Difficult Pediatric Airways
Myocardial infarction with papillary muscle rupture
Aspirated foreign body
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
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,
b. Abdominal pathology, acute abdomen, pancreatitis
c. Hyperkalemia, acute renal failure, MSOF, shock
d. Stress-induced cardiomyopathy, septic myocarditis
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
• 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
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.
- 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?