Episode 11b: Acute Illness and Known Metabolic Disease with Austin Larson

Emergency Medicine, Metabolic Disorders, Pediatric Emergency Medicine, Podcast

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

  1. Most children with known inherited metabolic disorder will have a letter with them, from their metabolic doc, about what to do if they show up to the with a new illness. If they do not, then the New England Consortium website is a great resource.
  2. Most protocols recommend 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.
  3. Be careful with patients who are on a ketogenic diet as treatment for their seizures, as giving them glucose can cause refractory status epilepticus. In those patients, the preferred calorie support would be lipids.

Point of Care Resources

  1. New England Consortium for treatment protocols
  2. Vademecum Metabolicum handbook in book form
  3. 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

Episode 11a: Crashing Neonate and Metabolic Disorders with Austin Larson

Emergency Medicine, Metabolic Disorders, Pediatric Emergency Medicine, Podcast

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

  1. 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.
  2. 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.
  3. If the ammonia level is >200 micromols/L and rising, dialysis will likely be needed and you need to start making plans for this.
  4. Neonates generally can not generate a significant ketosis, even if fasting or ill, without an inherited metabolic disorder.
  5. Other labs to consider obtaining in an ill child with hypoglycemia or concern for metabolic disorder
    1. Cortisol
    2. Serum Amino Acids
    3. Urine Organic Acids
    4. Serum ketones
    5. Free fatty acids
    6. Growth Hormone
    7. Insulin
    8. Acylcarnitine profile

Point of Care Resources

  1. New England Consortium for treatment protocols
  2. Vademecum Metabolicum handbook in book form
  3. 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

Episode 10: Post-resuscitation Hypotension After Cardiac Arrest with Alexis Topjian

Cardiac Arrest, Emergency Medicine, Medical Education, Pediatric Emergency Medicine, Podcast

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

  1. 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.
  2. 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.
  3. 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.
  4. 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.

 

Episode 9: Suicide Prevention and Firearms

Emergency Medicine, Firearm Violence, Pediatric Emergency Medicine, Uncategorized

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 

References

  1. 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.
  2. Betz ME, Wintersteen M, emergency EBAO, 2016. Reducing suicide risk: challenges and opportunities in the emergency department. annemergmedcom
  3. 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.
  4. 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.
  5. Wintemute GJ, Betz ME, Ranney ML. Yes, You Can: Physicians, Patients, and Firearms. Ann Intern Med 2016;165(3):205–10.

Episode 8: Firearm and Youth Violence in Canada

Education, Emergency Medicine, Firearm Violence, Medical Education, Pediatric Emergency Medicine, Podcast, Uncategorized

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/

  1. 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.
  2. Snider CE, Ovens H, Drummond A, Kapur AK. CAEP Position Statement on Gun Control. Canadian Journal of Emergency Medicine. 2009;11(1):64-72
  3. 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
  4. 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

Episode 6: What is the ED role in Child Abuse Evaluation and Documentation?

Education, Emergency Medicine, Medical Education, Pediatric Emergency Medicine, Podcast, Uncategorized

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?

Episode 4: Youth Concussions with Joe Grubenhoff

Concussion, Education, Emergency Medicine, Medical Education, Pediatric Emergency Medicine, Podcast, Uncategorized

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.

Episode 3: Leaving the ED with an Oxygen Tank – Bronchiolitis with Lalit Bajaj

Bronchiolitis, Education, Emergency Medicine, Medical Education, Pediatric Emergency Medicine, Podcast

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.

Episode 2b: Guidelines Update for Pediatric Sepsis

Education, Emergency Medicine, Medical Education, Pediatric Emergency Medicine, Podcast, Sepsis

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.

Episode 2a: Lactate in Pediatric Sepsis with Halden Scott

Education, Emergency Medicine, Medical Education, Pediatric Emergency Medicine, Podcast, Sepsis

Host Jason Woods MD sits down with Halden Scott MD to discuss the state of pediatric sepsis, and specifically the use of lactate measurements in the Emergency Department. Dr. Scott is a leading expert in pediatric sepsis in the Emergency Department, with multiple articles published on the topic of the use of lactate measurement in the treatment of pediatric sepsis.