- Ultrasound has utility in almost all ED patients and should be a cornerstone of both diagnosis and aiding in resuscitation for a critically ill patient (don't forget to document your images!)
- Utilize peak flow to trend patient's burden of illness in asthma exacerbations.
- Consider single/two dose regimens of dexamethasone as a viable alternative to a 5-day course of prednisone/prednisolone.
- Think about myiasis in a non-healing papule/plaque/ulcer in a patient coming from a tropical area. Treatment is skin biopsy with removal of larvae.
I. Characteristics of respiratory artifact
II. The clinical significance of respiratory artifact
III. Respiratory artifact can aid in the recognition of sleep-disordered breathing
b. an abrupt increase in heart rate and the
c. simultaneous appearance of very fast RA
b. simultaneously occurring very long respiratory (snoring) artifact followed by
c. a sudden increase in the heart rate and resolution of the RA
b. the onset of most periods which contain the RAs show the characteristics of central sleep apnea
- broad spectrum of disease, high level of suspicion is essential
- myocarditis can mimic STEMI and Wellens syndrome among others
- EKG, echo, and cardiac enzymes cannot rule in/out the diagnosis
- No hesitation to consult Peds Cards
- no discrimination, occurs in all people groups
- history, exam, and physical findings may raise suspicion for abuse.
- must place child in gown.
- make sure story matches up... loose ends must be tied
Marfan and PTX:
- Must be personally knowledgeable about equipment associated with procedures (ie: suction device for chest tubes)
- Pigtail catheters equivalent to thoracostomy tubes for uncomplicated PTX with decreased pain - http://pedemmorsels.com/pigtail-catheter/
Thanks to Dr. Troha's diligent efforts, we will be initiating a new protocol to help streamline the decision making and coordination of care for patients with small PEs, Submassive PEs, and Massive PEs.
Step 1: Risk stratification
- Obtain BNP, troponin, perform echo and assess vitals
Step 2: If massive or submassive, call out Code PE. Pull Code PE pack that contains treatment algorithm and lysis checklist
Step 3: Administer heparin
Step 4: Assess bleeding risk using lysis checklist
Step 5: If decision is made to give IV lysis, stop heparin drip during infusion
Step 6: If decision is made to administer catheter-based lysis, contact interventionalist on call
1. Left to right - VSD, ASD, cushion defect, PDA
2. Cyanotic - truncus, transposition, total anomalous, tricuspid atresia, tetralogy
a. Cyanosis - decrease of deoxygenated hgb by 3-5 mg/dl
1. Shunting from lung
2. Mixing blue and red blood
3. Single ventricle
Break the left side of the heart (Hypoplastic left, aortic stenosis, coarct) --> hepatomegaly, gray, pulmonary edema, etc
Break the right side of the heart (hypoplastic right heart, tricupsid atresia, pulmonary atresia, tetrology of fallot) --> Blue, poor perfusion, acidosis
Not all ductal dependent lesions are cyanotic - AS, coarct
Not all cyanotic lesions are ductal dependent - truncus arteriosis, TAPR
a. Truncus Arteriosus -
Blue because they're mixing - mixing happens before duct, therefore not ductal dependent -
Pulmonary exam will vary;
You can give them O2 - won't worsen cyanosis but won't help
b. Transposition of Great Arteries -
Cyanotic because you have mixing blood;
If you find these later (ie, in the ED and not immediately after birth) these kids will all have VSD;
O2 wont help but wont hurt
c. Tricuspid Atresia -
Blue because not perfusing lungs; Right ventricle doesn't develop (Hypoplastic right heart)
Ductal dependent; only pulmonary artery flow will come through ductus from aorta
ECG will show LVH but only because right side isn't balancing it out
O2 will prob not help, but won't kill
d. Tetrology of Fallot -
Cyanotic because of decreased pulmonary perfusion and mixing -
O2 can help
e. Totally Anomalous Pulmonary Venous Return -
Cyanotic because of mixing
- 10 minutes of 100% O2 and see response > may help differentiate between pulmonary and cardiac etiology
* For cyanotic lesions oxygen is not going to kill - it just may not help*
* O2 can hurt you on left to right shunts*
Left to right shunts are usually dyspneic/hypoxic because they are over-perfusing the lungs and they get fluid overload.
Oxygen will cause vasodilitation of the pulmonary vessels and increase left to right shunting worsening the problem.
Prostaglandins - 0.05-0.1 mcg/kg/min > will cause apnea - tube the kid
Based on 2 concepts
- Increased hydrostatic pressure
- Decreased oncotic pressure
- Upright films will detect effusions >400mL
- Lateral decubitus films will detect as little as 50mL of fluid
- Order: cell count, gram stain, culture, pH, protein, LDH
Exudate vs transudate - use Light's Criteria
- Treat the underlying pathology!
- Avoid large volume taps (>1L) if CHF, renal or hepatic pathology
- Unstable - septic shock, tension hydropneumothorax
- If tapping:
- Avoid NV bundle
- Have patient lean over table
- Use ultrasound
- When to tap:
- Typically, these patients will not need a tap or tube in the ED.
- If patients have persistent hypoxia in spite of other interventions, consider tap.
- Severe respiratory failure.
Rare - air embolism, sheared catheter loss
Kids are Different
- Larger heads, tongues, smaller nostrils
- Cricoid ring determines size of ET tube
- Bradycardia is a BAD SIGN.
Signs of Increased Respiratory Effort
- Assumed position
- Bobbing head
- If kids are pulling off their mask, they might need to be intubated.
- sniffing position, sometimes achieved without any padding
- jaw thrust is preferred to chin tilt
- always use an oral airway, measure from angle of mouth to angle of jaw
DOPE for ETT problems
- Check ETCO2 waveform
Not recognizing compromise early!
Not thinking to clean out the nose!
Not thinking in terms of axis alignment!
The Return ED Visit
"BB" Shot to Right Groin...
- Bullet embolism is extremely rare.
- Requires multidisciplinary management.
- Consider possibility if missile lays next to major vessels or bullets are found in unexpected locations.
- Venous more common than arterial
1st presentation - viral symptoms. 2nd presentation - viral symptoms. 3rd presentation (within 24 hours) - SHOCK with Resp Failure
Tamiflu is not magic...