I. STEMI without STE
II. de Winter sign
III. aVR sign
IV. Wellens sign
Case #1 (minor TBI + discussion about clinical decision rules [CDR]) – SLIDE #30
· GCS 15 ≠ 14 ≠ 13
· Know what each CDR gets you
· Pick a rule and use it (ATLS prefers Canadian, ACEP prefers New Orleans, Gibbs prefers Canadian)
· Be cautious with the intoxicated patient (Canadian only 70% sensitive… must achieve clinical sobriety 1st)
Case #2 (TBI on warfarin) – SLIDE #49
· Very high risk… be liberal with imaging
· No CDR to identify the low-risk patient
· Order INR on arrival
· Reversal of anticoagulation = resuscitation!
Case #3 (severe TBI) – SLIDE #94
· RSI with neuroprotective drugs
· Hyperosmolar therapy with either hypertonic saline or mannitol
· Do not hyperventilate unless there is clear clinical evidence of herniation
Trauma Resuscitation: Not ACLS
It's Not Always Sepsis!
#1. FUO is most commonly: 1) infection, 2) collagen vascular disorder, and 3) neoplasm
#2. Always consider uncommon presentations of common diagnoses
#3. Repeating the clinical exam is key
a) think about the child that has returned to the CED for the 3rd time in as many weeks... the new findings on your exam may be what leads to the final diagnosis
#4. No clear-cut rules for home vs. admit, but consider age, follow-up, and clinical severity
See Ped EM Morsel - http://pedemmorsels.com/fever-of-unknown-origin/
1. Never get involved in a land war in Asia.
2. Never go in against a Sicilian when death is on the line.
3. Headache with an abnormal neuro exam is always worrisome... and always look at there fundus.
4. Avoid diagnostic momentum - just because it sounds like gastroenteritis doesn't mean it is.
5. If a child has conjunctivits, always look at the ears and consider treatment should include oral antibiotics covering beta-lactam producers.