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Carolinas Core Concepts - Dr. West

7/30/2015

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Difficult Pediatric Airways
  • Know your equipment! Preparation is key! 
  • Key differences from adult airway: larger tongue, smaller pharynx, larger epiglottis, more anterior larynx, airway narrowest at cricoid 
  • Pediatric cricothyroid membrane is smaller and horizontal.  Minimum age for a cric between 5-12 years old, though more related to patient’s development & ability to ID landmarks.
  • If performing a surgical airway on a pediatric patient, use a pediatric tracheostomy tube or small ETT, being cautious not to intubate the mainstem bronchus.

 Incidental findings
  • Incidental findings are very common and can be a significant cause of litigation
  • In one study, 43% of trauma patients had incidental findings, 15% of which were considered concerning (possible malignancy, aortic aneurysm, etc.).  Despite this, only half of patients were referred for appropriate follow up. 
  • Document your discussions with patient and recommendations for follow up. 


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TEAM Challenge CoRE Concepts

7/30/2015

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Myocardial infarction with papillary muscle rupture
  • Rare complication, cited in 1-2% of acute MI. Most often secondary to papillary muscle necrosis following RCA infarction. 
  • Present with new onset severe mitral valve regurgitation with complicating heart failure.
  • Ultimately, patient requires surgical intervention for valve repair/replacement, though intra-aortic ballon pump can be used as bridge. 
  • Avoid fluids given heart failure; nitroglycerine also problematic given preload dependence. Need vasopressors, with dobutamine being mainstay of treatment. 
  • Literature cites usage of afterload reducing agents such as nicardipine, though difficult in practice. Emergent interventional cardiology and CV surgery consultation is paramount.
  • Intubation should be approached with great caution, given high risk of arrest in setting of preload reduction,  increased intra-thoracic pressure and catecholamine suppression.

Thyroid storm
  • Most commonly due to severe exacerbation of underlying hyperthyroidism (i.e. Graves’ Disease) caused by trigger (pregnancy, substance abuse, infection, surgery, trauma, iodine load).
  • Consider in young patients with new onset atrial fibrillation with RVR with concomitant altered mental status/agitation, GI disturbance, heart failure. 
  • Treatment must occur in stepwise manner to prevent worsening of disease process: 
  1. Block synthesis (methimazole, PTU)
  2. Block hormone release (iodine solutions given >1hr after methimazole)
  3. Block peripheral conversion (steroids)
  4. Block peripheral effects (propranolol)
  5. Give supportive measures/treat trigger.
  • May rapidly progress to high output heart failure! Endocrinology consultation and ICU admission a must!


Aspirated foreign body
  • 70% of aspirated FB occurs in pediatrics, with food items accounting for 49% of aspirations.
  • Important to assess level of obstruction: Larynx, trachea, bronchus.
  • Right primary bronchus most common level of deep aspiration.
  • Often objects not radio-opaque; consider expiratory/decubitus films.
  • All objects need to be removed, given potential for delayed complications (i.e. post-obstructive pneumonia).

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Retropharyngeal abscess - Dr. Steed

7/30/2015

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  • Rare diagnosis, but keep on your differential for patients with fever, neck pain/stiffness, dysphagia, drooling, voice change, respiratory distress, or neck mass.
  • Advanced preparation a must for management of airway! Difficult airway given the size of the mass and airway compression. Call anesthesia early and prep transtracheal jet insufflator for pediatrics.  Consider exam in the OR
  • Lateral neck x-ray cannot rule in or rule out the diagnosis, but may be helpful. Look for increased pre-vertebral soft tissue (indicated RPA) or thumbprint signs of epiglottitis. Get a TRUE lateral to increase sensitivity.
  • RPAs are complicated by sepsis, carotid rupture, atlanto-axial subluxation, mediastinal extension and airway compromise. Patients require IV antibiotics, ENT consult, and admission.

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Carolinas Case Conference - Dr. Nichols

7/16/2015

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1) Respect the elderly, but especially in geriatric trauma!      
      -Many of these patients are beta blocked and anticoagulated
      -High risk for occult fracture, higher risk for mortality following any trauma
      -Remember to apply geriatric trauma scoring, and triage conservatively

2) Don't fear the chronic tracheostomy patient in respiratory distress
    -Remember your airway toolbox, gauge how much time you have!
    -A NG tube can be a great placeholder for trach exchange
    -Never forget you can (usually) still intubate these people from above
    -Fiberoptic nasotracheal intubation as a failsafe

3) Consider imaging of the hip in pediatric leg pain
    -SCFE can present as subacute knee pain, patients may still be able to walk!
    -Consider in both boys and girls, obese and average sized
    -Low threshold for imaging of the hips with knee or thigh pain complaints

4) Ensure you examine every trauma patient's eyes, checking for ocular trauma
   -Globe rupture requires immediate optho consultation

   -Do not perform further exams until this is ruled in or out
   -Hyphema is a collection of blood in the anterior chamber, usually traumatic
   -More anterior chamber filling associated with worse visual recovery
   -Emergent consultation with opthomology, elevate head of bed, check for coagulopathy

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TEAM Challenge Core Concepts

7/16/2015

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ADULT EPIGLOTTITIS
  • LOCATION DOES NOT DEFINE ILLNESS
  • Be leery of TRIAGE BIAS!
  • Early recognition of airway disasters helps avoid the disaster!
  • Epiglottitis presents more subtly than in kids
  • Need advanced airway? Don’t use supraglottic device.

Septic Abortion
  • Never trust a pre-teen / teen
  • Female + complaint = get a UPT
  • Pregnancy with CMT or diffusely tender uterus raises concern for endometritis!
  • Broad spectrum abx for endometritis!

Pheochromocytoma
  • Always review your ECG and CXR promptly
  • Keep Zebras on Ddx, but pursue Horses 1st 
  • Think about endocrine tumors if dramatically worsens after Iodinated contrast 
  • Don’t be ignore “incidental findings” on CT
  • Give Alpha blockade (phentolamine) before any Beta blockade (use beta blockers later to control tachycardia if needed).
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Leadership in the Trauma Bay - Dr. Colucciello

7/16/2015

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  • Cooperation and communication key
  • Attention to Trauma Protocols
  • Keep track of the time!!
  • Team Captaincy Skills
  • Control Pain
  • Dangers of Distracting Injuries (Physician gets distracted)


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Sharpen Your Calipers and Your ECG Skills     - Dr. Littmann

7/16/2015

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I.      STEMI ECG Pattern in the ICU
        1.     In the ICU setting, 5% of all ECGs show a STEMI pattern
        2.     At least 85% of these patients are found not to have STEMI
        3.     Frequent causes of STEMI ECG in the ICU:

                 a.   Pericardial irritation by chest tube, mediastinal mass, pneumothorax,         
                        hemothorax, hemopericardium
                 b.   Abdominal pathology, acute abdomen, pancreatitis
                 c.   Hyperkalemia, acute renal failure, MSOF, shock
                 d.   Stress-induced cardiomyopathy, septic myocarditis
                 e.   Uncertain
        4.     Evaluation and management:
                 a.   Try to find the underlying cause
                 b.   Stat bedside echocardiogram
                c.   Urgent cardiac catheterization is reasonable in selected cases

II.    The Pacemaker ECG
1.     If the paced QRS is upgoing in lead I: RV apical pacing
         Indication: bradycardia (A-V block or atrial fibrillation with slow ventricular response)

2.     If the paced QRS is downgoing in lead I: biventricular pacing
         Indication: severe systolic heart failure (EF < 35%) and left bundle branch block


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COPD Exacerbation - Dr. Akomeah

7/9/2015

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• Acute treatment: bronchodilator and steroids
   – Consider antibiotics with sputum changes
• Use NIV early for increasing WOB


• Disposition guide:
   – Sa02, treatment response, COPD severity
• Discharge meds: SABA, steroids
   – 
Consider antibiotics and LABA/ICS

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Pediatric Chest Pain - Dr. Malka

7/9/2015

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1. History and physical exam are key elements of discerning benign chest pain from cardiopulmonary pathology.

2. Obtain an EKG in all children presenting with chest pain or syncope.

3. EKG is the most sensitive diagnostic test for pericarditis.

4. Many cases of myocarditis will present with primarily respiratory complaints.

5. Ask about family history of deafness and unexplained sudden death.

6. Check for hepatomegaly in infants with vague or respiratory complaints.



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Ped Resuscitation: Basics are Best - Dr. Fox

7/9/2015

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- 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

         - ECMO?

- 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?

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  • RESIDENCY
    • About CMC
    • Curriculum
    • Benefits
    • Explore Charlotte
    • Official Site
  • FELLOWSHIP
    • EMS
    • Global EM
    • Pediatric EM
    • Toxicology >
      • Tox Faculty
      • Tox Application
    • (All Others)
  • PEOPLE
    • Program Leadership
    • PGY-3
    • PGY-2
    • PGY-1
    • Alumni
  • STUDENTS/APPLICANTS
    • Medical Students at CMC
    • EM Acting Internship
    • Healthcare Disparities Externship
    • Resident Mentorship
  • #FOAMed
    • EM GuideWire
    • CMC Imaging Mastery
    • Pediatric EM Morsels
    • Blogs, etc. >
      • CMC ECG Masters
      • Core Concepts
      • Cardiology Blog
      • Dr. Patel's Coding Blog
      • Global Health Blog
      • Ortho Blog
      • Pediatric Emergency Medicine
      • Tox Blog
  • Chiefs Corner
    • Top 20
    • Current Chiefs
    • Schedules >
      • Conference/Flashpoint
      • Block Schedule
      • ED Shift Schedule
      • AEC Moonlighting
      • Journal Club/OBP/Audits Schedule
      • Simulation
    • Resources >
      • Fox Reference Library
      • FlashPoint
      • Airway Lecture
      • Student Resources
      • PGY - 1
      • PGY - 2
      • PGY - 3
      • Simulation Reading
      • Resident Wellness
      • Resident Research
      • Resume Builder
    • Individualized Interactive Instruction