

* Differential

* Traumatic causes: non-accidental trauma, fracture, dislocation, sprain, strain, tendonitis, osgood schlatter



* Non-traumatic causes: septic arthritis, transient synovitis, osteomyelitis, SCFE, LCP disease, rheumatologic disease, bony tumors





* Work-up

* XRay



* Labs to evaluate for septic arthritis – CBC BMP ESR CRP





* Kocher Criteria

* Non-weight bearing



* Fever >38.5C



* ESR >40



* WBC >12





* Kocher Criteria Statistics

* 0 points: 0.2% (or 2% in prospective studies)



* 1 point: 3% (or 9% in prospective studies)



* 2 points: 40%



* 3 points:93%



* 4 points: 99%





* Septic Arthritis DX

* >50,000 WBC

* Age 0-3mo : group B strep



* Age 3mo – 12 years: Staph Aureus



* Age 12-18 years: Gonorrhea



* Sickle Cell Disease: Salmonella






Pediatric Septic Arthritis (Deep Dive R14 MW)

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You are working at Clerkship General when one of the nurses comes and grabs you. “Hey doc, we need you in bed 10. I think this patient is having a stroke.” 



Initial Vitals:



HR: 51



BP: 201/98



Temp: 98.0F



RR: 18



O2: 99% (Room Air)



Critical Actions:




* Check a Blood Glucose



* Activate a Stroke Alert



* Assess Contraindications to tPA



* Consent for tPA



* Transfer via Air for Thrombectomy


Round 20 (MW) Stroke Symptoms



* Common during the first year of life as well as during puberty



* Presents with nausea/vomiting, abdominal pain, and/or testicular pain



* ALWAYS examine a child for signs of torsion who presents with abdominal pain (especially lower abdominal pain)



* Look for tenderness, firmness, high riding testicle or testicle with unequal lie, swelling, and the absence of a cremasteric reflex   



* Consult Urology IMMEDIATELY if you have high suspicion, otherwise proceed to ultrasound



* Ultrasound is only 85% sensitive, so clinical gestalt can trump even a negative US



* Attempt manual detorsion if there will be a significant delay to surgery


Testicular Torsion (Deep Dive MW R19)


You are working at Clerkship General when the next patient is put into your rack. It is an 8 year-old male with vomiting



Initial Vitals:



HR: 119



BP: 104/63



Temp: 98.0F



RR: 20



O2: 99% (Room Air)



Critical Actions:




* Finger Stick Blood Glucose



* Treat Patient’s Pain



* Diagnose Testicular Torsion



* Immediate Urology Consult



* Perform Manual Detorsion




References:



Mellick LB, Sinex JE, Gibson RW, Mears K. A Systematic Review of Testicle Survival Time After a Torsion Event. Pediatr Emerg Care. 2019 Dec;35(12):821-825. doi: 10.1097/PEC.0000000000001287. PMID: 28953100.

Round 19 (MW) Tummy Ache in Child with Diabetes


Phase One: CNS




* Ataxia, Slurred Speech, Confusion, N/V, Seizures




Phase Two: Cardiopulmonary 




* CHF, Cardiogenic Shock/Hypotension, Pulmonary Edema, ARDS




Phase Three: Renal




* Flank pain, Hematuria, Oliguria, Renal Failure




Diagnosis:




* HIGH INDEX OF SUSPICION



* Ethylene Glycol Serum Level



* Elevated Osmolar Gap



* Serial Anion Gap Measurements




Treatment:




* Fomepizole or Ethanol to prevent breakdown to toxic glycolic acid/oxalic acid



* Hemodialysis



* Consider Bicarb drip, pyridoxine, and thiamine








Further Reading:



 EMCrit Toxic Alcohols





Ethylene Glycol (Deep Dive MW R18)


You are working at Clerkship General when you hear an EMS call on the radio. Clerkship General, we are bringing you Arthur. He is intoxicated… Again



Initial Vitals:



HR: 116



BP: 150/70



Temp: 98.8



RR: 26



O2: 85% (Room Air)



Critical Actions:




* Recognize Hypoxemia



* Diagnose Toxic Alcohol Ingestion



* Consult Nephrology Emergent Dialysis



* Administer Fomepizole



* Workup Anion Gap Metabolic Acidosis


Pediatric Septic Arthritis (Deep Dive R14 MW)

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