1. Believe parents when they said their kid looks puffy.
2. If the chief complaint is swelling/puffiness, especially periorbital or dependent, get a Urinalysis (UA).
3. If UA is concerning for Nephrotic Syndrome (NS) (ie, heavy proteinuria), get Urine protein/Cr ratio, lipid panel, RFP and then call nephrology.
4. Fever in patients with NS is a serious bacterial infection until proven otherwise. Get blood and urine cultures and start empiric antibiotics.
5. Spontaneous Bacterial Peritonitis and thromboembolism are well known complications in patients with NS. You must have a high suspision for them to make the diagnosis.
6. Most of these children with require admission to the hospital.
- Pheochromocytoma is an extremely rare cause of hypertension, but diagnosing it can lead to curative surgery.
- Suspect the diagnosis in unusual cases of hypertension such as paroxysmal episodes, severe orthostatic hypotension, those with the Classic Triad of headache + diaphoresis + palpitations, cases of very resistant HTN, paradoxical hypertensive response to Beta-Blockers, unexplained shock from trauma or surgery, and HTN in the young.
- Make sure to get Plasma Free Metanephrines during an acute episode if you have clinical suspicion.
- Medical management in acute presentation should start with Phentolamine first, anticipate the need for fluid resuscitation from vasodilation, then addition of Esmolol or Labetalol only after alpha blockade. Can go to Nitroprusside if resistant. Lidocaine, Amiodarone, Metoprolol or Atenolol for continued tachydysrhythmias.
- Emergent surgery is associated with worse outcomes and should only be considered a last resort after all other medical management has failed.
- Patients need to be prepped for surgery with at least 3 weeks of PO alpha and beta blocker therapy.
• Higher risk of PE, post-thrombotic syndrome
• If low risk for bleed with an acute clot, consider catheter directed thrombolysis
• Consult vascular surgery and consider transfer if at an outside community ED
Coarctation of the Aorta
• Physical exam findings include:
- Signs of heart failure including respiratory distress, wet lungs, hepatomegaly
- Diminished pulses of lower extremities
• When seeing an infant in shock, THINK SEPSIS and remember your resuscitation pathways, but don't forget about the heart.
- Giving a dose of prostaglandin E will help you more often than hurt you
- Give fluids judiciously; give a bolus and reassess.
• Bedside echo can help you in extremes of cardiac function, but otherwise murky.
· None of the current short term risk stratification tools for TIA perform well enough to identify patients for outpatient versus pre-discharge work-up.
· Large artery atherosclerosis (usually carotid bifurcation stenosis) accounts for the largest proportion of early strokes after TIA.
· Based on the CHANCE trial, the combination of ASA/Clopidogrel urgently after TIA appears more beneficial than ASA alone, but this strategy remains unproven in US.
· Ambulatory or continuous cardiac telemetry for days to months after TIA or minor stroke detects A-Fib significantly more frequently than conventional A-Fib evaluation methods.
• The aquarium trade and modern travel have brought marine organism related ED visits inland.
• Consider covering any marine wound for Vibrio and skin flora with prophylactic antibiotics. Practice excellent wound care!
• Many marine toxins can be denatured with heat.
• Supportive care in severe envenomation means close observation for clinical improvement, these patients may require admission!
• Your Yellow Steam of Justice (urine) may not be the best idea following a marine envenomation, and may make things worse.
• Beware the blue ringed octopus, delightful as it may appear.
SPONTANEOUS CORONARY ARTERY DISSECTION
• SCAD is a rare cause of ACS-type chest pain, more often seen in younger, female, post-partum patients. Consider in cocaine and caffeine induced chest pain.
• PCI and thrombolytics less successful in SCAD, suffering from higher failure and complication rates, respectively. Medical management with beta blockers is mainstay of treatment.
SUPERIOR MESENTERIC ARTERY SYDROME
• SMA syndrome presents with recurrent post-prandial emesis and abdominal pain, usually in the setting of increased catabolic state, internal or external abdominal compression.
• Consider SMA syndrome in post-scoliosis patients given the relative lengthening of the spinal column that results in a decrease in the SMA/aorta angle, causing compression of the duodenum.
THORACIC AORTIC ANEURSYM DISSECTION
• Thoracic aortic aneurysm dissection/rupture is the deadliest complication of thoracic aortic aneurysmal disease. Operative decisions for aneurysms depends on clinical scenario, but generally adopted at ~5.5cm.
• Intubation in the critically ill patient should be done by the most experienced operator, with consideration for use of video laryngoscopy, given higher 1st pass success rates despite difficult airway characteristics.
A CAT PILES MUD
A - Acetaminophen
C - CO, CN
A - AKA, Starvation ketoacidosis
T - Toluene
P - Paraldehyde, phenformin, propylene glycol
I - Isoniazid, Iron, Ibuprofen, Ischemia
L - Lactate elevation
E - Ethanol, Ethylene glycol
S - Salicylates
M - Methanol, Metformin
U - Uremia
D – DKA