EM Clerkship

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)

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)

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)

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 → Episode Summary

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

P→ Episode Summary

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)

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)

Always ask about pediatric patient’s ‘P-I-S-S’ status!!!

Core Function Questions (P-I-S-S Status)

* Peeing* Evaluates for dehydration* Number of wet diapers per day?* Same number as usual?* Intake* Rule of 3s* Estimates how much milk/formula an average infant should be taking* 3oz of milk or formula every 3 hours* Sleeping* Is the patient sleeping MORE than usual?* LESS than usual?* Stooling* Normal stool* Changes from dark meconium to tans/yellows

Pediatric Medical History

* Prebirth* Did the patient have prenatal care?* Any issues with the pregnancy?* Was mom GBS positive?* Peribirth* What gestational age was patient born at?* Vaginal delivery or c-section?* How long did baby have to stay in hospital after delivery?* Postbirth* Diagnosed medical/surgical problems* Immunization status

Additional Reading

* The Truth About Baby Poop (WebMD)