Case: 55 year male several hours crushing chest pain. Medic ECG shows inferior STEMI with reciprocal ST depression. Patient is Hypertensive. Sats 90%. CXR with BL edema. Trop 4.5, Lactate 6.7, Cocaine positive. AORTIC DISSECTION WITH STEMI
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1) SCD pain is complex and real (despite lack of objective findings). - 1/2 have no objective findings. - Those with higher baseline Hgb have higher risk of pain crisis. - Adult patients increased pain frequency have higher mortality. 2) Evaluate for potentially critical masqueraders. 3) Give pain medications fast; strongly encourage intranasal fentanyl as first-line opioid. THESE ARE PREVENTABLE INJURIES AND DEATHS
Child Passenger Restraints! If you remember nothing else, please remember basics of child passenger restraint so you can teach your patients
Other Important Sources of Injury Other common causes of death from unintentional injury- suffocation/SIDS, drowning, poisoning, fire/burns, falls
INJURY PREVENTION IN THE ED Use your “teachable moment” to reinforce or teach families about injury prevention. Consult social work. Many issues require ongoing community services and support, and you can make sure your patients sent in the right direction.http://pedemmorsels.com/injury-prevention/ CORE CONCEPTS •Incidence of CT scan ordering for IBD patients has more than doubled in the past 10 years. •Patients with Crohn’s disease are much more likely to have critical findings. •Patients with IBD are at increased risk of malignancy from radiation. •Take into account certain characteristics, ESR, & CRP when considering imaging. IBD Review Crohn's Disease - transmural inflammation, affects whole GI tract, skip lesions Ulcerative colitis - involves colon only Do We Image? --Yarur et al found that 93% of people with IBD in the ED with GI complaints had abnormal CT scan and in Crohn's disease 1/3 had clinically actionable findings and 12% of UC had clinically actionable findings. --Mo' CTs, Mo' Problems.. $$$$ - $1000 per CT scan Radiation - 1 in 1500 risk of death from malignancy from 50 mSv. --Keep in mind - IBD folks tend to be young with baseline increased risk of cancer from rapidly multiplying cells and immunsuppressive meds -- How to decide who to scan - Yarur et al - underweight, biologics use, previous IBD surgery, black race and HR > 90 were associated with increased risk for clinically actionable CT findings for Crohn's patients; salicylate use was protective. - proposed prediction models - PA+ model = ESR + (5xCRP); if less than 10, then no scan - 97% sensitivity Black Widow SpiderSymptoms
LEADSymptoms
Cyclopeptite containing mushrooms
Pearls for Pancreatitis in Kids
Case 2 - Ludwig's Angina- Ludwig’s angina is infection within the sublingual/submandibular potential space, isolated by superficial fascia. Infection demonstrates rapid progression with posterior deflection of the tongue, obstructing the airway. - Airway management, ENT consultation and IV antibiotics (penicillin + metronidazole, clindamycin or ampicillin/sulbactam) are the necessary steps for management of Ludwig’s angina. Severe Mucositis- Mucositis is a common side effect of most chemotherapy and head/neck radiation regimens that is associated with significant morbidity. - Severe mucositis carries 75% risk of serious co-infection and 9% risk of associated mortality. Ehler's-Danlos and Aortic DIssection- Ehler’s-Danlos Syndrome, an inheritable collagen vascular disease, is associated with hyperextensible skin and hyperflexible joints; many subtypes are at risk for arterial aneurysm, dissection or rupture at young ages.
- Management of acute aortic dissection or perforation includes vascular surgery consult (for emergent intervention) and decreased BP/sheer stress with IV nicardipine or esmolol. |
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