EM Clerkship

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Peds T- Tummy and Non-Accidental Trauma Feb 18, 2018

Show notes

Non-Accidental Trauma
* Estimated 10% of pediatric patients are victims of abuse* Sexual abuse* Physical abuse* Neglect* Common red flags* Changing story* Story that doesn’t make since* Delays in seeking care* Unusual bruising locations* Torso* Ears* Neck* Common tests if non-accidental trauma suspected* Skeletal survey x-rays* Head CT* Especially if altered mental status* Abdominal CT* Especially if abdominal trauma* Report to child protective services (CPS)
Tummy Ache
* Necrotizing enterocolitis* Classic presentation* Premature baby* 1st month of life* Ill appearing* Classic finding on x-ray* “Pneumatosis intestinalis”* Volvulus* Classic presentation* 1st month of life but previously healthy* Distended abdomen* Bilious vomiting* Testing* Abdominal Xray* Upper GI Series (ideal test)* Toxic megacolon* Complication of Hirchsprung Disease* Seen on x-ray* Intussusception* Telescoping bowel resulting in ischemia* Classic presentation* 2 months – 2 years old* Intermittent abdominal pain followed by lethargy* Diagnose with abdominal ultrasound* Pyloric stenosis* Classic presentation* Projectile vomiting* Normal appetite/hungry* Palpable “olive” in epigastrium * Testing* Electrolyte panel* Hypokalemia* Hypochloremia* Alkalosis* Abdominal ultraound
Additional Reading
* Pediatric Abdominal Pain (EM Clerkship)

Peds I- Inborn Errors of Metabolism and Endocrinology Feb 11, 2018

Show notes

Don’t be overwhelmed knowing/memorizing each inborn error of metabolism. The basic approach is actually quite easy!!!
Inborn Errors of Metabolism (IEM)
* Almost always result in one of the following three clinical abnormalities* Buildup of toxins* Ammonia* To test for this, obtain an ammonia level* Buildup of acids* Methylmalonic acidemia* To test for this, obtain electrolyte panel and look for decrease CO2* Shortage of glucose* Glycogen storage disorders* To test for this, obtain a blood glucose level
Congenital Adrenal Hyperplasia (CAH)
* Decreased 21-hydroxylase enzyme* Physiologic abnormalities* Decreased aldosterone* Low sodium (hyponatremia)* High potassium (hyperkalemia)* Decreased cortisol* Low glucose level* Hyperpigmentation* INCREASED sex hormone (androgens)* Fused labia* Partial male genitalia
Additional Reading
* Congenital Adrenal Hyperplasia (Wikipedia)

Peds H- Heart Failure and Congenital Heart Disorders Feb 04, 2018

Show notes

Common Chief Complaints
* Cyanosis* Difficulty feeding* Failure to thrive
Cyanotic Heart Lesions
* Truncus arteriosus* Aorta and pulmonary artery are fused* Single vessel comes from both ventricles* Transposition of great vessels* Aorta comes off RIGHT ventricle* Pulmonary artery comes off LEFT ventricle* Tricuspid atresia* Blood unable to get from right atrium to right ventricle* Tetrology of fallot* Overriding aorta* Ventricular septal defect* Right ventricular outflow tract obstruction* Hypertrophy of right ventricle* Total anomalous pulmonary venous return* Pulmonary vein empties into the right ventricle
Ductal Dependent Lesions
* Classically presents in first 30 days of life* Treatment = Prostaglandins* Common lesions* Hypoplastic left heart* Aortic stenosis* Coarctation of the aorta
Congestive Heart Failure
* Common Presentation* Difficulty feeding* Organomegaly* Cardiomegaly on CXR* Treatment* Furosemide* Vasopressors* Admit
Additional Reading
* Congenital Heart Disease Emergencies (EM Cases)* Ductal Dependent Congenital Heart Defects (CodeHealth)

Peds S- Sepsis and Serious Bacterial Infections Jan 28, 2018

Show notes

Pediatric “Sepsis”
* Consider in any toxic appearing child/neonate* Especially with fever (or hypothermia)* Treatment* Early antibiotics* Fluid bolus
“Serious Bacterial Infections” (SBI)
* Consider in any baby with fever* Three classic categories* Age 60 days* (Assumes immunizations are up to date)* Workup is more targeted* Blood cultures, Urine cultures, Chest X-Rays still common
Additional Reading
* Rochester Criteria Febrile Infants (MDCalc)* PECARN Rule for Low Risk Febrile Infants (MDCalc)

Peds H- Hyperglycemia and Hypoglycemia Jan 21, 2018

Show notes

Introduction
* In pediatric patients, have a low threshold to check blood sugar* Undiagnosed diabetics commonly identified in ED during first episode of DKA* HYPOglycemia is very common in multiple conditions, especially in ill children
Hyperglycemia
* DKA is different in kids* They get cerebral edema* Increased intracranial pressure with rapid fluid administration* Common symptoms* Headache* Altered mental status* Neurologic deficits* Cushings triad* Hypertension* Bradycardia* Irregular breathing* Treatment = mannitol
Hypoglycemia
* Multiple causes* Sepsis* Inborn errors of metabolism* Endocrine disorders* Replace glucose using “Rule of 50s”* Dextrose % x Volume = 50* Neonates: 5ml/kg of D10* Pediatrics: 2ml/kg of D25* Teens/Adults: 1ml/kg of D50* 1 “amp” of D50 = 25g of sugar = 50ml
Additional Reading
* Rule of 50s (PEMBlog)* Pediatric DKA (EM Cases)

Peds O- Oxygen, Airway, and Respiratory Disorders Jan 14, 2018

Show notes

Applying oxygen is one of the first steps in treating any crashing child!!!
Airway Emergencies
* Foreign body (FB)* Patient presentation* Stridor* Choking episode* Testing* CXR* May directly show foreign body* May show secondary effects of a foreign body* Hyperinflated/collapsed lobes of the lung* Patient needs bronchoscopy if suspicion is high* Peritonsillar abscess* Visible in the pharynx* Bacterial tracheitis* HIDDEN IN the airway* Epiglottitis* HIDDEN ABOVE the airway* Retropharyngeal abscess* HIDDEN BEHIND behind the airway* Common presentations of airway emergencies* Voice changes* Drooling* Stiff neck* Testing* Most are seen on neck X-Ray* Peritonsillar abscess is clinical diagnosis* Treatment* Manage the airway* IV Antibiotics * Peritonsillar abscess needs drainage
Breathing Emergencies
* Bronchiolitis = Badly breathing booger babies* Upper respiratory infection caused by virus* Signs of severe illness requiring admission* Grunting* Nasal flaring* Retractions* Hypoxemia* Unable to tolerate PO* Treatment* Deep suctioning* Can consider albuterol trial* Oxygen supplementation as needed* Generally avoid* Chest X-rays* Steroids* Antibiotics* Asthma* Treatment* First line* Albuterol/ipratropium* Steroids* Additional options as needed* Magnesium* Ketamine* IV epinepherine* Croup* Presentation* Barky cough* Stridor* Treatment* Steroids* Consider racemic epinephrine* Pneumonia* Diagnosed by x-ray* Treat with antibiotics* Cystic fibrosis* Albuterol/ipratropium* Nebulized saline* Antibiotics
Additional Reading
* Approach to Asthma (EM Clerkship)* More Than a Sore Throat (emDOCs)

How to Save a Dying Baby Jan 07, 2018

Show notes

When you have a critically ill child in front of you, always remember, OH SHIT, Grab the Broslow!!!
Oxygen- Apply Oxygen and Consider Airway/Respiratory Emergencies
* Foreign body* Peritonsillar abscess* Bacterial tracheitis* Epiglottitis* Retropharyngeal Abscess* Bronchiolitis* Asthma* Croup* Pneumonia* Cystic Fibrosis
Hyper/Hypoglycemia- Check Blood Glucose
* Hypoglycemia* DKA
Sepsis- Consider Sepsis and Serious Bacterial Infections
* Pediatric sepsis* Fever 60 days of age
Heart- Consider Congenital Heart Abnormalities
* Truncus arteriosis* Transposition of great vessels* Tricuspid atresia* Tetrology of fallot* Total anomalous pulmonary venous return* Ductal dependent lesions* Congestive heart failure
Inborn Errors of Metabolism/Endocrinology
* Congenital adrenal hyperplasia
Tummy/Trauma- Consider Abdominal Processes and Non Accidental Trauma
* Non-accidental trauma* Necrotizing enterocolitis* Volvulus* Toxic megacolon* Intussusception* Pyloric stenosis
And never forget… If you feel flustered… GRAB THE BROSLOW!!!
Additional Reading
* Peds Oxygen, Airway, and Respiratory Disorders (EM Clerkship)* Peds Hyper/Hypoglycemia (EM Clerkship)* Peds Sepsis and Serious Bacterial Infections (EM Clerkship)* Peds Heart Failure and Congenital Heart Disorders (EM Clerkship)* Peds Inborn Error of Metabolism and Endocrinology (EM Clerkship)* Peds Trauma and Tummy Ache (EM Clerkship)

Bleeding Disorders Dec 31, 2017

Show notes

These are most important in trauma patients!!!
Platelet Disorders
* Symptoms of SUPERFICIAL bleeding* Mucosal bleeding* GI bleeding* Recurrent epistaxis* Thrombocytopenia* When the platelets ARE LOW* Refer to THIS episode* Von-Willebrand disease* When the platelets CAN’T BIND* Treatment * Desmopressin (DDAVP)* Causes increase in amount of von-willebrand factor (vWF) available* Also causes free water retention* Treatment of diabetes insipidus* Replace vWF* Transfuse factor VIII* Contains vWF (factor VIII binds vWF)* Transfuse cryoprecipitate
The Hemophilias
* Symptoms of DEEP bleeding* Hemarthrosis* Hematomas* Intracranial Bleeding* Factor IX deficiency (Christmas disease)* Treat by replacing factor IX* Rate the “severity” of the bleeding on a scale of 1-100* Dosing equals the severity score in milligrams* For example* 25 = 25mg/kg factor = mild bleeding (mild hematuria with stable hemoglobin, painful but contained hemarthrosis)* 50 = 50mg/kg factor = moderate bleeding = (rapid nose bleeds, rapid bleeding that won’t resolve)* 75 = 75mg/kg factor = severe bleeding = (GI bleeds with dropping hemoglobin, retroperitoneal hematoma)* 100 = 100mg/kg factor = deadly bleeding = (intracranial hemorrhage)* Factor VIII deficiency (Hemophilia A)* Treat by replacing factor VIII* Dosing similar to factor IX but you take severity score and divide by 2* For example* 25 = 12mg/kg factor = mild bleeding (mild hematuria with stable hemoglobin, painful but contained hemarthrosis)* 50 = 25mg/kg factor = moderate bleeding = (rapid nose bleeds, rapid bleeding that won’t resolve)* 75 = 37mg/kg factor = severe bleeding = (GI bleeds with dropping hemoglobin, retroperitoneal hematoma)* 100 = 50mg/kg factor = deadly bleeding = (intracranial hemorrhage)
Additional Reading
* Approach to Thrombocytopenia (EM Clerkship)* Treatment of Hemophilia (Hemophilia.org)

How to Read an EKG Dec 03, 2017

Show notes

Always remember…1, 2, 3, get an old EKG!!!
Step 1: Identify the Rate and Rhythm
* Is it sinus rhythm?* P wave before every QRS* Is it one of the tachycardias? (Refer to THIS episode)* Is it one of the bradycardias? (Refer to THIS episode)
Step 2: Look for Signs of Ischemia
* Most consistent way is to examine by anatomic region of the heart* II, III, and aVF are “inferior” leads* I, aVL, V5, V6 are “lateral” leads* V1 and V2 are “septal” leads* V3 and V4 are “anterior” leads* Check for Q waves* Check for ST segment elevation or depression* Compare the J point with baseline (TP segment)* Check for peaked T waves and T wave inversions* T wave inversions in V1 and aVR are normal
Step 3: Look at Intervals
* PR interval* Wolf-Parkinson White Syndrome* 1st degree heart block* QRS interval* Left bundle branch block* Right bundle branch block* Sodium channel blockade* QT interval* Long QT syndrome* Hypokalemia* Risk of torsades de pointes
Step 4: Get an Old EKG
* If you find anything abnormal looking, compare to an old EKG
Bonus: Scarbossa Criteria
* Identifies ischemia in patients with a left bundle branch block* 1 lead with concordant ST elevation* 1 lead with concordant ST depression (V1-V3)* Severely discordant ST elevation (>25% preceding S wave)
Additional Reading
* Basic Approach to Tachycardias (EM Clerkship)* Basic Approach to Bradycardias (EM Clerkship)* EKGs for the Emergency Physician (Amazon)

Pediatrics Exam Nov 26, 2017

Show notes

Mnemonic: ABCDEF
Appearance
* The ‘A’ in the pediatric assessment triangle* Interactive vs distant* Good tone vs floppy* Calm and happy vs inconsolable
Breathing
* The ‘B’ in the pediatric assessment triangle* Signs of respiratory distress* Nasal flaring* Retractions* Abnormal respiratory sounds
Color/Circulation
* The ‘C’ in the pediatric assessment triangle* Pink = good* Abnormalities* Pallor* Cyanosis* Mottling
Distraction
* Almost impossible to do a good peds exam in a crying kid* Easiest ways to keep kids distracted* Let parents hold/play with them* Toys* Stethoscope* Funny sounds/noises
ENT
* Many times the kids don’t localize the symptoms* May present with vomiting, fever, irritability, etc* If difficulty examining pharynx, consider triggering a gag reflex
Fully Undress
* Look for bruising, rash, blisters* Signs of non-accidental trauma* GU exam (especially in boys, check the testes!)
Additional Reading
* Peds Respiratory Disorders (EM Clerkship)* Pediatric Assessment Triangle (Wikipedia)

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