Author: Zack (Page 5 of 9)

Blood in the Diaper

May 13, 2018 / Zack

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The 4 Most Common Causes of Blood in Diaper

Urinary crystals
- Will be guaiac negative
- Common in first few weeks of life
Vaginal bleeding
- Common in newborn females as they withdraw from maternal estrogen
Maternal blood
- Swallowed during birthing process
- Breastfeeding with cracked/bleeding nipples
Anal fissures
- Common and will improve on its own

Basic Approach

Step 1: Check if guaiac positive
- If negative, it’s not blood
- Urinary crystals, food coloring, etc
Step 2: Consider vaginal bleeding
Step 3: Perform apt test
- Diagnoses maternal blood
Step 4: Check for anal fissure
- Self resolve
Step 5: Expand the differential diagnosis
- Necrotizing enterocolitis
- Intussusception
- Cow’s milk allergy
- Colitis
- Red Food Dye

Additional Reading

Neonate With Bloody Stool (Pediatric EM Morsels)

Nutritional Emergencies

May 6, 2018 / Zack

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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

April 29, 2018 / Zack

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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

Approach to STEMI (EM Clerkship)

tPA Basics

April 15, 2018 / Zack

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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)
  - E– Endocarditis
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

April 1, 2018 / Zack

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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

March 25, 2018 / Zack

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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

Approach to Neonatal Jaundice (emDOCs)

Thrombocytopenia

March 11, 2018 / Zack

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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

March 4, 2018 / Zack

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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

Antiemetic Pearls (EM Cases)

Complications of Cirrhosis

February 25, 2018 / Zack

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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

How to Perform Paracentesis (Medscape)

Peds T- Tummy and Non-Accidental Trauma

February 18, 2018 / Zack

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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

Pediatric Abdominal Pain (EM Clerkship)

Peds I- Inborn Errors of Metabolism and Endocrinology

February 11, 2018 / Zack

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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

Congenital Adrenal Hyperplasia (Wikipedia)

Peds H- Heart Failure and Congenital Heart Disorders

February 4, 2018 / Zack

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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)

Peds S- Sepsis and Serious Bacterial Infections

January 28, 2018 / Zack

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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

January 21, 2018 / Zack

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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)

Peds O- Oxygen, Airway, and Respiratory Disorders

January 14, 2018 / Zack

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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)

How to Save a Dying Baby

January 7, 2018 / Zack

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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)

Bleeding Disorders

December 31, 2017 / Zack

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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)

How to Read an EKG

December 3, 2017 / Zack

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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)

Pediatrics Exam

November 26, 2017 / Zack

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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)

Pediatrics History

November 19, 2017 / Zack

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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)

Author: Zack (Page 5 of 9)

Blood in the Diaper

Nutritional Emergencies

Complications of Myocardial Infarction

Mnemonic: DARTH VADER

tPA Basics

Sepsis

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

Neonatal Jaundice

Thrombocytopenia

Nausea and Vomiting

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

Complications of Cirrhosis

Peds T- Tummy and Non-Accidental Trauma

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!!!

Peds H- Heart Failure and Congenital Heart Disorders

Peds S- Sepsis and Serious Bacterial Infections

Peds H- Hyperglycemia and Hypoglycemia

Peds O- Oxygen, Airway, and Respiratory Disorders

Applying oxygen is one of the first steps in treating any crashing child!!!

How to Save a Dying Baby

When you have a critically ill child in front of you, always remember, OH SHIT, Grab the Broslow!!!

Bleeding Disorders

These are most important in trauma patients!!!

How to Read an EKG

Always remember…1, 2, 3, get an old EKG!!!

Pediatrics Exam

Mnemonic: ABCDEF

Pediatrics History

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

Links

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