Carolinas Emergency Medicine Residency

Pediatric Altered Mental Status - Dr. MacNeill

10/31/2013

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There is a lot to think about... but don't forget the sugar!!

BASICS

Brain needs glucose, O2, electrolytes, nl electrical activity, no structural defects, no inflammation or infection

Transient vsPersistent Change in MS

Transient - usually benign, common, think electricity and perfusion
Persistent - dangerous, structural, metabolic, electrical

Seizure

CT?
Emergent CT - Less than 2 yrs, focality, abnl neuro exam, status, evidence of increased icp
Infant sz hard to detect- behavioral arrest, hypomotor, pallor, cyanosis, repetitive movt

Set the expectation -

Outpt EEG and MRI only if EEG supports the need or syndrome
Return to ED for sz in next 24hr, or last more than 5 min.
Send home with diastat.

Syncope

Lifetime incidence up to 40%,
Plumbing issue - decreased Cardiac Output, decreased TPR. Reflex syncope is combo of both

Sudden cardiac death - 50% with CV cause

HOCM - deep and narrow q waves in lateral leads, tall r waves in v1, high left ventricular voltage, syncope not always exertional, atypical CP, 1/2 family hx, Doppler echo for dx
Anomalous coronary arteries - 1/2 sx before death, syncope with exercise, nl EKG, ventric arrhythmia, dx by echo or CTA
Long QT syndrome - stress syncope,exercise, bradycardia, 1/3 will have nl EKG, 10% of healthy people have long QT
Brugada - rbbb and downs sloping ST in V1-V3, vtach, fib, triggers for Dysrhythmia sleep and rest when Vagal tone is high, fever, check lytes
Arrhythmogenic RV Dysplasia - autosomal dominant, RV myocardium deposition with fibrofatty tissue, widened QRS
Catecholeminergic polymorphic VTACH - Rare, structurally normal, nl EKG, family hx
Myocarditis - recent febrile illness rash fatigue, PE nl, EKG ectopy, nl sinus tach, cardiac MRI

Red flags of syncope - exertional (not after the exertion), family hx, cp, palpitations, syncope, brought on by sudden loud noise, febrile illness, abrupt syncope, <10 years

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Pediatric M&M - Dr. Mofield

10/31/2013

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Case 1 - Bloody Diaper in the Neonate

Common causes of BRBPR in kids

1. Ingested maternal blood
2. Necrotizing enterocolitis
3. Milk protein allergies
4. Anal fissure

Key learning points

1. Hgb nadir at 6-8 weeks in full term down to 9g, premies drop faster and farther, 7g by about 3-4 weeks
2. Reassess potentially sick frequently
3. NEC is possible in full term, keep it in your differential!

Nec info:
Mortality 15-30%.
Pathophys: intestinal immaturity and over active immune response
Generally affects preterm infants, but not uncommon and increasing in frequency in full term infants

Case 2 - 14 month old cold, seizing baby

History of an Takayasu arteritis and new seizures. ICH seen on CT

Takayasu Arteritis

Most commonly involved vessel

Aorta
Renal
Large arteries

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Hips - Dr. Bates

10/31/2013

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Ouch!!

Key ligaments

Anterior and Posterior SI ligaments - Think about them with or without fractures if SI joint widened

Key Arteries

Superior and inferior gluteal
Venous > arterial in common cause of blood loss

Fracture Classification - Young-Burgess

Lateral Compression (LC) - Think about associated head injury and intrabdominal injuries:Three grades of severity with increasing internal rotation.

Lc1 - fracture of rami.
LC 2 - iliac wing fracture plus rami fracture.
LC3 - external rotation of contralateral pelvis.

Anterior Posterior Compression (APC) - More likely to bleed severely; external rotation of hemi pelvis around sacrum. Diastasis of pubic symphysis should be <2.5cm.

APC1 - pubic symphysis gap- lig stretched, not torn, less than 2.5 cm diastasis SI
AP2 - open book pelvis, anterior SI ligament rupture, pub symphysis widening
APC3 - complete separation of ilium from sacrum - need binder, require massive resusc. Apply to greater trochanter. Knotted sheet can cause pressure ulcers so should only be temporary.

Vertical Shear

Pelvic ring injuries

Severe injury
Anatomy- ilium, ischium, pubis, symphysis less than 5 cm, SI

Physical- leg rotation, instability, degloving, limb shortening, look for open injuries- look in vagina and perineum\
Damaged visceral anatomy- bladder, urethra rectum

Radiographs- signs of instability- si too wide, post frx gap, leg deformity

AP- high yield, for immediate mgt, coccyx directly over pubis
Inlet- anterior or posterior displacement of ilium/pub rami frx
Outlet- sacral frx, superioir displacement of hemipelvis
CT- posterior injury, visceral or vascular injury, Good for operative planning.
Judet- acetabulum frx

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Management of Otalgia - Dr. Hoover

10/24/2013

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Acute Otitis Externa

Key is topical therapy (antiseptic such as vinegar/rubbing alcohol is just as effective as topical antimicrobials).

Use Ciprodex as it provides more rapid pain relief but is expensive. Otherwise, use Floxin as it's half the cost.
Neomycin is ototoxic (whether it's in a solution or suspension)

Place an otic wick if the canal is swollen shut after removing canal debris.
Only give oral antibiotics if patient is diabetic/immunocompromised or infection extends beyond EAC.
Malignant otitis externa is really temporal bone osteomyelitis

Cerumen Impaction Options

Do nothing,
Colace,
Hydrogen peroxide,
Irrigation

Foreign Body Removal

Positioning - restrain the patient if necessary
Lighting
Have the right instruments

Acute Otitis Media

Acute otitis media - pain & hearing loss
Otitis Media with Effusion - pressure & hearing loss
Bulging of the TM is the best predictor of bacterial infection
Translucent, pearly grey - normal ear

Treatment for AOM

Do nothing (80% get better on their own)
Amoxicillin (adults: 875 mg BID, kids: 90 mg/kg/day divided BID; consider 3rd gen cephalosporin or azithromycin if pen-allergic)

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Patient Satisfaction - Dr. Sullivan

10/24/2013

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Basic Tips

Treat patients as you would want your family members treated.
Keep patients informed about your plan and the potential pathways it may lead to.
Give patients as much information up front as possible. Being in the dark, uninformed, makes time go even slower and is very frustrating.
Be honest at all times.
Smile. Seriously... positive energy is just as infectious as negative energy, but is supportive rather than destructive.
Sit down. It makes your time in the room feel longer. You will also be perceived as being more attentive.
Manage people up, including yourself!

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M&M - Dr. Bronner

10/24/2013

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CMCEDMasters Master

Acquired Long QT

Drug list is long - most with K+ channel blockade, quinolones, methadone, TCAs, Amiodarone
Becareful with Antibiotic choice in patients with either QTc prolongation and/or underlying structural heart disease. Macrolids and Quiniolones are worse. Moxi > Levo > Cipro.
Treat by repleting lytes (K, Ca, Mg) then electrical overdrive pacing versus chemical overdrive pacing (isoproterenol).

Bad Trauma Airway (Cricothyroidotomy, Traumatic Brain Injury

Supraglottic devices are underutilized. Don't forget about iLMA and King LT in patient who is difficult to bag.
Percutaneous cric kits are not ideal in patients with large necks and poor landmarks.
In TBI, important steps in the ED are to avoid hypoxia and avoid hypotension. Mortality is doubled with a single time SBP <90!

Occult Hip Fracture

Plain films are 90% sensitive for hip fractures
Suspect in patients with new weight bearing status i.e., if can't walk and previously could, get advanced imaging.
If plain films negative and unable to walk, obtain further imaging CT vs. MRI

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Pediatric Headache - Dr. Pinzon

10/24/2013

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Basics

Viral illness- most common cause HA in pediatrics, followed by migraines
"Bad" Causes of HA- meningitis, encephalitis, orbital, cerebral abscess, infection, tumor

Bacterial meningitis- fever, HA, irritable, lethargic, AMS, meningeal (late finding)
Viral encephalitis- progressive symptoms, HSV, recent travel, immunocompromised, hallucinations
Orbital, cerebral abscess- right to left shunt/immunocompromised RF

Some Concerning History?

Occipital HA - worrisome
Tumor - HA, NV, visual disturbance, ataxia, wake from sleep
Intracranial hemorrhage - vomiting, seizures, hemiparesis

Migraine

2nd most common cause of HA in kids - absence of aura, photophobia less likely, bilateral, shorter duration, family history
Hx - pattern of previous, behavioral change, environmental exposure,
PE - VS, HEENT, dental, skin, neuro, fundoscopic exam

Consider Imaging for:

chronic progressive, worst HA, abnormal neuro, skin findings

Treatments for benign HA

ibuprofen, Tylenol, Antiemetics, Triptans, sumatriptans,
Cocktail- ibuprofen + phenergan or compazine,+ Benadryl + caffeine, IVF

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STRESS TESTING - Dr. Dahlquist

10/10/2013

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Dr. Dahlquist

1. Sensitivity and specificity of treadmill, echo, and myocardial perfusion stress testing:

* Treadmill Sn: 68%, Sp 77%.
* Dobutamine Stress Echo: Sn 81%, Sp 80%.
* Myocardial Perfusion: Sn 87%, Sp 73%.

2. 50% of the plaques that rupture and cause AMI/ACS are <50% stenoses, and are generally not detected on stress testing. A NEGATIVE STRESS TEST DOES NOT RULE OUT ACS!

* For this reason, if the clinical history is concerning, no prior stress test should be reassuring, regardless of how recent.

3. AHA recommendations on stress testing are based on "very limited" evidence. Particular populations where utility is limited:

* Patients <40 years old.
* Patients with recent (last 14 days) cocaine use. Journal of EM 2004 (Littmann) - All stress tests were positive, but all of their caths were normal. Deemed false positive stress test for up to 2 weeks.

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CHEST PAIN - Dr. Garvey

10/10/2013

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Master of Code STEMI

Some Thoughts to Keep in Mind

Cardiovascular dz is age dependent
Diagnostic algorithm depends on age and history of known CAD
Erlanger protocol: all comers tested over 2 hrs, troponin and ckmb monitoring, EKG, clinical eval, serial rechecks...with troponin, if you go from normal to indeterminate on your delta trop that could be concerning and shouldn't be ignored.
No longer use ckmb testing
Do yourself a favor and get serial troponins -- a single troponin is potential useful after 6hrs, but often our patient population cannot tell you when the pain stopped accurately.

No two troponin I assays that have the same absolute values or cut off points -- a fundamental flaw to keep in mind

Using our Pretest Probability Calculator? You need n= 20-25 for it to be valid. Use it and document in your chart.

Calcium Score

A Score of ZERO is helpful.
All other scores (even 0.1) is not helpful.
A Scote of Zero is "durable" for ~ 4 years

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M&M - Dr. Zahn

10/10/2013

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Dr. Zahn - The Zahn-inator

CASE 1 - Pupura, Diffuse Lymphadenopathy, Fatigue, Arthralgia, 20lb weight Loss.

DDx: HUGE and includes: HIV/AIDs, syphilis, tick borne disease, endocarditis, meningococcemia, thrombocytopenia

Core Concept: LUPUS

Rheumatology patients are complicated with multiple organ systems usually involved.
Must consider side effects of medications including but not limited to immunosuppression.
Anti-dsDNA and smith Ab are more specific than ANA
SLE: Check CBC, UA, CMP. Pleural and pericardial effusions require admission. Low dose prednisone taper if stable. Leave autoimmune markers to inpatient team.

CASE 2 - 55yo with n/v/d after eating fast food. Hx of previous CVA, TIAs, and Mitral Valve Repair. Is this Acute Gastroenteritis?

Nope - Imaging: right vertebral artery occlusion with posterior CVA.

Core Concepts: Posterior CVA

Posterior circulation strokes are exceedingly difficult to diagnose.
The 5 D's: Dizzy, Diplopia, Dysarthria, Dysmetria
Keep a high degree of suspicion in order to not miss subtle presentations.
Keep vertebral artery dissection on the differential in young patients.
CT has extremely poor sensitivity in the diagnosis of posterior fossa lesions.
MRI much better test yet can miss early presentations. HINTS testing likely useful yet never studied when performed by EM providers.
And... BE AWARE OF INTRACTABLE VOMITING

CASE 3 - Teenager with complains of persistent shoulder pain, Normal x-rays, Tachycardic. Later found to have Hypoxia!
Initially he looked well... then he didn't. Found to have CA-MRSA subperiosteal abscess.

Core Concepts - CA-MRSA

Increasing incidence of CA-MRSA in previously healthy pediatric populations.
Majority of these are soft tissue infections that result in significant morbidity and mortality.
Keep a high degree of suspicion in patients with a possible source and any abnormality of vital signs.
Vancomycin needs to be given early.
Patients with systemic illness often will have co-existing DVT near site of infection and high likelihood of septic emboli.

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<<Previous

Pediatric Altered Mental Status - Dr. MacNeill

Pediatric M&M - Dr. Mofield

Hips - Dr. Bates

Management of Otalgia - Dr. Hoover

Patient Satisfaction - Dr. Sullivan

M&M - Dr. Bronner

Pediatric Headache - Dr. Pinzon

STRESS TESTING - Dr. Dahlquist

CHEST PAIN - Dr. Garvey

M&M - Dr. Zahn

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