Author: Zack (Page 4 of 8)

Nutritional Emergencies

Consider In High Risk Patients

  • Alcoholics
  • GI disorders
  • Eating disorders
  • Starvation/poor diet
  • Extremes of age

Thiamine (B1) deficiency

  • Causes damage to neurons and cardiac myocytes
  • Manifestations
    • Dry beriberi
      • Neuropathy
      • Paresthesias
    • Wernicke’s encephalopathy
      • Ophthalmoplegia
      • Ataxia
      • Altered mental status
    • Korsakoff syndrome
      • Ophthalmoplegia, ataxia, altered mental status
      • PLUS
      • Confabulation
      • Memory loss
    • Wet beriberi
      • Heart failure from cardiac damage
  • Treatment
    • High dose thiamine

Niacin (B3) Deficiency

  • “Pellagra”
  • Clinical Triad
    • Diarrhea
    • Dementia
    • Dermatitis
      • Scaly rash
        • Neck
        • Dorsum of hands
  • Treatment
    • Vitamin B3

Folate (B9) Deficiency

  • Megaloblastic anemia
  • Treatment
    • Folate

B12 Deficiency

  • Classically occurs in vegans (in addition to the previous high risk groups)
  • Manifestations
    • Megaloblastic anemia
    • PLUS
    • Neurologic complaints
      • Subacute combined (posterior and lateral column) degeneration of spinal cord
        • Posterior columns
          • Impaired vibratory sensation and propioception
        • Lateral columns
          • Sensory loss
          • Motor weakness

Additional Reading

  • Thiamine Deficiency: Pearls and Pitfalls (emDOCs)

Complications of Myocardial Infarction

Mnemonic: DARTH VADER

Death

Arrhythmia

  • ACS patients need to be placed on cardiac monitor
  • Frequently degenerate into non-perfusing rhythms

Rupture of Ventricle

  • Occur within a few days of myocardial infarction
  • Rapid decompensation
  • Bedside ultrasound will show pericardial effusion and tamponade

Tamponade

  • Multiple etiologies
    • Rupture of ventricle (see above)
    • Pericarditis
  • Becks Triad
    • Jugular vein distension
    • Muffled heart sounds
    • Hypotension
  • Diagnosed with bedside ultrasound
  • Treatment is pericardiocentesis

Heart Failure

  • Occurs in approximately 1/3 post-MI patients
  • Leads to cardiogenic shock
  • Treatment
    • Fluid bolus
    • Vasopressors (esp. norepinephrine)
    • Inotropes (milrinone, dobutimine)
    • Left ventricular assist devices
    • Intra-aortic balloon pumps

Valve Failure/Rupture

  • Rapid decompensation (similar to ventricular wall rupture)
  • PLUS
  • New heart murmur
  • Surgical emergency

Aneurysm

  • A classic STEMI mimic
  • Large Q waves with ST segment elevation (IN ASYMPTOMATIC PATIENT)

Dresslers Syndrome/Pericarditis

  • Rule out cardiac tamponade
  • Treatment
    • NSAIDS/colchicine

Embolism

  • Occur in damaged ventricles and in cardiac aneurysms
  • Require anticoagulation

Recurrence

  • Emphasize lifestyle management

Additional Reading

tPA Basics

My original source for this episode was the MDCalc tPA contraindication guidelines which are based off older recommendations (2015). Stroke guidelines and tPA contraindications have changed and are rapidly changing. Always follow the most up to date AHA/ASA guidelines or your institutional protocol, as much of this information may be outdated.

Introduction

  • tPA is one of the core treatments for acute ischemic stroke
  • The history of tPA is filled with controversy
  • Mechanism
    • Activates plasminogen to plasmin
    • Plasmin breaks down fibrin

Contraindications to tPA

  • Objective contraindications
    • Hypoglycemia
    • Blood pressure (>185/110)
    • Hemorrhagic CVA seen on head CT
  • Other common contraindications
    • Mnemonic: ABCDE
      • A– History of Aneurysm, AVMs (or other intracranial structural problems)
      • B– Actively Bleeding
      • C– IntraCranial injuries (trauma, surgery, or strokes) within last 3 months
      • D– Bleeding Diasthesis (blood thinners, abnormal coagulation panels, clotting disorders)
      • EEndocarditis
  • Relative Contraindications (Discuss with neurology)
    • Minimal or resolving symptoms
    • Recent surgery or major trauma
    • Seizure
    • Recent lumbar puncture
    • Pregnancy
    • Active pericarditis
  • 3-4.5 Hour Contraindication Addons
    • A- Age >80
    • B- Bad Stroke (NIH >25)
    • C- CT shows multilobar stroke
    • D- Bleeding diasthesis (even if coagulation studies normal)
    • E- Ever had old stroke or diabetes

Additional Reading

  • tPA Contraindications for Ischemic Stoke (MDCalc)
  • 2018 Stroke Management Guidelines (AHA/ASA)

Sepsis

Sepsis guidelines are constantly changing. Refer to your national guidelines or institutional protocol for most up to date treatment information.

Introduction

  • Sepsis is bad and needs to be treated aggressively
  • Confusion around multiple conflicting guidelines and requirements
    • Surviving Sepsis Campaign recommendations
    • CMS requirements
    • Sepsis-3
    • SOFA/SIRS/qSOFA
    • Institutional protocols

Sepsis-3 Proposed Recommendations

  • Screen for sepsis by applying qSOFA instead of SIRS criteria
    • qSOFA criteria
      • Altered mental status
      • Tachypnea
      • Hypotension
    • SIRS criteria
      • Tachycardia
      • Tachypnea
      • Leukocytosis
      • Hyper/hypothermia
    • qSOFA criteria miss cases of sepsis (too specific)
    • SIRS calls everything “sepsis” even if the patient is fine (too sensitive)
  • Change definition of “Sepsis” (no more SIRS plus source)
    • New definition
      • Source of infection
      • PLUS
      • Organ disfunction
        • Determined by SOFA score (different purpose than qSOFA)
  • Eliminate the term “severe sepsis” completely
  • Redefine “septic shock”
    • Persistent hypotension
    • OR
    • Lactic acid >4

Current Approach to Sepsis

  • Step 1- If the patient has SIRS plus source
    • Get labs including a lactic acid
  • Step 2- If the patient has organ dysfunction
    • Diagnose sepsis
  • Step 3- If the patient has sepsis
    • Order broad spectrum antibiotics
    • Order blood cultures
    • Needs to be completed in <3 hours
  • Step 4- If the patient has persistent hypotension or lactate >4
    • Diagnose septic shock
  • Step 5- If they have septic shock
    • Give 30ml/kg crystalloid bolus
    • Start vasopressers if hypotension doesn’t improve with bolus

Additional Reading

  • CMS Sepsis Core Measures (ACEP)
  • Sepsis-3 Recommendations (EMJ)
  • Surviving Sepsis Campaign (SCCM)

Neonatal Jaundice

Physiology

  • RBC hemoglobin breakdown -> unconjugated (indirect) bilirubin
  • Unconjugated (indirect) bilirubin -> liver -> conjugated (direct) bilirubin
  • Conjugated (direct) bilirubin -> Eliminated in stool

Causes of Hyperbilirubinemia

  • Increased RBC turnover
    • Sepsis
    • Rh incompatibility
    • RBC disorders
    • Maternal diabetes
    • Scalp hematoma
  • Decreased/slow conjugation by the liver
    • Peaks around day 5 of life
    • Congenital liver disorders
      • Gilbert/Crigler Najjar Syndromes
    • Breast milk jaundice
      • Breast milk inhibits conjugation of bilirubin
  • Decreased excretion
    • Bowel obstruction
    • Breast feeding failure (dehydration)
      • Decreased stool output results in reabsorbed bilirubin

Kernicterus

  • Brain damage from severe hyperbilirubinemia (>25 mg/dL)
  • Compare measured bilirubin to established nomogram
  • Treatment is phototherapy
    • (Worst case scenarios require exchange transfusion)

Additional Reading

Thrombocytopenia

Clinical Presentation

  • Incidental finding on routing CBC
  • Petechiae/purpura
  • Mucosal bleeding
  • Epistaxis
  • Gingival bleeding
  • Hematuria
  • Vaginal bleeding

5 Major Causes of Thrombocytopenia

  • Thrombotic Thrombocytopenic Purpura (TTP)
    • Clinical presentation (pentad)
      • Thrombocytopenia
      • Fever
      • Microangiopathic hemolytic anemia
        • “schistocytes”
      • Neurologic abnormalities
      • Renal dysfunction
    • Physiology
      • Low ADAMTS13 results in impaired vWF breakdown
        • Widespread “platelet plugs”
    • Treatment
      • Plasma exchange
  • Hemolytic Uremic Syndrome (HUS)
    • Clinical presentation
      • Pediatric patient with bloody diarrhea
      • Renal dysfunction
      • Thrombocytopenia
    • Treatment
      • Supportive care
  • Heparin Induced Thrombocytopenia (HIT)
    • Clinical presentation
      • Recent heparin administration
      • Acute thrombocytopenia (<150) or 50% decrease in platelets
    • Treatment
      • Stop heparin and choose different anticoagulant
  • Disseminated Intravascular Coagulation (DIC)
    • Clinical presentation
      • Patient septic, severe trauma, or otherwise critically ill/injured
      • Multiple abnormal labs
        • Increased PT/PTT
        • Increased D-dimer
        • Increased fibrinogen degradation products
    • Treat underlying trigger
  • Immune/Idiopathic Thrombocytopenic Purpura (ITP)
  • Common condition
    • Relatively benign
  • Treatment
    • Steroids
    • Occasionally platelet transfusion
  • Other causes
    • HIV
    • Hepatitis
    • Heavy alcohol use

Additional Reading

  • Thrombocytopenia: An ED Approach (emDOCs)

Nausea and Vomiting

The hardest part about this chief complaint is expanding your differential beyond gastritis!!!

Step 1: Expand Your Differential Diagnosis

  • Early appendicitis
  • Bowel obstructions
  • Myocardial infarction
  • Elevated ICP
  • Diabetic Ketoacidosis

Step 2: Give a Testing Plan

  • High yield tests to consider
    • EKG – older adults
    • Pregnancy test – women of child bearing age
    • Electrolytes – most patients
  • Other tests to consider
    • CBC
    • LFTs/Lipase
    • Urinalysis

Step 3: Give a Treatment Plan

  • IV fluids (1L normal saline)
  • Antiemetics
    • Ondansetron (Zofran)
    • Promethazine (Phenergan)
    • Prochlorperazine (Compazine)

Step 4: PO Challenge

  • Prior to discharge patient needs to keep fluids down
    • Bonus points if you update your attending on this

Step 5: Repeat Abdominal Exam

  • Perform this prior to discharging patient

Additional Reading

Complications of Cirrhosis

Organ Failure Complications

  • Hepatorenal syndrome (renal failure)
    • Decreased urine output
    • Labs show elevated creatinine
    • Admit to hospital (high mortality)
  • Hepatic encephalopathy (brain failure)
    • Introduction
      • Liver clears ammonia from body
      • In advanced liver failure, ammonia increases
    • Symptoms
      • Altered mental status/confusion
      • Asterixis
    • Treatment
      • Lactulose
        • Binds ammonia and is excreted
      • Rifaximin
        • Eliminates bacteria responsible for producing ammonia

Portal Hypertension Complications

  • Gastric/esophageal varices
    • Symptoms
      • Altered mental status
        • Hepatic encephalopathy triggered by reabsorbed GI blood
      • Melena
        • Black stools from digested GI blood
    • Treatment
      • Proton pump inhibitor (PPI)
        • Pantoprazole
      • Octreotide
      • Antibiotics
      • Classic procedure
        • Blakemore tube (balloon tamponade)
  • Ascites with spontaneous bacterial peritonitis (SBP)
    • Symptoms
      • Abdominal pain/tenderness
      • Ascites
      • Fever
    • Testing plan
      • Diagnostic paracentesis
        • >250 neutrophils
        • High protein
        • Low glucose
    • Treatment
      • Antibiotics
      • Albumin

Liver Failure Complications

  • Coagulopathy
    • Diagnose with abnormal coagulation studies
      • PT with INR
    • Patients can be BOTH hyper and hypocoagulable

Additional Reading

Peds T- Tummy and Non-Accidental Trauma

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

Peds I- Inborn Errors of Metabolism and Endocrinology

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

Peds H- Heart Failure and Congenital Heart Disorders

Common Chief Complaints

  • Cyanosis
  • Difficulty feeding
  • Failure to thrive

Cyanotic Heart Lesions

  1. Truncus arteriosus
    • Aorta and pulmonary artery are fused
    • Single vessel comes from both ventricles
  2. Transposition of great vessels
    • Aorta comes off RIGHT ventricle
    • Pulmonary artery comes off LEFT ventricle
  3. Tricuspid atresia
    • Blood unable to get from right atrium to right ventricle
  4. Tetrology of fallot
    • Overriding aorta
    • Ventricular septal defect
    • Right ventricular outflow tract obstruction
    • Hypertrophy of right ventricle
  5. 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

Peds S- Sepsis and Serious Bacterial Infections

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)

Peds H- Hyperglycemia and Hypoglycemia

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

Peds O- Oxygen, 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

How to Save a Dying Baby

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

Bleeding Disorders

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

How to Read an EKG

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

Pediatrics Exam

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

Pediatrics History

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

Fever in a Returning Traveler

If a returning traveler has a fever, think malaria malaria malaria!!!

Step 1: Ask your patient if they have traveled within the last year

  • If yes… You should at least CONSIDER malaria

Step 2: If patient says yes, take a travel history

  • When did they go
  • Where did they stay
  • Where they exposed to anything concerning
    • Mosquitos
    • Animals
    • Weird foods
    • Sexual partners
    • Sick people
  • Where they in developed/tourist areas or “off the trail”

Step 3: Ask about prophylaxis

  • Did they see a doctor before leaving?
  • Did they take any immunizations or medicines prior to departure?
  • Did they continue prophylaxis as instructed?

Step 4: Go to the CDC website

  • Look up the country of concern
  • Will help establish your differential

Step 5: Test for malaria

  • If you are concerned that patient has malaria…
  • Order thick and thin blood smear

Additional Reading

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