Carolinas Emergency Medicine Residency - CMC COMPENDIUM

Upper GI Bleed in Pediatrics - Dr. Walker

6/8/2017

1. Signs and symptoms of an Upper GI bleed in the pediatric patient
-most common presentation is hematemesis
-melena also common presentation
-many things mimic GI bleed -> food coloring, raw meats, swallowed blood from oropharynx

2. Differential diagnosis for acute pediatric upper GI bleed
-determine if variceal vs nonvariceal
-variceal bleed (uncommon but can be life threatening)-> portal HTN from congenital liver pathologies
-mucosal bleed -> gastritis, esophagitis, caustic ingestion, foreign body most common in pediatrics

3. ED diagnostic workup for an upper GI bleed in a pediatric patient
-CBC, BMP, LFT's, and Type/Cross essential to the workup

4. ED Management of Pediatric Upper GI bleed patient
-Place an NG tube
-Get GI, Surgery, and Interventional Radiology Involved early
-Octreotide and vasopressin are important treatments for variceal bleed
-For mucosal bleeds control acid production

Scary Neonate Case COnference - Dr. Bryant

4/20/2017

- Neonate in respiratory distress: remember NRP!
- Neonate in respiratory distress with true unilateral absent breath sounds = Congenital Diaphragmatic Hernia??!!-> confirm with CXR

Congenital Diaphragmatic Hernia (CDH)
- Neonates likely have high risk for pulmonary hypertension!
- Do not give PPV -> worsens GI distention/lung compression = worsening pulmonary HTN
- In neonates intubate early to prevent hypoxia (hypoxia worsens pulmonary HTN) with low pressure vent settings
- Maintain systemic BP to reduce right to left shunting
- Older children with CDH, less likely to have significant pulmonary HTN, keep calm and try to avoid intubation

- Persistent/worsening cyanotic neonate - think cyanotic congenital heart defect -> Start Prostaglandins
- Remember Prostaglandins cause apnea, will likely need intubation
- Neonate in extremis = call for back-up early!

June 02nd, 2016

6/2/2016

URIs are common in children... acute sinusitis is not. Approximately 6-8% of children with URI symptoms meet criteria for acute bacterial sinusitis

Diagnostic criteria for acute bacterial sinusitis have been revised in the last few years. There are three clinical courses that constitute a diagnosis acute bacterial sinusitis...

- persistent symptoms without improvement
- severe onset of symptoms
- worsening clinical course

So that means, we don't diagnose sinusitis in children with imaging studies.
However, if you are worried about orbital or CNS involvement, it is recommended to evaluate with contrast CT or MRI.
It is most often caused by S. pneumoniae, H. influenzae, and M. catarrhalis. S. aureushas not been identified as a major etiology.

Antibiotic treatment should take into account S. pneumoniae resistance patterns and beta lactamase production of H. influenzae and M. catarrhalis - high dose amoxicillin (90mg/kg/day BID) or Augmentin (90mg amoxicillin/kg/day BID) are first line choices.

Pediatric Case COnference - Dr. Lawson

4/26/2016

Abdominal Pain of Unusual Cause
Abdominal pain in children is not always AGE, appendicitis, or UTI - keep your differential broad and use your exam skills (including GU and Tanner staging)
"Smokiness" on ultrasound may be due to blood (RBCs scattering sound waves) or stasis
Hematocolpos as a result of imperforate hymen can cause abdominal pain and urinary retention

PE vs Sepsis
PE is a rare occurrence in children and often presents atypically (classic symptoms often only present in large PEs)
Adult clinical decision rules (Wells Criteria and PERC) do not reliably apply to children
Obesity, OCP use, and previous thrombus (not PE) are the three leading risk factors for PE
History of central venous line is the most important predisposing cause of DVT
Several studies other than CTA can help lessen your suspicion for PE (CXR, EKG, cardiac echo, extremity DVT US, BNP, troponin)

Sepsis in children can be subtle and precipitous

Pediatric ECGs - Dr. Bryant

4/21/2016

Normal Peds EKG Variations
- Right heart dominance
  - From infancy to adulthood ventricular dominance transitions from a relatively thicker RV in utero/infancy to thicker LV as adults
  - Right axis deviation
  - Tall R waves in V1-V3
  - RSR' in V1
  - Deep S waves and Q waves in lateral leads
  - Juvenile T wave pattern in V1-V3
- Small cardiac size = shorter intervals, faster rate
- J-point depression
- Early repolarization
- Sinus arrhythmia

NOT Normal Peds EKG Variations
- Brugada Syndrome
  - EKG: Leads V1-V3
    - RSR’ with ST elevation
  - 3 Types
    - Type 1 – coved
      - Diagnostic
    - Type 2/3 – saddle-back
- Arrhythmogenic Right Ventricular Dysplasia (ARVD)
  - EKG: Leads V1-V3
    - Epsilon waves
    - Inverted T waves
- Catecholaminergic Paroxysmal Ventricular Tachycardia (CPVT)
  - EKG:
    - Normal baseline, bidirectional QRS polymorphic Vtach with exertion/excitement
- Hypertrophic Obstructive Cardiomyopathy (HOCM)
  - EKG: Lateral leads
    - Dagger-like deep narrow Q waves
    - Deep narrow T wave inversions
    - +/- LVH, left axis deviation
- Wolff-Parkinson-White (WPW)
  - EKG:
    - Delta waves
    - Wide QRS
    - Short PQ segment
- Anomalous Left Coronary Artery from the Pulmonary Artery (ALCAPA)
  - EKG:
    - Anterolateral ischemic changes
    - Lateral leads
      - Deep wide Q waves
      - T wave inversions
- Long QT Syndrome
  - EKG:
    - QTc > 450ms
    - At risk for Torsade de Pointes/Vtach

Pediatric Syncope - Dr. Bryant

4/21/2016

Pediatric Syncope Algorithm

VP Shunts - Dr. Angela Johnson

2/18/2016

Be suspicious of shunt problems in …. Kids with shunts
HA, nausea, vomiting, irritability, behavior change are the weaker predictors you may miss if not vigilant
Malfunction common early, but eventually almost ALL get revised
Infection most common in first six months
Look at your own images!
Not stable – Call NSGY and consider tap

Pediatric Airway - Dr. Goode

2/11/2016

• The pediatric airway has known unique challenges. Prepare yourself physically and cognitively!

• Maintain spontaneous ventilation if there is any doubt about obtaining successful advanced airway.

• Practice using airway equipment when you don't need it, so you are ready when you do need it.

CMC Case COnference - Dr. West

12/10/2015

Septic arthritis of the hip
-Most common hematongenous spread
- Up to 20% of patients with non-gonococcal septic arthritis will have 2 or more joints involved –> always do a full musculoskeletal exam!
- 50% will have positive blood cultures –> always obtain cultures.
- Risk factors: Extremes of age, hardware/recent instrumentation, skin infection, underlying arthritis, IV drug use
- You cannot rule out septic arthritis with inflammatory markers or any physical exam findings, so err on the side of obtaining joint fluid.

Pediatric septic arthritis vs. transient synovitis
- Kocher criteria can help differentiate: Temperature >38.5, WBC >12K, ESR >40, unable to bear weight.

0/4: <0.2%, 1/4: 3%, 2/4: 40%, ¾: 93%, 4/4: 99.6
Note: this was a retrospective study and external validation studies did not perform as well.
Can not be used if patient recently on antibiotics.

- There is a MSK screening MRI protocol if you are concerned about LE deep space infection but having difficulty localizing the joint

Contrast Extravasation

Monitor area for signs of compartment syndrome or airway compromise (depending on location)
Complications rare now that we routinely use low-osmolar nonionic contrast

Spontaneous Pneumomediastnum

Under recognized cause of chest pain
Similar risk factors as spontaneous pneumothorax (asthma, tall, thin, valsalva, intense sporting activities)
Alveolar ruptures into surrounding bronchovascular sheath and free air tracks into mediastinum
Rarely causes tension physiology
If history concerning for esophageal pathology, consider CT esophagram
Treat conservatively by avoiding valsalva and barotrauma

TEAM Case: Ped Status Epilepticus - Dr. Magill

12/3/2015

Define status epilepticus:

>5 min seizure- impending status epilepticus
>30 min- established SE
>60 min- refractory SE

Consider etiologies:

Trauma/bleed
AVM Malformation
Febrile seizures
Infection
Tumor
Subtherapeutic meds
Lowered threshold with infection
Stroke
Cardiac/arrhythmia
Hypertensive Crisis
Pyridoxine deficiency/INH overdose
NMDA receptor Ab
FIRES

Remember ABCs and supportive care in addition to treating seizures

Learn dosing for hypoglycemic seizure with dextrose

Rule of 50's

Learn dosing for hyponatremia seizure with 3% NaCl

Medications
First line:

Midazolam 0.15 mg/kg IV, 0.3 mg/kg buccal
Lorazepam 0.05-0.1 mg/kg IV, max 4 mg/dose rpt x 1
Diazepam 0.05-0.3 mg/kg IV, 0.5 mg/kg PR, max 5 mg

Second line:

Fospheny load 15-20 mg/kg IV
Levetiracetam load 15-20 mg/kg IV
Valproate load 20-40 mg/kg IV

Refractory/Third line:

Phenobarb load 20 mg/kg IV, 1 mg/kg/min
Pentobarb 5 mg/kg load
Propofol 2.5-3.5 mg/kg IV, rate 0.1-0.3 mg/kg/min
Ketamine 0.5-2 mg/kg IV, rate 5-20 mcg/kg/min
Pyridoxine 70 mg/kg max 5g, repeat as needed