Carolinas Emergency Medicine Residency

Runs of Wide-Complex Tachycardia on Telemetry - Dr. Littmann

11/12/2015

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Differential Diagnosis

SVT with aberrancy (SVT with RBBB or SVT with LBBB)
Nonsustained VT
Artifact
Uncertain (“I don’t know”) – this is a better choice than incorrect guessing!

When the intrinsic rhythm is sinus:
I. What was the first beat of the tachycardia?

If the first early beat was a PAC (premature P wave in front of the QRS) -> SVT
If the first early beat was a PVC (no premature P wave in front of the QRS) -> VT

II. What is the P-QRS relationship?

A-V dissociation present -> VT
More QRS complexes than P waves -> VT

III. Fusion complexes present? -> VT

Combination QRS morphology (QRS wider than during sinus but narrower than the widest QRS)
P waves must be present in front of the combination morphology QRS complexes

When the intrinsic rhythm is atrial fibrillation:

If the WCT is regular -> VT

Artifact
Always consider artifact if:

It is uncertain which was the first or the last beat of the WCT
The rate of the tachycardia was excessive
The patient remained asymptomatic during a long run of a very fast tachycardia

Prove artifact by demonstrating that the

Intrinsic QRS complexes march through
“Notches” march through
Simultaneous hemodynamic tracing indicates regularity

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Osteomyelitis in Kids - Dr. Smith

11/12/2015

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1. Osteomyelitis can be difficult to detect in the ED so always maintain a high suspicion for it in children with refusal to bear weight or persistent pain in a long bone.

2. Bloodwork rarely helps diagnose osteomyelitis, but can be reassuring if normal and you have low suspicion.

3. X-rays help rule-out other causes of pain such as fracture but more definitive imaging (i.e. MRI vs bone scan) are usually needed to diagnose.

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Carolinas Case COnference - Dr. Robertson

11/12/2015

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Steven-Johnsons Syndrome:
- Diffuse, PAINFUL rash after viral prodrome, mucocutaneous lesions
- Severity described by percentage of bulous lesions: SJS at < 10% coverage (10% mortality) vs. TEN at > 30% coverage (30% mortality)
- Treatment: stop offending agent, IVF, supportive care, consider steroids

DVT Negative PE:
- Consider follow-up US in clinically appropriate population of negative lower extremity US.
- In PEA of unknown origin remember Goal Directed Echo to evaluate for PE: RV enlargement, poor RV function, flat or leftward bowing septum.

CODE COOL Update:
- Improvement needed with early vasopressor therapy. Early, aggressive Norepi use for MAP < 70.
- When cooling remember 15 ice packs, cold fluids at 30ml/kg and paralytics.

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Describing Derm like a Pro - Dr. Lawson

11/12/2015

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1. A systematic approach to describing rashes should include the following:
   - Identification of primary lesion type with or without secondary changes;
- Lesion color;
- Lesion shape/pattern;
- Lesion distribution

2. Red flag history/exam features, suggestive of life threatening rash, include:
   - Fever/hypotension,
- Immunocompromised status,
   - Extremes of age,
- Petechiae/purpura,
   - Mucosal involvement,
- Diffuse erythroderma

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Carolinas Ped EM Case Conference - Dr. Magill

11/6/2015

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Family Presence During a Code

Families want to be given the choice to be present.
Most like to be present and feel they comfort the child and that witnessing the resuscitative efforts help with the grieving process.
Designate someone assigned to parent, not helping with code, to explain everything to parent.
Be gentle, but concrete in telling what is happening. No sugar-coating.
“Your child is dead and we are doing everything we can to reverse that, but his/her heart is not beating and has not been since he/she arrived here.”

If a parent becomes irate:

Remain calm. Their reaction is normal denial/anger.
It is not personal.
Just ensure they are not harming medical staff.
Empathize for their unimaginable loss and support.

Cardiac syncope

Anomalous Left Coronary from the Aorta

                                               i.     0.6% of general population (72M children in US = 445K cases)
                                             ii.     Normal EKG and Physical exam
                                            iii.     Unlike ALCAPA where the EKG and PE will be abnormal from chronic ischemia
                                            iv.     Diagnosed in older children and teens
                                              v.    Usually presents with exertional syncope
                                            vi.     Needs PEDIATRIC cardiology referral

Exertional syncope is cardiac until proven otherwise!

Always check EKG
Needs thorough physical exam
Does not need stat cardiology consult at 3am, but does need good follow up and referral to peds cardiology clinic for echo.
Activity restrictions until cleared by cardiology.

Pediatric CPR

Compressions 100/minute for infants and children
Breaths every 3-5 seconds- don’t overventilate
Weight and dosing from Broselow tape
Defib 2 J/kg, then 4 J/kg, then 4 J/kg….

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Naloxone and Street Drugs - Dr. Murphy

11/5/2015

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Naloxone:

Think about having a discussion regarding use of IM/IN naloxone and the availability of kits with our high risk patients or their families – if they have a ton of opioid/opiate prescriptions on the prescription monitoring database, they are high risk.
Other groups: sickle cell, cancer patients, chronic pain, fibromyalgia, elderly patients on opioids/opiates, heroin overdose patients. Think about offering this to parents of pediatric patients with sickle cell disease and other young children in the home.

Kits are $32.29 at the Walgreens across from CMC University and you can walk in without a prescription and get a kit from the pharmacy.
Great resources available at the NC Harm Reduction Coalition and Project Lazarus websites.
There are many good You tube videos demonstrating use out there.

Cocaine:

Most cocaine in US adulterated with levamisole.
Agranulocytosis can occur in patients exposed to levamisole repeatedly leading to immune compromise or more serious infections.

Heroin:

Be on the look out for clostridial infections in patients using IV or skin popping.
Consider asking this sub group of patients about tetanus status at they are at increased risk for developing tetanus.
Be wary of patients with heavy eyelids, complaints of dysphagia and dysphonia who use IV/subcutaneous heroin as they are at risk for developing wound botulism – a clinical diagnosis.
Treatment of wound botulism is more involved than infant botulism – patients need wound debridement, antibiotics AND antitoxin.

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Steroids for Shock - Dr. Thacker

11/5/2015

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Consider administration of steroids in patients with shock that is unresponsive to appropriate IV fluid resuscitation and vasopressors.

Consider adrenal crisis in any patient who has risk factors (particularly chronic steroids), an acute stressor, and vague systemic symptoms.

Hydrocortisone is the steroid of choice in patients with adrenal insufficiency given it’s glucocorticoid and mineralocorticoid action.

Etomidate has not been shown to cause clinically significant adrenal suppression. Use it for RSI in any appropriate clinical setting.

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Runs of Wide-Complex Tachycardia on Telemetry - Dr. Littmann

Osteomyelitis in Kids - Dr. Smith

Carolinas Case COnference - Dr. Robertson

Describing Derm like a Pro - Dr. Lawson

Carolinas Ped EM Case Conference - Dr. Magill

Naloxone and Street Drugs - Dr. Murphy

Steroids for Shock - Dr. Thacker

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