1) Not all vomiting in the Peds ED is gastroenteritis! Consider trauma, metabolic, foreign body, etc..
2) Always do your own history and exam; never assume that previous providers thought of everything.
3) Must be cognizant of abuse across the spectrum of patients that present to the CED, and know risk factors and red flags
Case Conference - Dr. Lawson
1. Leukemia is the most common form of childhood cancer (30% of all pediatric malignancies)
2. Presenting symptoms for acute leukemia are typically non-specific and the WBC is usually normal! Have a high degree of suspicion.
3. Red flags include: unexplained fever, multiple cytopenias, hepatosplenomegaly, petechiae/purples, easy bleeding, lymphadenopathy.
4. Risk factors for medical error in the ED: Night shift, handoff, high volume times with many interruptions, "difficult" patient
5. Recall specific cognitive error types:
A. Premature closure
B. Confirmation bias
C. Order effect
1. Primary injury - overpressure from blast waves
- air-containing organs most susceptible to injury
- damage to lungs (pulmonary blast injury) most common injury to immediate survivors
2. Secondary injury - from projectiles
3. Tertiary injury - victim thrown against wall, etc
4. Other injuries - burns, smoke inhalation, delayed complication
- same as any other mass casualty event (START)
- danger to first responders from secondary blast, building collapse
- most immediate survivors will not have life threatening injury, but triage is challenging
- close monitoring and thorough evaluation for development of pulmonary blast injury
- positive pressure ventilation and air transport increase risk for developing air embolism
- nearly all patients with PBI will also have ruptured TMs
- empiric antibiotics for all patients with soft tissue injury or if concerned for intraabdominal injury
Trauma Cases Core Concepts - Dr. Gibbs
1. Only 10% of injured patients are initially managed at regional Trauma Centers
2. Community hospital emergency physicians play a pivotal role in the management of acute injury
3. Over-testing before transfer may cause hazardous delays in care
4. Adult and children who suffer blunt traumatic arrest are almost always dead
5. Contact trauma with cases that may be transferred solely for organ donation - we almost always take these
6. Action steps to take BEFORE transfer include: (a) airway management, (b) treatment of pneumothorax, (c) repair of actively bleeding lacerations, (d) basic resuscitation, (e) reversal of anticoagulation, (f) splinting of extremities
7. Avoid long-acting paralytics in TBI during transfer - this will compromise the exam
There are two phases to the development and presentation of a "memorable lecture": (1) preparation, (2) delivery.
Elements of PREPARATION include:
a. Picking the right topic
b. Mastering the material
c. Sequencing the lecture
d. Right-sizing the content
e. Designing slides that work
Elements of DELIVERY include:
a. Getting ready for the big day
b. Learning your audience
c. Developing your delivery style
d. Tie everything together
e. Planning for next time
• Give epinephrine early and in the correct dose for anaphylaxis
• Be prepared for the difficult airway in all cases of severe anaphylaxis
• There are no contra-indications to epinephrine when it comes to severe anaphylaxis.
• Consider anaphylaxis in every patient who presents in shock, because anaphylaxis can rarely present with isolated hypotension
Lipid Rescue - Dr. Kerns
Case CONFERENCE - Dr. Lounsbury
• PID is a common disease amongst young women and has a wide variety of clinical presentations
• PID is a rare but known cause of small bowel obstruction in adolescents
• Beware the sterile pyuria
• Errors in the emergency department are multifaceted and fall into three domains: cognitive, environmental, and systems errors
• Most cognitive errors are caused by use of heuristics (cognitive shortcuts)
• There are steps to mitigating cognitive error: baseline knowledge of cognitive errors, attempt to disconfirm, and cognitive stops.