Carolinas Emergency Medicine Residency

TEAM Conference: Ped Hip - Dr. Smith

10/22/2015

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Always think hip in a young child with knee pain
Prompt evaluation and orthopedic consultation imperative with septic hip
Do not delay antibiotics after joint/blood cultures obtained
Hip pain in a neonate or infant is septic hip until proven otherwise

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Delivery Complications - Dr. Lounsbury

10/22/2015

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Uncommonly encountered however critical to manage
Always Type & Cross, difficult to predict complications
Stage 2 complications include
- Shoulder Dystocia- difficult to predict and morbid. Consider HELPERR mnemonic and know maneuvers
- Umbilical cord prolapse- Elevate fetal parts, tocolysis, and wait for OB
- Uterine rupture- identify by acute pain, vaginal bleeding, and loss of station, wait for OB
- Malpresentation- Best plan is tocolysis and wait for OB. If delivery is unavoidable, delivery is presentation-dependent
Stage 3 complications include
- PPH- 4T’s (tone, trauma, tissue, and thrombin). Stepwise approach and know rescue measures
- Uterine inversion- replace it early

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Cervical Artery Dissection - Dr. Asimos

10/22/2015

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1. Remember to consider spontaneous cervical artery dissection in the differential diagnosis of a headache patient.

2. The majority of patients who develop an spontaneous cervical artery dissection will not develop a stroke.

3. Cerebral ischemia caused by cervical dissection is usually embolic rather than hemodynamic compromise caused by dissection-related stenosis or occlusion.

4. Stroke prevention is with antiplatelet or anticoagulant therapy, with no data supporting improved outcomes with either therapy compared to the other.

5. Endovascular therapy is increasingly being used in the acute treatment of stroke related to spontaneous cervical artery dissection.

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Atypical Pediatric Seizures - Dr. Magill

10/15/2015

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Simple Partial
- Sensory (aura)
- Brief motor
Complex Partial
Secondary Generalized
Juvenile Atypical Seizures
- BECTS- benign childhood epilepsy with centrotemporal spikes
  - Aka Benign Rolandic Epilepsy
- Nocturnal Autosomal Dominant Frontal Lobe Epilepsy
- Landau Kleffner
- Absence
- Juvenile Myoclonic Epilepsy
- Gelastic Seizures
- Frontal Lobe Seizures
- Benign Infantile Familial Convulsion Syndromes
- Myoclonic Seizures
- Infantile Spasms (West Syndrome)
  - And another
Neonatal Seizures
- Immature brain more excitable
  - Subtle
  - Clonic
  - Tonic
  - Spasms
  - Myoclonic
- Seizures vs Jitters
- Drug Withdrawal Seizures
- Benign Idiopathic Neonatal Seizures
- Benign Familial Neonatal Seizures
- Early Myoclonic Encephalopathy (Ohtahara)
The Great Mimickers
- Apnea
- Breath Holding Spell
- Hyperekplexia
- Vasovagal syncope
- Vagovagal syncope
- Cardiac syncope- Long QT syndrome
- Familial Hemiplegic Migraine
- Migraine Induced Syncope
- Psychogenic nonepileptic seizures
- Torticollis
- Sandifer syndrome

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HELLP - Dr. Yavorcik

10/15/2015

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HELLP
- >20 weeks pregnancy with RUQ/epigastric pain, HTN
- Elevated AST/ALT, Low Platelets on CBC/COMP - should trigger diagnosis
- reflex order smear, OB consultation, Heme/Onc consultation
- Fear the Glucose - often neglected portion of HELLP syndrome since it didn't make the cut for the acronym.
- Don’t forget about other causes of abdominal pain, other heme syndromes

- Magnesium sulfate for treatment, Labetalol for blood pressure control, +/- Dexamethasone depending on fetal age

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Carolinas Case COnference - Dr. West

10/15/2015

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Placental Abruption

Suspect in blunt abdominal trauma
Clinical diagnosis – suspect with vaginal bleeding (though 20% don’t have bleeding), abdominal/back pain, fetal distress. US is only 25-50% sensitive – 88% PPV.
If signs of fetal distress or maternal hemodynamic instability, management is delivery
Complication include Rh alloimmunization and DIC

Gangrenous Cholecystitis

Increased pressure in gallbladder causes impaired gallbladder wall perfusion and progresses to gangrene
Up to 2/3 will not have a Murphy’s sign due to denervation of the gallbladder
Suspect in older patients, leukocytosis >17K, and comorbidities (CAD, DM)
22% mortality
Surgical emergency

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Ped EM Case Conference - Dr. Smith

10/9/2015

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1. Children have fantastic physiologic reserve but will fall off the cliff quick if illness is under appreciated.
2. Listen to parents - even if they are being too persistent, they know their children better than anyone
3. If you think a patient needs a test because you are concerned they have a significant illness, be persistent and willing to make go do what is in the patient's best interest (even if you have to call in specialists from their cozy homes).
4. Always be wary of questionable vaginal bleeding in pregnancy - sometimes you get more than blood when you look.

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Ketamine: Not Just for Kids - Dr. Mollo

10/1/2015

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Consider Ketamine for:

Awake patients who need short, painful procedures
RSI in critically ill trauma/burn patients
DSI (delayed sequence intubation) in patient with asthma/poor reserve
Hysterical patients in pain
Dangerous, actively suicidal patients
Chronic pain patients with high opiate demands
Pre-hospital setting for pain

Consider administering zofran concomitantly (NNT=7), but do not prophylactically treat with benzos

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Carolinas Case Conference - Dr. Beverly

10/1/2015

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Cryptococcal Meningitis:

Opportunistic infection in HIV/AIDS patients
Symptoms can be vague but most commonly present with fever, neck stiffness, headache and altered mental status
Diagnosis is by lumbar puncture; if you are thinking about this, treat properly and treat fast
Mainstay of treatment is with Amphotericin B and Flucytosine

Ebstein's Anomaly:

Congenital malformation characterized by abnormalities of tricuspid valve and right ventricle
1 in 20,000 live births; No predilection for either gender
Chronic hypoxemia leads to changes in blood vessel function and structure
These changes are likely maladaptive and may increase risk for thrombotic events

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Child Abuse & Toxins - Dr. Beuhler

10/1/2015

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·         Consider poisoning when confronted with confusing clinical presentations

·         Always save and freeze initial urine from suspicious cases

·         “Munchausen’s by proxy” is now known as “Factitious disorder imposed on another” or “child abuse” and does not require exotic toxins.

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TEAM Conference: Ped Hip - Dr. Smith

Delivery Complications - Dr. Lounsbury

Cervical Artery Dissection - Dr. Asimos

Atypical Pediatric Seizures - Dr. Magill

HELLP - Dr. Yavorcik

Carolinas Case COnference - Dr. West

Ped EM Case Conference - Dr. Smith

Ketamine: Not Just for Kids - Dr. Mollo

Carolinas Case Conference - Dr. Beverly

Child Abuse & Toxins - Dr. Beuhler

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