EM Clerkship

Pediatrics

Febrile Seizures * Simple (All features must be present)* Age 6 months – 5 years* Febrile* Lasts less than 15 minutes* Only one seizure in 24 hour period* No focal neuro deficits on exam* Generalized seizure (must have LOC)* Treat with acetaminophen and reassurance* Complex* Does not meet ALL of the criteria for a simple febrile seizure* Consider full workup including lumbar puncture Pediatric Abdominal Pain * Intussusception* Classic history* Severe emesis* INTERMITTENT severe abdominal pain* Common causes* Meckles diverticulum* Henoch-Schonlein purpura* Diagnose with abdominal ultrasound* Look for target sign* Treat with air enema* Malrotation with Volvulus* Classic symptoms* Bilious emesis* Projectile* CONSTANT severe abdominal pain* Peritonitic abdominal exam* Common tests (if stable)* Upper GI Series* Corkscrew sign* Coffee-bean sign* Necrotizing Enterocolitis* Classic symptoms* Premature neonate* Bloody stool* X-Ray shows pneumotosis intestinalis* (Air in the bowel wall)* Hirschsprungs Disease* Delayed passage of meconium* Diagnosis* Contrast enema (not typically done in ED)* Look for distal transition point* Rectal suction biopsy (DEFINITELY not done in the ED)* Gold standard for diagnosis Bronchiolitis * Commonly caused by RSV* Initial fever and URI* Progresses to respiratory distress Croup (laryngotrachealbronchitis) * Commonly caused by parainfluenza* Initial fever and URI* Progresses to stridor* Barky cough* Neck xray will show “steeple sign” (subglottic narrowing)* Treatment* Steroids* Nebulized epinephrine Epiglottitis * Commonly caused by Haemophilus influenzae * Classic symptoms* Fever* Sore throat* Drooling* Muffled voice* Treatment* Keep the child calm* Intubation in a controlled environment* Antibiotics Additional Reading * Pediatric Abdominal Pain (EM Clerkship)* Peds O – Oxygen, Airway, and Respiratory Disorders (EM Clerkship)

Trauma

Penetrating Abdominal Trauma * Anything below the 4th intercostal space (nipple) is potentially an abdominal injury* Gunshot wounds to the abdomen* Needs immediate exploratory laparotomy* Stab wounds to the abdomen* Needs immediate exploratory laparotomy IF…* Hemodynamically unstable* Peritonitis on exam (rebound, rigidity, guarding)* Organs hanging out of abdomen Blunt Abdominal Trauma * If the patient is unstable* Perform FAST exam* If the patient is stable* CT scan of the abdomen/pelvis with contrast Basilar Skull Fracture * Bilateral post-auricular ecchymosis (Battle’s Sign)* Raccoon eyes* Hemotympanum* Otorrhea/Rhinorrhea Tension Pneumothorax * Classic findings* Hypotension* Obstructive shock* Absent breath sounds* Jugular vein distension (JVD)* Treatment* Needle decompression* 2nd intercostal space* Mid-clavicular line* Tube thoracostomy Hemothorax * Hypotension* Hemorrhagic shock* Absent breath sounds* NO jugular vein distension Cardiac Tamponade * Beck’s Triad* Hypotension* Obstructive shock* Jugular vein distension* Muffled heart sounds* Perform bedside ultrasound* Diastolic collapse of right ventricle (RV)* EKG* Electrical alterans Traumatic Aortic Rupture * Rapid deceleration injuries* Tears at ligamentum arteriosum* Widened mediastinum on chest X-Ray Pulmonary Contusion * Blunt chest trauma* Respiratory distress* NO paradoxical chest movement with breathing* Chest X-Ray* Shows non-lobar infiltrates* Located near location of injury Additional Reading * Abdominal Trauma (EM Clerkship)* Head Trauma (EM Clerkship)* Thoracic Trauma (EM Clerkship)

Introduction and Electrolytes

General Approach to a Test Question * Read the last sentence of the question* Read the answer choices* THEN read the vignette Common Scenarios with Quick Answers * Hypotensive patients* Give a fluid bolus* Altered mental status* Check a blood glucose* Hypoglycemia* Orange juice if can swallow safely* D50 if patient cannot swallow and mildly altered* IM glucagon if unresponsive* Patient with altered mental status and possible drug overdose* Give empiric naloxone * Female patients of childbearing age* Get a pregnancy test* If you need to give contrast for a CT scan (example CTA for pulmonary embolism)* Need renal function Hyperkalemia * Common scenarios* Crush injury* Severe burns* End stage renal disease* Especially if missed dialysis* Leukemia on chemotherapy* Remember: Don’t give succinylcholine to a patient with hyperkalemia* Common EKG findings on test* Hyperacute T waves* Sinusoidal waves* Treatment* Stabilizes cardiac cell membranes* Calcium* Shifts potassium into the cells* Insulin/Glucose* Albuterol* Sodium Bicarbonate* Removes potassium* Furosemide* Dialysis* Kayexalate Hypokalemia * EKG findings* Flattened T waves* QTC prolongation* U waves* At risk for ventricular arrhythmias* Treatment* Oral potassium replacement* IV potassium replacement* Consider magnesium replacement Hyponatremia * Hypertonic saline IF* Comatose* Actively seizing* Otherwise treat with normal saline* Pseuohyponatremia * Correct the sodium if patient has severe hyperglycemia* Add 1.6 to sodium for every 100 glucose above normal limit Hypercalcemia * Symptoms* “Stones, bones, groans, psychiatric overtones”* Treatment* IV fluids (promotes excretion) FIRST* Then calcitonin/bisphosphates Torsade de Pointes * Common in patients with prolonged QTc* Hypokalemia* Hypocalcemia* Treat with magnesium Additional Reading * Hyperkalemia (EM Clerkship)

Cancelling my episode this week. Be careful with what you post online and find a mentor!

C→ Episode Summary

Congratulations on getting those applications submitted! This week I will give some tips for interview season.

C→ Episode Summary

When should you stop CPR and pronounce death?  Jordan MR, O’keefe MF, Weiss D, Cubberley CW, Maclean CD, Wolfson DL. Implementation of the universal BLS termination of resuscitation rule in a rural EMS system. Resuscitation. 2017;118:75-81. Jabre P, Bougouin W, Dumas F, et al. Early Identification of Patients With Out-of-Hospital Cardiac Arrest With No Chance of Survival and Consideration for Organ Donation. Ann Intern Med. 2016;165(11):770-778. Goto Y, Funada A, Goto Y. Duration of Prehospital Cardiopulmonary Resuscitation and Favorable Neurological Outcomes for Pediatric Out-of-Hospital Cardiac Arrests: A Nationwide, Population-Based Cohort Study. Circulation. 2016;134(25):2046-2059.

Why is this Important? * It is a poor stewardship of resources to continue a resuscitation when the prognosis is clearly dismal. * Hospitals need to steward their resources to distribute equitable care between its patients When is it Appropriate to Stop CPR on a Pulseless Patient? * Patient shows signs of irreversible death* Rigor mortis* Decapitation* Rotting/decaying* Patient has dismal prognosis (3 studies discuss this)* Implementation of the universal BLS termination of resuscitation rule in a rural EMS system* Non-EMS witnessed arrest* No return of spontaneous circulation prior to transport* Only non-shockable rhythms present* Early identification of patients with out-of-hospital cardiac arrest with no chance of survival and consideration for organ donation* Non-EM witnessed arrest* Non-shockable INITIAL rhythm* No ROSC despite 3 doses of epinepherine* Duration of pre-hospital CPR and favorable neurologic outcomes for pediatric out-of-hospital cardiac arrests. A nationwide, population based cohort study* Less than 1% chance of recovery after 46 minutes of resuscitation Additional Reading * Jordan MR, O’keefe MF, Weiss D, Cubberley CW, Maclean CD, Wolfson DL. Implementation of the universal BLS termination of resuscitation rule in a rural EMS system. Resuscitation. 2017;118:75-81.* Jabre P, Bougouin W, Dumas F, et al. Early Identification of Patients With Out-of-Hospital Cardiac Arrest With No Chance of Survival and Consideration for Organ Donation. Ann Intern Med. 2016;165(11):770-778.* Goto Y, Funada A, Goto Y. Duration of Prehospital Cardiopulmonary Resuscitation and Favorable Neurological Outcomes for Pediatric Out-of-Hospital Cardiac Arrests: A Nationwide, Population-Based Cohort Study. Circulation. 2016;134(25):2046-2059.

Kidney stones are a diagnosis of exclusion. When you see flank pain or testicular pain or lower abdominal pain on that triage note, you have to consider leaking abdominal aortic aneurysm as well.

Kidney Stones are a Diagnosis of Exclusion!!! History * Risk factors* Age >60* Tobacco use* Classic presentations* Stable with sudden flank/back/abdominal pain or syncope* Unstable with pallor, hypotension, and ill appearance Exam * Pulsatile abdominal mass* Unstable vitals Testing Plan * Labs* TYPE AND SCREEN* CBC* Electrolytes* Coagulation studies* Lactic acid* Imaging* Bedside ultrasound (optimal)* Aorta protocol* Look for aorta >3cm* RUSH protocol* Mnemonic: HI-MAP* Heart* IVC* Morrisons Pouch (RUQ)* Aorta* Pulmonary* CT scan with IV contrast (less optimal) Treatment Plan * 2 Large bore IVs (16G)* Massive transfusion protocol* PRBCs* Platelets* Fresh Frozen Plasma* Blood pressure management* Goal Systolic ~100* Goal MAP ~60-65 Clerkship Pearls * Put AAA in your differential during your presentation for all older patients with back/flank pain* Attempt to perform a bedside ultrasound of the aorta OR find recent CT of the abdomen with normal sized aorta Additional Reading * Abdominal Aortic Aneurysm Review (Medscape)

Kidney stones are a diagnosis of exclusion. When you see flank pain or testicular pain or lower abdominal pain on the triage note, you have to consider testicular torsion. Testicular torsion is a high risk, high morbidity diagnosis that is very time sensitive.