EM Clerkship

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)

Physicians get concerned about 4 serious bacterial infections (SBIs) when a baby or young child comes in with fever or possible sepsis. UTI, bacteremia, meningitis, and pneumonia. Start those antibiotics early, especially if the child appears sick.

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 <30 days* Introduction* Weak immune system* No immunizations* Very high risk for serious bacterial infections* Require a significant amount of testing* Urinalysis with Urine Culture* Blood Cultures* Lumbar Puncture with CSF Cultures* Chest X-Ray* Require admission and antibiotics* Age 30-60 days* ILL appearing* Treat same as fever in <30 day patient* WELL appearing* Testing and treatment differ by institution* Multiple criteria established to help in this age range* Rochester criteria* Philadelphia criteria* PECARN criteria* Choose one and use consistently* 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)

H stands for hyperglycemia and hypoglycemia. Always check that blood sugar when you have a sick pediatric patient!

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)

OH SHIT (grab the Broselow) is the mnemonic I use to help me think through my approach to the sick child. This week we are covering oxygenation, airway and respiratory disorders.

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)

This is the introduction episode for our upcoming series on the approach to a sick child.

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 <30 days of age* Fever 30-60 days of age* 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)

As another special holiday treat we will be talking about the Big 3 hemostatic disorders that make people bleed too easily and how to fix them.

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)

I just stumbled on a study by The Doctors Company, a big malpractice insurer, looking at 332 closed claims against ED physicians. MOST of these cases were from missed or delayed diagnosis, and statistically, it was TWELVE diagnoses that made up the majority of these. So, in the musical spirit of Christmas,  my gift to you is the most high yield, medicolegal, differential diagnosis that exists In the world… Happy Holidays! ~~~~~~~~ The Doctors Company. Emergency Medicine Closed Claims Study. April 2015. Accessed December 22, 2017 *Music Licensed by AudioJungle

I → Episode Summary

Have a great week. No episode. We’re working on updating the show notes.

Have a great week. No episode. We’re working on updating the show notes.