• Early blood product use improves morbidity and mortality.

• DCR may lead to improved outcomes in patients without TBI.

• Aggressive use of Normal Saline is associated with worse outcomes.

• Observation may be warranted to rule out delayed ICH in pts on coumadin following blunt head trauma.

• 4-factor PCC is now available for reversal of Vit K / Factor X Antagonists; works more quickly and completely.

Congenital Adrenal Hyperplasia

• Autosomal recessive, no cortisol due to 21-hydroxlase deficiency most commonly
• No cortisol, no aldosterone... Only testosterone
• Classic- salt wasting, simple virilizing
• Non classic- late virilization
  

• Genital ambiguity - female more obvious, males may have only large phallus
• Hyper pigmentation - mucosa, palmar creases
• Androgen excess - early puberty- males less than 9, girls less than 8
• Fertility issues, testes cancer, adrenal crisis
  

Consider CAH in sick neonate
Always consider adrenal insufficiency in hypotensive patients who remain hypotensive despite appropriate fluid resuscitation and initiation of pressors (whether adult or pediatric)... but particularly think of it in neonates!!

• Hyperkalemia,  hyponatremia
• Management: fluids, glucose, treat hyperK, manage airway
• Stress dose steroids
  

1) BSA dosing - 100mg/m2 IV hydrocortisone
2) Age-based - 0-3 yo: 25mg IV; 3-12 yo: 50mg IV; >12 yo: 100mg IV
3) Randy's Rules (from the brilliant mind of Dr. Cordle) - Give at LEAST 25mg; 3x their current dose; or 2mg/kg

    -- Limitations - requires patient cooperation, not definitive airway.
    -- Intubate when the above doesn't work - but increased morbidity and mortality with intubation

1. Over 1/2 complications occur immediately after intubation
2. Ketamine - improves airway compliance and reduces bronchospasm  
3. PRVC and SIMV/VC preferred
4. Initial vent settings
   

       - Low tidal volume
       - Respiratory rate
       - Short inspiratory time
       - I:E ratio 1:3 to 1:5

Delayed sequence intubation 

• Think of it as procedural sedation when the procedure is preoxygenation.
  

1. Ketamine
2. Preoxygenate with BiPAP
   
3. Administration of a paralytic agent 
4. Don't forget to adjust the vent (before High-5's).
   

10 day old with vomiting

  - Hx of "GERD" since day of life 4; Mom GBS + but treated and baby full term without complications; +constipation
  - Green emesis day of presentation - looks great at bedside

  - Neonate with Bilious Emesis - KEEP IT SIMPLE... Neonate with Bilious Emesis = Badness until proven otherwise.
        -- Surgical vs non surgical - Surgical includes duodenal atresia, malrotation with volvulus, NEC. Also consider Sepsis.

Malrotation
    - arrest of normal rotation of embryonic gut > usually presents in infancy
        -- >50% of kids will present before one month of age
        -- >90% have vomiting - it won't always be bilious
        -- > Urgent surgical consultation if kid looks bad

    - Imaging
        -- Plain films - not sensitive or sepcific
                - May see double bubble sign
        -- Upper GI = study of choice

Conjunctivitis: Allergic, viral, bacteria

1. Allergic: global BL injection.  Clear watery or mucoid discharge.  Cobblestoning of palpebral conjunctiva.  Usually in patients that have other allergic sx.
2. Viral conjunctivitis: Majority of cases.  Usually adenovirus.  Usually begins in one eye and spreasds to the other.  Global injection with watery discharge.  Preauricular lympadenopathy.  Will see follicular reaction.  Typically no pain or photophobia, unless onr of two subsets: Pharyngoconjunctival fever or epidemic keratoconjunctivitis.  Still, its virus and no intervention, just supportive care with NSAIDS, artificial tears, cold compresses, hand washing.
3. HSV conjunctivitis: dendrites.  Unilateral usually.  Preauricular LAD.  Pain, burning, tearing in eye.  Foreign body sensation and decreased vision.  Tx is topical antiviral such as trifluridine 1% 5x/day. If there is skin or other involvement, drops 9x/day and acyclovir oral.  If cells or flare, topical cycloplegic
4. HZV conjunctivitis: Hutchinson's sign; vesicles at tip of nose that increases likelihood of ocylar involvement.  More "medusa" pattern than dendritic on fluorescein.  NO STEROIDS
5. Bacterial conjunctivis: Staph and strep.  Adults more H. influenza.  ABrupt onset.  Starts unilateral and spreads to both eyes within 48 hrs.  Tx with topcial abx.  Kids erythromycin ointment, adults polymixin B.  For contact users, fluoroquinolone to cover pseudomonas, use slit lamp to assess for corneal ulcerations and refer to ophtho if found.
6. Bacterial hyperacute conjunctivitis: GC.  3-5 days after birth in neonate.  Genital-hand eye contact in adults.  Copious discharge, can be threatening to vision.  Tx same as above but add 3rd generation cephalosporin.
7. Chlamydia: trachoma is most commmon cause of preventable blindness in the world.  Inclusion conjunctivitis more common.  Tx erythromycin plus oral azithro/doxy

Uveitis: inflammation of iris, ciliary body, choroid

• Anterior uveitis; sudden onset red painful eye.  Worse with movement.  Direct and consensual photophobia which is pathognomonic. Pupil constricted, irregular, sluggish.
• Posterior: not as common, no redness
• Uveitis dx: cells and flare in anterior chamber on slit lamp
• Uveitis tx: topical steroids, with optho consult.  mydriatics and cycloplegics.  Mydriatics prevent synechia
  

Acute closed angle glaucoma: emergency need to make dx, can have visual loss.

• Peripheral iris tissue blocks outflow of canals of schlemm.
• Mydriasis will worsen condition.
• Presentation: severe pain, redness, visual decrease, mid dilated pupil, blurred vision, headache, N/V.  Usually pretty severe presentation.
• Exam: Global injection with steamy/cloudy cornea.  On funoscopic exam will see cupping.  IOP >30.  Check pressures in both eyes to compare!!
• Tx topical beta-blocker, topical alpha agonist, acetazolamide in non sickle cell pts, and pilocarpine.  Use all 4, then call ophtho.
• If pressure still elevated after tx, admit for optho consult.  Also may need to be admitted for further pain control.
  

Myth 4 - The extent of surface burn determines the extent of the injury. Unfortunately, skin findings can be misleading.

Myth 5 - The pathway the electricity takes through the body predicts the pattern of injury.  It is helpful to be able to see evidence of the path that the electricity took (ex, from toe to hand), but once again, this can be misleading.

Myth 6 - All patients with electric injuries require 24 hours of cardiac monitoring.  Most patients who arrive to the ED without having had an arrhythmia and who have a normal ECG with no symptoms do not require prolonged monitoring.

Myth 7 - Cardiac monitoring and further testing is always required for TASER injuries. There have been deaths noted with TASER injuries, but these have all been associated with patients who had "excited delirium" -- PCP and TASER is a bad combination.

Myth 8 - Victims of lightning injury should not undergo prolonged resuscitation.  Lightning victims can have meaningful recoveries after prolonged resuscitation.  They can even present with Fixed and Dilated pupils.  Do not tell EMS providers to pronounce the victim in the field. Continue to resuscitate and bring them to the ED to further assess.