Keep a broad differential in pediatric altered mental status.
Be systematic in your approach to pediatric AMS.
Avoid common pitfalls in management such as:
- Assuming no head trauma b/c none stated
- Failing to secure airway prior to imaging/ transport
- Assuming no toxin b/c none stated in history
- Forgetting to check the glucose!
Post-op Incisional Hernia
- Seen in over 10% of patients; up to 25% of patients with incision infection.
- More common in midline incision, more common in upper abdomen vs lower abdomen.
- Dr. Gibbs Pearl: If a patient presents to the ED with 30 days of their surgery (and is not there for an obviously unrelated complaint) contact the Surgeon to discuss the patient's presentation.
- Surgery Pearl: evaluation for post-operative pain from lap chole can involve RUQ ultrasound to look for signs of abscess. Also consider biliary studies if concerned for biliary leak, biloma development.
Negative CT Calcium score in ACS
- Negative CT calcium score misses ACS very rarely.
- Quick test that is non-invasive, has no contrast, does not require patient participation, does not rely on patient heart rate or ability to exercise.
- If used in correct patient population, NPV is between 93-97% with a sensitivity of 99-100%.
- Dr. Garvey Pearl: Recognize that your clinical gestalt trumps any protocol or clinical decision rule and do what you think is best for the patient.
- Wernicke's is an underdiagnosed constellation of neuropsychiatric symptoms that include altered mental status, confusion, memory impairment, nystagmus, gaze palsy, and ataxia.
-Symptoms are due to dietary thiamine deficiency that impairs energy utilization in the brain
-Wernicke's is not exclusive to alcoholics. High risk: the elderly, pregnant women, bariatric surgery pts, HIV/AIDs, diabetics, TPN-dependence, and hematologic malignancy
-Treatment: thiamine 200mg IM or IV. ORAL IS NOT EFFECTIVE.
-Treat with parenteral thiamine if a patient is altered, ataxic, has ocular abnormalities, impaired memory, hypotension, or hypothermia.
-We are on the front lines to make this diagnosis. Don't miss it.
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Teaching Tips for the Emergency Department
IcePopsicle Stick Impaled into Parapharyngeal Space
Traumatic Intracranial Hemorrhage in Patients on Warfarin.
Prothrombin complex concentrates (PCC) vs Fresh frozen plasma (FFP)
- PCC normalizes the INR much more rapidly than FFP (0.5 hr vs 6-12 hours from initiation of administration)
- Rapid normalization/and protocol driven care which expediates administration of either FFP or PCC has demonstrated a reduction in the expansion of traumatic intracranial hemorrhage
- ... however, this has never been demonstrated to improve mortality or neurologic outcomes.
- Similarly rapid INR correction can lead to faster neurosurgical intervention... although no proven improvement in outcomes
- FFP is associated with considerable risk of fluid overload (TACO- 1:68-1:1500 units transfused) in a volume dependent manner and is more likely in patients with chronic kidney disease and congestive heart failure (precisely the patients who frequently are on warfarin). FFP is also associated with rarer complications such as viral transmission and anaphylaxis.
- PCC does not have any of the complications associated with FFP, although it is believed to have an increased risk of thromboembolic events with incidence of ~1.8% based of retrospective studies primarily.
(note the below are COSTS which are usually multiple times less than CHARGES to patients)
- PCC is considerably more expensive than FFP.
- FFP is estimated to cost ~$1 mL. With average patient requiring 4 units of FFP that equals approximately $1000 in COSTS.
- PCC is $1.27 per UNIT. Dosing costs typically range from 2500-5000 units, which corresponds to costs of $3157 and $6350 respectively. CHARGES to patients are typically ~3x this amount.
Bottom Line: If cost were no issue then PCC would be the treatment of choice for probably all patients. Data appears to trend towards improved outcomes with more rapid reversal, which of course is a logical conclusion in a bleeding anticoagulated patient. Cost, however, is a consideration and at this time patient selection is key. For the younger, healthy patient with intracranial hemorrhage with high propensity for expansion (ex. subdural hematoma, epidural hematoma, intraparenchymal hemorrhage) reach for PCC without second thought. Patients with high risk of fluid overload are also a key population to consider PCC as treatment of choice.
- Classically, classified based on tonicity and volume status, but consider acuity when treating in emergency department.
- Do not feel you have to treat asymptomatic patients while in the ED.
- 1 ml/kg 3% saline will raise sodium by 1 mEq – start with 100 mL over 10-60 min and re-evaluate.
- Do not exceed 6 meq in 24 hours (consider D5W 6mL/kg and 1 mcg DDAVP if you overshoot).
- Send labs for admitting team to help with work up including urine electrolytes/osm, UA, serum osmoles, uric acid.
- Acute (salt ingestions or DI with acute inability to obtain water)
– 3-6 mL/kg/hr D5W with goal to decrease serum sodium by 1-2 meq/L/hr
- Chronic – 1.35 mL/kg/hr D5W with a goal to lower no more than 10 mEq/L in 24
1. Most commonly presents with anemia, bone pain, elevated creatinine, fatigue, and asymptomatic hypercalcemia.
2. Suspect in elderly who present with vertebral or chest pain with anemia, hypercalcemia, or elevated creatinine.
3. Multiple myeloma emergencies include acute/chronic renal failure, infection, and more rarely hypercalcemia and spinal cord compression.
4. Best imaging for punched out lesions are plain films of axial skeleton and proximal humerus/femur.