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Pediatric Altered Mental Status - Dr. MacNeill

10/31/2013

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PictureThere 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
  1. Transient - usually benign, common, think electricity and perfusion
  2. 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 -
  1. Outpt EEG and MRI only if EEG supports the need or syndrome
  2. Return to ED for sz in next 24hr, or last more than 5 min.
  3. 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
  1. 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
  2. Anomalous coronary arteries - 1/2 sx before death, syncope with exercise, nl EKG, ventric arrhythmia, dx by echo or CTA 
  3. Long QT syndrome - stress syncope,exercise, bradycardia, 1/3 will have nl EKG, 10% of healthy people have long QT
  4. 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
  5. Arrhythmogenic RV Dysplasia - autosomal dominant, RV myocardium deposition with fibrofatty tissue, widened QRS
  6. Catecholeminergic polymorphic VTACH - Rare, structurally normal, nl EKG, family hx
  7. 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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Picture
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
  1. Aorta
  2. Renal
  3. Large arteries

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Hips - Dr. Bates

10/31/2013

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PictureOuch!!
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.
  1. Lc1 - fracture of rami. 
  2. LC 2 - iliac wing fracture plus rami fracture.
  3. 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.
  1. APC1 - pubic symphysis gap- lig stretched, not torn, less than 2.5 cm diastasis SI
  2. AP2 - open book pelvis, anterior SI ligament rupture, pub symphysis widening
  3. 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
  1. AP- high yield, for immediate mgt, coccyx directly over pubis
  2. Inlet- anterior or posterior displacement of ilium/pub rami frx
  3. Outlet- sacral frx, superioir displacement of hemipelvis
  4. CT- posterior injury, visceral or vascular injury, Good for operative planning.
  5. Judet- acetabulum frx

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Management of Otalgia - Dr. Hoover

10/24/2013

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Picture
Acute Otitis Externa
  • Key is topical therapy (antiseptic such as vinegar/rubbing alcohol is just as effective as topical antimicrobials).
  1. Use Ciprodex as it provides more rapid pain relief but is expensive. Otherwise, use Floxin as it's half the cost.
  2. 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

  1. Do nothing,
  2. Colace,
  3. Hydrogen peroxide,
  4. Irrigation


Foreign Body Removal

  1. Positioning - restrain the patient if necessary
  2. Lighting
  3. 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
  1. Do nothing (80% get better on their own)
  2. 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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Picture
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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PictureCMCEDMasters 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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Picture
Basics
  • Viral illness- most common cause HA in pediatrics, followed by migraines
  • "Bad" Causes of HA- meningitis, encephalitis, orbital, cerebral abscess, infection, tumor
  1. Bacterial meningitis- fever, HA, irritable, lethargic, AMS, meningeal (late finding)
  2. Viral encephalitis- progressive symptoms, HSV, recent travel, immunocompromised, hallucinations
  3. 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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PictureDr. 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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PictureMaster 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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PictureDr. 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

  1. Rheumatology patients are complicated with multiple organ systems usually involved.
  2. Must consider side effects of medications including but not limited to immunosuppression.
  3. Anti-dsDNA and smith Ab are more specific than ANA
  4. 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

  1. Posterior circulation strokes are exceedingly difficult to diagnose. 
  2. The 5 D's: Dizzy, Diplopia, Dysarthria, Dysmetria
  3. Keep a high degree of suspicion in order to not miss subtle presentations.
  4. Keep vertebral artery dissection on the differential in young patients.
  5. CT has extremely poor sensitivity in the diagnosis of posterior fossa lesions.
  6. MRI much better test yet can miss early presentations. HINTS testing likely useful yet never studied when performed by EM providers.
  7. 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
  1. Increasing incidence of CA-MRSA in previously healthy pediatric populations.
  2. Majority of these are soft tissue infections that result in significant morbidity and mortality.
  3. Keep a high degree of suspicion in patients with a possible source and any abnormality of vital signs.
  4. Vancomycin needs to be given early.
  5. Patients with systemic illness often will have co-existing DVT near site of infection and high likelihood of septic emboli.
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