Jaron

1. Most common “mechanical” causes:

• Cardiac tamponade (including STEMI and myocardial rupture)
• Tension pneumothorax
• Massive PE

 
2. Most common “metabolic” causes:

• Severe hyperkalemia with or without metabolic acidosis
• Severe sodium-channel blocker toxicity (including TCA toxicity)
• STEMI with agonal rhythm and other agonal rhythms

1. Several types of angioedema

• Acute allergic/Anaphylactic
• ACE-inhibitor induced
• Hereditary Angioedema
• Acquired

2. Each has a different treatment

• Acute allergic/Anaphylactic - Epinephrine, steroids, anti-histamines
• ACE-inhibitor induced -Stopping offending agent
• Hereditary Angioedema -C1 esterase inhibitor replacement, FFP
• Acquired - Treatment of underlying condition

3. Airway and hemodynamic management is critical

• Video laryngoscopy, flexible fiber optics, surgical airway

4. Cricothyrotomy

• Anatomy, indications, and techniques

1. Traditional hook and dilate
2. Scalpel, finger, bougie
3. Percuatneous Seldinger

Working in a pediatric ED isn't just diagnosing viruses - child abuse/neglect is more prevalent than we'd like to think:

• 2-10% of children presenting to the ED are victims of abuse or neglect
• children that are abused often have multiple healthcare visits before it is recognized

 
Providers should be mindful of sentinel injuries - injuries without a plausible explanation

• soft tissue injuries - bruising in children who cannot cruise, or in high risk areas
• remember TEN-4 - ANY bruising in a child less than 4 months, or bruising on the Trunk, Ears, and Neck in a child less than 4 years

 
Skeletal injuries are the second most common presentation of abuse - certain fractures should raise your suspicion for abuse

• rib fractures (make sure you check that CXR ordered to look for pneumonia)
• any fracture in a child that cannot walk
• long bone fractures in an infant or toddler

 
Abusive head trauma (formally known as “shaken baby syndrome”)

• This is the most common cause of death following abuse
• 30% of cases are missed initially – remember to consider it in cases of excessive fussiness or altered mental status

 
Chest and abdominal injuries

• the abdomen can hide injuries and hold a lot of blood
• elevated liver enzymes or lipase should raise your concern for occult intra-abdominal injury

 
What can you do to help prevent a missed diagnosis of abuse?

• Perform a “top-toe” exam on every patient and examine their skin for bruising (this means everyone should be in a gown)
• Make sure the explanation of the injury makes sense developmentally – “those who don’t cruise rarely bruise”
• If you’re concerned about possible abuse, initiate a screening work up or admit the child to a service that can complete an abuse evaluation
• Remember that you are a mandated reporter – involve Social Work early, even if you plan to refer the child to another hospital for evaluation.

 

Large MCA Strokes
* Although headache is less common in ischemic stroke, the presentation may be deceiving. Some patients with large vessel occlusion will mimic signs of hemorrhagic stroke--headache, vomiting, hypertension, altered mental status.
 
* Irrespective of the 6-hour window or 3 hour post wake up window, consider paging out a code stroke if you're concerned or hedging. Thrombectomy is to be considered!
 
* Time is brain. Data suggests there is likely a direct correlation between speed of treatment and better outcomes, particularly with endovascular data. 
 
* Neurons over nephrons? When considering contrast burden of CT perfusion studies, consider the devastating effects of the stroke vs potential kidney damage
 
* Data on IV tPA may be controversial but the endovascular/thrombectomy data suggests a NNT of as low as 4 patients! This could be the way of the future for stroke care. 
 
* tPA is likely okay with carotid dissection. tPA is NOT okay with aortic dissection
 
* Aortic dissection would affect R hemisphere but would be rare and quite unlikely to cause solely L hemispheric deficits
 
Unstable Junctional Bradycardia
* Junctional rhythm with unstable bradycardia? Think about drugs before the need for transvenous pacemaker

* Severe digitalis toxicity can rarely result in temporary cessation of atrial fibrillation and the appearance of a slow junctional rhythm without P waves. Occasionally, when the digitalis toxicity improves, the atrial fibrillation returns
 
* Hyperkalemia, essentially a Na channel blocker, should be considered with all junctional rhythms
 
* We don't always perform medication reconciliation but an argument could be made that looking at the drug list tells you more about the PMH and PSH than perusing the record
 
Central line trouble shooting: 
       -- do not force the guide wire
       -- do not re-use a bent guide wire
       -- use your ultrasound to confirm placement with modified bubble study
       -- consider chest x-ray while still sterile to gauge line placement
 
Modified bubble study for confirming central line placement:
       1. Obtain US view of the RA/RV
       2. Shake up a flush (without adding air)
       3. Rapidly push flush through one of the ports
       4. Should see dynamic echogenicity within the RA/RV if venous access

1. HSV Encephalitis has significant morbidity and mortality, during your history ask about Maternal AND Paternal history of HSV.
2. You should cover for HSV meningitis with acyclovir when:

• Seizures
• Elevated LFTs
• DIC
• Toxic/Lethargic infant
• Vesicular lesions
• CSF Pleocytosis

3. Suspect idiopathic intracranial hypotension in a patient with symptoms similar to a post-LP headache without the history of an LP.
4. Signs of traumatic aortic injury include:

• widened mediastinum
  
• abnormal contour of aorta
• depressed left mainstem bronchus
• deviation of NGT to right
• apical cap
• loss of aortopulmonary window