Carolinas Emergency Medicine Residency

Carolina Case CONFERENCE - Dr. West

4/28/2016

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Retained Foreign Body

X-ray or US if mechanism involves glass or is high risk
Consider retained FB if wounds not healing well
US will demonstrate wooden foreign bodies
Common cause for EP to be sued

Ectopic pregnancy

2 % all pregnancy are ectopic in location – increasing risk if history of ectopic
9% will present with only painless vaginal bleeding
Can be associated pseudogestational sac

Mushroom induced hepatotoxity

Most common Amanita ingestions
Consider in new immigrants to the US who present with acute liver injury
Consult your local toxicologist, treatment can include silibinin, NAC, high dose PCN, and ultimately possible liver transplant

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Pediatric Case COnference - Dr. Lawson

4/26/2016

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Abdominal Pain of Unusual Cause
Abdominal pain in children is not always AGE, appendicitis, or UTI - keep your differential broad and use your exam skills (including GU and Tanner staging)
"Smokiness" on ultrasound may be due to blood (RBCs scattering sound waves) or stasis
Hematocolpos as a result of imperforate hymen can cause abdominal pain and urinary retention

PE vs Sepsis
PE is a rare occurrence in children and often presents atypically (classic symptoms often only present in large PEs)
Adult clinical decision rules (Wells Criteria and PERC) do not reliably apply to children
Obesity, OCP use, and previous thrombus (not PE) are the three leading risk factors for PE
History of central venous line is the most important predisposing cause of DVT
Several studies other than CTA can help lessen your suspicion for PE (CXR, EKG, cardiac echo, extremity DVT US, BNP, troponin)

Sepsis in children can be subtle and precipitous

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Pediatric ECGs - Dr. Bryant

4/21/2016

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Normal Peds EKG Variations
- Right heart dominance
  - From infancy to adulthood ventricular dominance transitions from a relatively thicker RV in utero/infancy to thicker LV as adults
  - Right axis deviation
  - Tall R waves in V1-V3
  - RSR' in V1
  - Deep S waves and Q waves in lateral leads
  - Juvenile T wave pattern in V1-V3
- Small cardiac size = shorter intervals, faster rate
- J-point depression
- Early repolarization
- Sinus arrhythmia

NOT Normal Peds EKG Variations
- Brugada Syndrome
  - EKG: Leads V1-V3
    - RSR’ with ST elevation
  - 3 Types
    - Type 1 – coved
      - Diagnostic
    - Type 2/3 – saddle-back
- Arrhythmogenic Right Ventricular Dysplasia (ARVD)
  - EKG: Leads V1-V3
    - Epsilon waves
    - Inverted T waves
- Catecholaminergic Paroxysmal Ventricular Tachycardia (CPVT)
  - EKG:
    - Normal baseline, bidirectional QRS polymorphic Vtach with exertion/excitement
- Hypertrophic Obstructive Cardiomyopathy (HOCM)
  - EKG: Lateral leads
    - Dagger-like deep narrow Q waves
    - Deep narrow T wave inversions
    - +/- LVH, left axis deviation
- Wolff-Parkinson-White (WPW)
  - EKG:
    - Delta waves
    - Wide QRS
    - Short PQ segment
- Anomalous Left Coronary Artery from the Pulmonary Artery (ALCAPA)
  - EKG:
    - Anterolateral ischemic changes
    - Lateral leads
      - Deep wide Q waves
      - T wave inversions
- Long QT Syndrome
  - EKG:
    - QTc > 450ms
    - At risk for Torsade de Pointes/Vtach

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Pediatric Syncope - Dr. Bryant

4/21/2016

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Pediatric Syncope Algorithm

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Appendicitis - Dr. Craig

4/15/2016

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The classic presentation of appendicitis is seen ~50% of the time.
There are several well-known atypical presentations that are commonly misdiagnosed at the initial encounter.
The common theme is that symptoms are NOT localized to the right iliac fossa.
Know these atypical presentations so that you can nail the diagnosis:

·         Young healthy male with cystitis symptoms
·         Toddler with a RLE limp
·         Infant with inflamed right hemiscrotum
·         Pregnant female with right flank pain, pyuria
·         Right sided truncal cellulitis
·         RUQ discomfort with normal RUQ ultrasound
·         Urinary retention

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Carolina Case CONFERENCE - Dr. West

Pediatric Case COnference - Dr. Lawson

Pediatric ECGs - Dr. Bryant

Pediatric Syncope - Dr. Bryant

Appendicitis - Dr. Craig

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