of 138 consecutive cases. J AAPOS. 2013 Dec;17(6):565-7. PMID: 24215806. [PubMed] [Read by QxMD]

Shazly TA1, Al-Hussaini AK. Pediatric ocular injuries from airsoft toy guns. J Pediatr Ophthalmol Strabismus. 2012 Jan-Feb;49(1):54-7. PMID: 21261240. [PubMed] [Read by QxMD]

Liu ML1, Chang YS, Tseng SH, Cheng HC, Huang FC, Shih MH, Hsu SM, Kuo PH. Major pediatric ocular trauma in Taiwan. J Pediatr Ophthalmol Strabismus. 2010 Mar-Apr;47(2):88-95. PMID: 20349901. [PubMed] [Read by QxMD]

Albiani DA1, Hodge WG, Pan YI, Urton TE, Clarke WN. Tranexamic acid in the treatment of pediatric traumatic hyphema. Can J Ophthalmol. 2008 Aug;43(4):428-31. PMID: 18711456. [PubMed] [Read by QxMD]

Salvin JH1. Systematic approach to pediatric ocular trauma. Curr Opin Ophthalmol. 2007 Sep;18(5):366-72. PMID: 17700228. [PubMed] [Read by QxMD]

Motley WW 3rd1, Kaufman AH, West CE. Pediatric airbag-associated ocular trauma and endothelial cell loss. J AAPOS. 2003 Dec;7(6):380-3. PMID: 14730288. [PubMed] [Read by QxMD]

Calzada JI1, Kerr NC. Traumatic hyphemas in children secondary to corporal punishment with a belt. Am J Ophthalmol. 2003 May;135(5):719-20. PMID: 12719088. [PubMed] [Read by QxMD]

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