1. Osteomyelitis can be difficult to detect in the ED so always maintain a high suspicion for it in children with refusal to bear weight or persistent pain in a long bone.
2. Bloodwork rarely helps diagnose osteomyelitis, but can be reassuring if normal and you have low suspicion.
3. X-rays help rule-out other causes of pain such as fracture but more definitive imaging (i.e. MRI vs bone scan) are usually needed to diagnose.
1. Children have fantastic physiologic reserve but will fall off the cliff quick if illness is under appreciated.
2. Listen to parents - even if they are being too persistent, they know their children better than anyone
3. If you think a patient needs a test because you are concerned they have a significant illness, be persistent and willing to make go do what is in the patient's best interest (even if you have to call in specialists from their cozy homes).
4. Always be wary of questionable vaginal bleeding in pregnancy - sometimes you get more than blood when you look.
Confusion about epinephrine
o Standard: 0.3-0.5 mg IM 1:1,000 (can repeat q5 minutes)
o Pediatric: 0.01 mg/kg IM 1:1,000
o Severe/refractory: 0.1mg 1:10,000 IV over 5 minutes + start epinephrine drip
- Sources of error include high stress scenarios, confusion about concentrations, multiple concentrations and routes available
- Recognize that epinephrine is a medication prone to errors and be clear with orders, double check if need be
Rocky Mountain Spotted Fever
- Symptoms: Hyponatremia, thrombocytopenia, AMS, fever, abdominal pain/GI symptoms, rash (classically petechial but can vary)
- Only about ½ have history of tick exposure
- Treat adults and children with doxycycline 100 mg BID in adults, 2.2 mg/kg/dose BID in children. Use chloramphenicol in pregnant females (though less effective than doxycycline).
- Doxycyline shortage has resolved, average cost for a 7 day course around $35.
- Presentation: constipation, weakness, intact sensory
- Less than 12 months of age (though majority 6wk-6mo)
- Diagnose by sending stool sample to CDC
o More effective if initiated early (within 7 days)– do not wait for confirmation diagnosis
o Human derived botulism immunoglobulin (BabyBIG) - $45,000
o Binds free toxin to prevent worsening however will not remove toxin already bound to motor endplate (must sprout new motor endplates for recovery)
o Only available through California Department of Health Services – www.infantbotulism.org proves specific instructions on how to acquire immunoglobulin
- broad spectrum of disease, high level of suspicion is essential
- myocarditis can mimic STEMI and Wellens syndrome among others
- EKG, echo, and cardiac enzymes cannot rule in/out the diagnosis
- No hesitation to consult Peds Cards
- no discrimination, occurs in all people groups
- history, exam, and physical findings may raise suspicion for abuse.
- must place child in gown.
- make sure story matches up... loose ends must be tied
Marfan and PTX:
- Must be personally knowledgeable about equipment associated with procedures (ie: suction device for chest tubes)
- Pigtail catheters equivalent to thoracostomy tubes for uncomplicated PTX with decreased pain - http://pedemmorsels.com/pigtail-catheter/
- Respect the anatomic and physiologic differences that exist between adults and kids.
- Focus on the basics!
- Compressions >100/min, Good Depth, Good Recoil
- Don’t hyperventilate.
- EtCO2 can be a helpful guide.
- Have a Post-Arrest System in place... at the end of an arrest is not the time to try to figure this out.
- Temperature management
- Ask the hard questions to help other family members.
- Prior syncopal events?
- Prior “seizures?”
- Prior Submersion Events?
- Fam Hx of Sudden Death?
- Fam Hx of Submersion Events?
Stages of repair (Please look at the pictures):
1:Norwood: RV redirected to aorta (systemic). Shunt placed from RV into pulmonary artery as well (Sano shunt). Post norwood, patient highly fluid sensitive and high risk for clotting
2: Bidirectional Glenn (4-6 months): Connect SVC to pulmonary artery, disconnect RV from PA.
3: Fontan (1.5 - 4 yrs): Connect IVC to PA. Fenestrate IVC into the RV as pressure relief for the pulmonary artery. At this point pt is VERY fluid dependent, venous return is crucial for cardiac output.
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/