Ortho Peds & Other

Open intraarticular wound:

  • Use a 30 ml syringe with an 18 gauge needle.
  • Select a site for arthrocentesis away from the wound tract.
  • Sterilly aspirate the joint. Blood return signifies hemarthrosis likely from intraarticular extension of the wound.
  • If no blood is aspirated, inject normal saline with a few drops of sterile fluorescein or methylene blue until the joint is fully distended.
  • Observe for extravasation of the dye from the wound, which would confirm intraarticular involvement.

If confirmed, pt needs OR for joint washout, Tdap, and iv abx.

Wound FB

If a WFB is small, in a harmless location, deep, asymptomatic, and an inert material (i.e. glass, metal), than it may be more damaging to attempt removal than to leave it in place. A WFB that is causing symptoms, soiled, in a location likely to cause future problems (i.e. sole of foot), or a reactive material (i.e. wood) is more likely to require removal. WFBs such as wood, plastic, clothing and vegetative matter can be detected by ultrasound however. Not all WFBs can be removed by irrigation or exploration in the ED. In these cases, the area should be padded and the patient should be referred to the appropriate consultant for removal. Consider antibiotics for retained WFBs. Give good disx instructions as this is a huge source of litigation.

Fight bite:
-appropriate antibiotics include ampicillin/sulbactam, piperacillin/tazobactam, ceftriaxone with metronidazole, or ciprofloxacin with metronidazole or clindamycin. Clindamycin does not cover Eikenella so it should NOT be used as a sole agent. The joint should be splinted.
-if NO infection present and pt can f/u for re-exam in 24h, outpt abx ok
-if infection present OR tendon/bone/joint capsule involved, admit for iv abx

Flexor tenosynovitis
-injury may be minor or even remote. Course may be fulminant or indolent
-may lead to tendon rupture, loss of function, and sepsis
-need Staph and Strep coverage +/- MRSA, GNR, or anaerobic coverage depending on risk factors
-Cover for Pseudomonas if the patient is diabetic and for Pasteurella multocida if the patient was bitten by an animal
-Kanavel signs:
1. Exquisite tenderness over the flexor tendon
2. Finger held in flexion at rest
3. Exquisite pain upon passive extension of the finger
4. Fusiform swelling of the finger
-consult ortho & hand surgeon ASAP; this is a surgical emergency requiring I&D in the OR

Septic olecranon bursitis
-history of local trauma (laceration, puncture) or preceding infection should raise suspicion. However, the absence of trauma or a wound does not rule out the possibility
exam should differentiate swelling of the olecranon bursa (increased pain in terminal flexion) from joint effusion (increased pain at terminal extension)
-look for erythema or warmth over the olecranon bursa, which would raise the suspicion for septic bursitis
-septic bursitis is ruled out if there is no warmth or erythema.  If the diagnosis is unclear, fluid can be aspirated and sent for cell count, gram stain, culture, and crystal analysis
-septic bursitis may lead to bacteremia, sepsis, and permanent bursa damage
-tx with antiStaph abx +/- MRSA coverage depending on risk factors

Gout
-tx: Relief should begin at 24 hours after NSAID therapy and NSAIDs should be continued for 24 hours after symptoms resolve. Colchicine is dosed at 0.5-0.6mg PO q1-2h until pain is controlled, 3 tabs have been taken within 3 hours, or 10 tablets within 24 hours.

Fracture blisters
= from the initial shearing injury, not from the cast
-fracture blisters should prompt contact with the treating orthopedist because they frequently overlie sites of planned internal fixation or surgical incisions
-for any pt presenting with pain in a casted or splinted limb, must remove it to examine the limb

Subungual hematoma
-usu due to nailbed laceration
-do NOT confuse subungual hematoma with Kaposi sarcoma or melanoma (verify a history of trauma)
-wipe with chlorhexidine and trephinate with cautery to relieve pain and prevent pressure necrosis
-underlying fracture is not a contraindication to trephination

Compartment syndrome
pain with passive stretch of a muscle in the suspected compartment, which is more sensitive and specific than the other findings. The affected area will be exquisitely tender and may be tense, hard, or firm
-levels >30mmHg or within 30mmHg of the diastolic blood pressure are suggestive of compartment syndrome.

Open fracture
-If the wound is >10cm with loss of bone coverage and severe soft tissue injury, an aminoglycoside should be added to cover for gram-negative organisms.
-Significant contamination of the wound, either by dirt, soil, gravel, or any other outside material warrants anaerobic coverage (specifically clostridium perfringens) with a penicillin (other options include metronidazole or clindamycin if PCN allergic)

Peds

Iliac avulsion fracture – Advise rest, ice, and NSAIDS. When in bed, a position that avoids tension on the affected muscle should be advised. The patient can bear weight as tolerated with crutches for additional comfort. Refer for a routine orthopaedics follow-up. Athletic activities can resume when the patient is able to participate without pain.

Torus fracture (ex: distal radius) consists of immobilization in a short arm cast for 2-3 weeks with orthopedic evaluation one week

Be wary of diagnosing sprains in children with tenderness near a growth plate. Rather, immobilize with a splint and refer to orthopedics for repeat films in 7-10 days to ensure you don’t miss a Salter-Harris type I or V fracture (esp if history of axial load).

Osteochondritis Dissecans (rare) = a subchondral bony lesion of an articular surface. A piece of cartilage with attached subchondral bone becomes detached, either partially or completely, resulting in a loose body in the joint space. Pts are young and athletic (children age 11-13 or adults age <30) with knee, elbow, or ankle pain. Leads to significant morbidity. Pts have intermittent clicking, locking, and pain and swelling; it is a repetitive use injury and may be exacerbated by trauma. May have a positive Wilson’s test in which the knee is internally rotated and extended from 90 degrees. A positive test is increased pain at 30 degrees or if pain is relieved by external rotation. Wilson’s sign (walking with the knee externally rotated to avoid impingment of the fragment on the condyle) may also be present. Comparison views of the opposite knee are suggested, both to ensure that the lesion seen isn’t an anomalous ossification center (also may be bilateral). Knee immobilizer, NWB, f/u with ortho.
Screen Shot 2018-01-27 at 7.46.35 PM.png

Fractures of distal radial and ulnar shafts (“both bone” fracture)
-look for tense compartments and skin breaks (open fractures common)
-eval for supracondylar humerus fractures, which creates a ‘floating elbow’ requiring surgical management
-assess radial head alignment to prevent a ‘missed Monteggia’ fracture pattern
-Incomplete (greenstick)* and complete fractures with minimal or no displacement/angulation can be managed with a sugar-tong or long-arm splint.
-If using a long-arm splint, hand positioning depends on location of the fractures.

  • Fractures of the distal third should be splinted in with the hand pronated, midshaft fractures with the hand in neutral, and proximal third fractures with the hand in supination to reduce rotational deformity.

Those with significant angulation (greater than 10 degrees), displacement, or shortening require closed reduction performed in the emergency department. Reduction is performed in a similar manner to that of Colles fractures; finger traps are applied and gravity used to distract the fracture fragments, followed by closed reduction and immediate splinting (same rules as above). Older children typically require only hematoma block, while younger children will require conscious sedation. Due to their excellent remodeling abilities and functional outcomes, children rarely require surgical intervention for uncomplicated forearm shaft fractures

*greenstick/incomplete fx = cortical disruption and periosteal tearing on the convex side of angulation with plastic deformation and intact periosteum on the concave side
-in isolated ulnar shaft fx, evaluate for Monteggia fracture by checking for radial head tenderness which may indicate that the radial head has spontaneously reduced
-In infants, up to 30 degrees of angulation is acceptable. In children less than 10 years old, no reduction is needed for angulation less than 10 degrees.
-For volarly angulated fracture, the fracture is manipulated with the forearm in pronation. In a dorsally angulated fracture, it is manipulated with the forearm in supination. Place ulnar greenstick fractures in a long arm splint

Metaphyseal corner fractures (bucket-handle fractures) of femur (Type II Salter-Harris) – suspect child abuse! (esp if infants & toddlers)
-exam: unable to bear weight. The knee is often held in flexion secondary to hamstring spasm. May be knee effusions and soft tissue swelling
-other fractures suspicious for child abuse: rib fractures, humeral fractures and skull fractures
-place in long leg splint, NWB, with prompt orthopedic referral for operative repair (esp if displaced)
child abuse: long bone fractures in nonambulatory infants, scapula fractures, rib fractures (normally very pliable and resistant to breaks unless large force applied), sternal fractures, skull fracture, and multiple fractures in various stages of healing

Spiral fracture of distal tibia (Toddler fracture)
-NOT child abuse (unless proximal tibia involved)
-weak force fracture due to rotational component in mechanism of injury
-may not be seen initially on xray – consider ultrasound
-NWB, long leg cast

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Lower Extremity Fractures

FOOT

Lis-Franc Injury
= disruption of the tarsal-metatarsal (TMT) joint with or without associated fracture. The Lisfranc ligament is a major stabilizer of the TMT joint
= unstable fracture
-causes midfoot instability (may be noticeable on exam)
-may damage a branch of the dorsal pedis artery which crosses the base of the first and second metatarsal
-a fracture at the base of the second metatarsal is highly suspicious for a Lisfranc mechanism injury
-look for widening of the space between the first & second metatarsals and between the first & second cuneiform bones, look for dorsal displacement of the metatarsals on lateral view (may be only finding)
-if unsure, consider a weightbearing film, a comparison view of the other foot, or a CT scan
-consult ortho ASAP for internal fixation + NWB cast

Screen Shot 2018-01-25 at 12.56.12 PMScreen Shot 2018-01-25 at 1.04.59 PMScreen Shot 2018-01-25 at 1.05.22 PM

Base of 5th metatarsal fracture
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– <1.5cm of the styloid process = “avulsion” (pseudo-Jones) fractures
—Extra-articular tuberosity fractures will heal well requiring a walking cast or stiff shoe for approximately 2-3 weeks. Nondisplaced intraarticular fractures are treated with non-weight-bearing casting for 6-8 weeks with orthopedic evaluation one week from the ED visit. If the articular surface involved in tuberosity fractures is greater than 30% or displaced >2mm, fixation may be necessary and orthopedics should be involved early.
– >1.5cm from the end of the styloid = “metatarsal” (Jones) fractures
—consult ortho in ED

Other midfoot fractures:
-navicular: obtain reverse oblique view (tuberosity may otherwise not be visualized)
—3 types; err on managing as NWB with close ortho f/u
—if displaced >20′, consult ortho in ED – may require early OR for high risk of avascular necrosis
-fx of (distal) 5th metatarsal shaft or neck (Dancer’s fx): inversion injury
—NWB splint with routine ortho f/u unless sig displaced (then consult for ORIF as outpt)
-fxs of 3rd, 4th, 5th distal metatarsals: twist or direct force injury
—NWB splint with routine ortho f/u unless sig displaced (then consult for ORIF as outpt)

NWB stress fractures: stress fractures of the navicular, 5th metatarsal, and femoral neck. These bones have avascular centers and healing may be prolonged, so immobilization and non-weight bearing status is recommended. Stress fractures are not visible on xray until 4-6 weeks after injury, so have a high index of suspicion and f/u with ortho as outpt for MRI or bone scan

ANKLE

Calcaneus fracture:
-Bohler’s angle is formed by intersecting two lines. One is drawn from the most cephalic portion of the tuberosity (red dot) to the highest point of the posterior facet (white dot). The other line is drawn from the highest point of the posterior facet (white dot) to the most cephalic part of the anterior process (blue dot). Loss of normal angle is abnormal.
Screen Shot 2018-01-25 at 5.27.44 PM
-Normal can range from 20°- 40°, so a comparison view of the unaffected side may be helpful.
-also may see linear areas of sclerosis across trabecular lines (may be only indication of fracture)
-Management of calcaneus fractures should be decided in consultation with orthopedics because there is little true consensus on management. In general, extraarticular fractures can be managed closed, while management of intraarticular fractures varies. CT scanning is often required to aid the orthopedist’s decision. Any patient discharged from the ED with calcaneus fracture should be immobilized, non-weightbearing, and have orthopedics follow-up.

LEG

Tibial plateau fracture:
-exam should assess for associated ligamentous instability (60%), compartment syndrome, and peroneal nerve injury (foot drop, paresthesias, positive Tinel’s test over fibular head)
-obtain CT to help orthopods determine need for surgery. Indications for surgery include articular surface depression, axial malalignment, >10 degrees ligamentous instability when the knee flexed to 20 degrees
-may also see a small avulsion fracture of the lateral tibia condyle just below the joint line (Segond Fracture)
—high association of Segond fracture with anterior cruciate ligament (75%-100%) and meniscal tears (67%)
—exam reveals a painful, swollen, ecchymotic knee with limited range of motion and effusion. If the patient’s pain is controlled, classic signs of ACL or meniscal tears may be elicited

KNEE

Patellar fracture:
-usu from falling directly onto the patella (comminuted, damage to articular cartilage). The patella can also fracture from a jumping injury when the knee rapidly flexes against a fully contracted quadriceps (less comminuted and more likely to be transverse and displaced)
straight leg test – determine if the extensor mechanism of the knee is intact. Lying supine, the patient elevates the leg, keeping the knee straight. If the knee cannot remain extended, the extensor mechanism has been disrupted
-sunrise view – visualization of subtle fractures, provides the best view of the articular surface.
-Indications for surgery include: disruption of the extensor mechanism, displaced (>3mm) transverse fractures, skin compromise
-non-op pts: NWB with knee immobilizer or above-knee cast with the knee in full extension

Knee dislocation:
-look for popliteal artery injury (approximately 20%). About 50% of these injuries reportedly reduce spontaneously prior to presenting to the ED, so extra caution must be taken not to miss the diagnosis in these patients because the vascular injury risk is still present.
-check for pulse deficits and arterial pressure indices. A vascular exam should be performed before and after reduction attempts.
—typically reduced under conscious sedation by traction-countertraction
—angiogram if vascular deficit present
-check for gross instability in more than one direction which may be the only finding in a reduced injury. Other findings reported to be suspicious for a reduced knee dislocation are large posterior ecchymosis and ACL tear with large effusion
-if portable and have high suspicion, obtain lateral view

Patellar dislocation:
-usu rotational injury
-if presents dislocated, relocate quickly. Neurovascular exam before and after
-reduction: patient is positioned supine with the hip flexed 90 degrees. The physician extends the knee while simultaneously pushing the patella back medially, lifting it over the femoral condyle if necessary. This can usually be done swiftly and quickly without supplemental medication. The patient is then placed in a knee immobilizer and made NWB
-obtain xray after reduction – AP/lateral/sunrise views of the patella should be obtained, even in those that reduced spontaneously. Osteochondral fractures on the medial aspect of patella are common, occurring in up to 40% of patella dislocations

Patellar fracture:
-findings: swelling, cephalad* subluxation of patella, avulsion fracture
Screen Shot 2018-01-25 at 6.57.15 PM
unable to actively extend their knee. You can often palpate or visualize a high riding patella
-knee immoblizer, NWB, early ortho f/u for surgical repair
*vs low riding patella as seen with quadriceps tendon rupture

Fibular head fracture:
-Isolated proximal fibular fractures are uncommon and are most often associated with other injuries, such as tibia fractures, lateral collateral ligament (LCL) tears or medial ankle injuries (Maisonneuve fractures)
assess the peroneal nerve by checking ankle dorsiflexion and plantarflexion and lateral leg sensation. Medial ankle tenderness would suggest a Maisonneuve fracture. These patients will often be able to ambulate since the fibula bears little weight (only if isolated)

FEMUR

Femoral shaft fracture:
= orthopedic emergency. From high-energy forces, associated with multisystem trauma. Up to 40% of isolated femoral shaft injuries will require transfusion due to bleeding into the thigh
–look for neurovasc injury and other trauma
–watch out for respiratory compromise: DVT/PE, fat emboli
-Patients often arrive immobilized in traction devices, which should be removed while maintaining immobilization of the limb
-need traction until OR, however it is relatively contraindicated in the setting of open fractures or sciatic nerve injuries. Give abx and Tdap

HIP

Hip fractures:
-usu ring structures like the pelvix fractures in multiple areas, however an exception is low velocity falls in the elderly, in which pubic ramus fractures often occur in isolation
Screen Shot 2018-01-25 at 7.26.18 PM

  • illiopubic lines (purple line)
  • illioischial lines (brown line)
  • acetabulum (black arrow)
  • pelvic inlet (blue oval)
  • obturator foramina (green circle)
  • sacroiliac joints (yellow arrows)
  • pubic symphysis (red arrow)

Widening of SI joints > 4mm is abnormal (black arrow). Symphyseal widening > 5mm is abnormal (blue arrow).
Screen Shot 2018-01-26 at 10.34.00 AM

Hip dislocation:
-either high-energy mechanism (knee vs dashboard in MVC) in pts with native hips or minimal or no trauma in pts with prosthetic hips (weak ligaments & musculature)
—if pt is prosthetic hip suddenly has pain and is unable to bear weight, suspect dislocation
-usu posterior
-leg is shortened, internally rotated, slightly flexed at the hip, and adducted
-look for sciatic nerve injury – weakness with dorsiflexion and plantar flexion, loss of ankle deep tendon reflexes, and decreased sensation of the posterior leg and foot
-in trauma pts, obtain CT scan to screen for associated acetabular and other pelvic fractures
-reduce native hips within 6h to prevent avascular necrosis. Need procedural sedation; do not try more than 3x (further attempts increase risk of avascular necrosis)
-reducing prosthetic hips is not an emergency (no risk of avascular necrosis)

Acetabular fracture
-disruption of the iliopectinal line
Screen Shot 2018-01-30 at 8.53.26 AM
-usu high mechanism trauma, except in elderly
-soft tissue over the greater trochanter should be examined for damage which may represent a closed degloving injury (Morel Lavallee lesion), which is a contraindication to surgery
-eval sciatic nerve; look for other traumatic injuries
-call ortho in ED to determine management

Femoral neck fracture
-if displaced, shortened and externally rotated
-some pts may still bear weight on a nondisplaced fracture
-some may not be visualized on plain films – if pt in severe pain and unable to walk (high suspicion), obtain CT or MRI
-femoral head is essentially avascular from displaced fractures and will be subject to subsequent avascular necrosis and collapse without replacement

Intertrochanteric fracture
-extracapsular hip fracture of the proximal femur. The fracture line extends between the greater and lesser trochanters
-elderly pts who fall: direct axial loading of the femur with a rotational component
-leg is shortened and extremely externally rotated
-look for associated injuries and bleeding into thigh (no risk of avascular necrosis of femoral head)
-OR within 48h to prevent mortality
Screen Shot 2018-01-30 at 9.32.49 AM

Pubic Rami fractures

-elderly may have isolated pubic rami fractures (considered stable fractures) from minor fall – pain control, encouraged to bear weight
-if the fracture is near the acetabulum, obtain Judet views help to rule out acetabular involvement. Judet views are images obtained by log rolling the patient 45° to each side
-pubic rami fractures can also be occult – if high suspicion, obtain CT or MRI
-if both rami are fractured on the same side and/or the fracture fragments are significantly displaced, order CT scan to better characterize injuries
-dispo is home if pain is controlled enough to ambulate vs rehab

Peds DKA

Case: 5 y/o M presents with NBNB vomiting x 2 days. Mother states pt is becoming more lethargic today.
-began complaining of headache and abdominal pain beginning later in the day today
-mild cough and rhinorrhea for 2 days prior to onset of vomiting
-ROS otherwise negative

120 HR, 109/75 BP, 32 RR, Temp 98’ – 20 kg
See/hear/smell – somnolent but answers questions (don’t smell anything)
ABC – tachypneic, cap refill 4s
Dextrose – 320 BGM. (K 3.4)

Differential:
head trauma, ICH, meningitis, sepsis, pyelonephritis, error of metabolism, adrenal crisis, myocarditis?, hyperthyroidism

Diagnostics:
-cbc, BMP, VBG, urinalysis, serum beta hydroxybuterate, serum acetone

D: glucose >250
K: +ketones in urine
A: acidosis pH <7.3, bicarb <15

Classification by severity:
Screen Shot 2017-12-15 at 11.48.13 AM

Interventions:
-page endocrin = #1

(1) Replete K
-in contrast to adults, it is permissible to start insulin before having a potassium level back on your patient. Otherwise, use the following guide:

  1. K < 5.5 – add 30mEq/L
  2. 2.5 < K < 3.5 – add 40mEq/L
  3. K < 2.5 – add more

(2) Fluids – Which type? Bolus or continuous? What rate?
-boluses ONLY if pt hypotensive (decompensated shock): in 5-10cc/kg increments with reassessments
*note: systolic BP= 70 + (2 X Age) = lower limit

2 Bag System:
-set total fluid rate at 1.5 X maintenance. Fluids come from 2 separate bags (saline bag, glucose bag).

  • Saline bag: NS + K repletion. Avoid KCl (excess chloride creates additional metabolic acidosis). Halve the total K into K-Phosphate and K-Acetate. Ex: NS + 40mEq K = 20mEq K-Phos + 20mEq K-Acetate in NS.
  • Glucose bag: D10W

Titrate rate of each bag according to this chart:
Screen Shot 2017-12-15 at 11.40.41 AM

Use this chart to make further adjustments to rates at each q1h BGM check.
Screen Shot 2017-12-15 at 11.53.06 AM
https://www.aliem.com/2017/07/pediatric-diabetic-ketoacidosis-two-bag-method/

(3) Give insulin – Bolus or drip?
-insulin bolus contraindicated in peds DKA!
-0.05 – 0.1 U/kg/hr

Monitor:

  1. Bedside glucose q1h
  2. Electrolytes and VBG q2-4h
  3. Add dextrose as once glucose below 250mg/dL
  4. Target to glucose between 180-270mmol/L.
  5. Stop insulin drip only once ketonuria (and thus acidosis) resolves.

Complications:
Cerebral edema – due to rapid change in osmolality
-headache = most common early symptom; AMS, bradycardia, age-inappropriate incontinence, change in pupillary exam, vomiting during treatment
-may occur upon presentation! Patient should not be altered????
-bicarb ONLY if pt arrests – otherwise contraindicated as it increases risk cerebral edema 4x

The management of cerebral edema beyond the usual ABCs* includes:

  1. Positioning: elevate head of the bed 30 degrees
  2. Mannitol 0.5-1g/kg IV over 20min AND/OR
  3. Hypertonic (3%) NaCl 5-10cc/kg IV over 30min

-ALSO reduce fluid rate
-There is very little evidence to suggest whether mannitol or hypertonic saline should be first line treatments.
-DO NOT wait for a CT head to treat increased ICP!

*A is for Avoid intubation!
If intubation is required, know that this will be a risky procedure and may worsen the patient’s clinical outcome. BEFORE you intubate your patient make sure you have a PRE-INTUBATION pC02 level. Keep pt’s pC02 the same post-intubation. Both over-ventilating and under-ventilating them will dramatically affect the speed at which their acidemia corrects. Alternatively, match RR on vent to pt’s RR prior to intubation.

Disposition:
ICU admission:

  1. pH <7.1, or HCO3 <5
  2. Age <2yr
  3. Anyone with concern for cerebral edema

TREKK criteria to discharge home: resolution of acidosis following treatment of mild DKA with subcutaneous insulin and monitoring. ALSO older than 5 years of age, tolerate oral fluids and be otherwise well with good home supports.

Criteria to start SC insulin (long-acting): Glucose and acidosis normalized (bicarb>15) and tolerating PO fluids. Recheck BGM 15m later

How does a subcutaneous insulin pump work? Senses glucose levels and delivers insulin. Delivers rapid-acting insulin at a basal rate throughout the day as well as premeal bolus doses according to a set insulin-to-carbohydrate ratio (pt must count carbs). Correction factor = estimate of how much 1 unit of rapid acting insulin will generally lower your blood glucose over 2 to 4 hours when pt is fasting.

Screen Shot 2017-12-15 at 11.44.55 AM

Summary:
Screen Shot 2017-12-15 at 11.50.13 AM
Screen Shot 2017-12-15 at 11.51.09 AM
https://emergencymedicinecases.com/pediatric-dka/

 

 

Pediatric Seizures

Distinguish from mimics:

  1. Lateralized tongue-biting (high specificity)
  2. Flickering eye-lids
  3. Dilated pupils with blank stare
  4. Lip smacking
  5. Increased heart rate and blood pressure during event
  6. Post-ictal phase

Screen Shot 2017-12-05 at 8.06.23 AM

-if the seizure occurs >24hrs after the onset of fever, have higher suspicion for a bacterial cause of the fever (ie meningitis)
older pts who return to baseline after a complex seizure and at no point displayed any focal neurologic symptoms usually do not require an extensive work-up

Risk of Epilepsy is 2% after a simple febrile seizure and 5 % after a complex febrile seizure (compared to 1% in the general population)

Non-febrile seizures
-most common cause in <6mo is overdilution of formula -> 3ml/kg hypertonic (3%) NS
-check BGM

Labs if:

  1. Have prolonged seizures,
  2. < 6 months of age (specifically for hyponatremia)
  3. History of diabetes, metabolic disorder, dehydration, or excess free water intake
  4. Altered LOC

CT head if:

  1. Focal seizure or persistent seizure activity
  2. Focal neurologic deficit
  3. VP shunt
  4. Neurocutaneous disorder
  5. Signs of elevated ICP and history of trauma or travel to an area endemic for cysticercosis.
  6. Patients who have immunocompromising diseases (malignancy or HIV),
  7. Hypercoagulable states (sickle cell disease), or bleeding disorders

<6 months of age – generally require a full workup and are usually admitted for observation.
6 months and 2 years of age – disposition will depend on blood work, reassessment and the ability to have close follow-up.
>2 years of age – those who have returned to baseline, have a normal neurological exam with normal workup are often safe to be discharged to close outpatient follow-up. Otherwise, admit.

Screen Shot 2017-12-05 at 8.38.29 AM
*note that the first dose of benzo should NOT be given iv (other routes just as efficacious, and early time to benzo is more likely to stop the seizure)
*note that fosphenytoin is a precursor to phenytoin with fewer side effects

 

Cards

Bradycardia: HIDE = Hypothermia/Hypothyroidism, Ischemia/Infection (sepsis), Drugs (BB, CCB, Dig), Electrolytes (hyperK)

Lead reversal: if P and T inverted in same lead

Nomenclature: first 3 letters most important
Screen Shot 2017-11-09 at 7.29.32 AM
http://www.cardiacengineering.com/pacemakers-wallace.pdf

-“overdrive pacing” for torsades or VT = pacing over the rate of the underlying bradycardia which led to the transient monomorphic or polymorphic VT
–mechanism: bradycardia accentuates QT prolongation –> incr dispersion of refractoriness –> R on T phenomenon –> promotes re-entrant circuit (in ventricle)
–same theory for bigeminal PVC formation (“rule of bigeminy”) – the bradycardia in this case is the compensatory pause after the PVC
-stable VT – give 4-6 Gm Mag (goal level >4)

afib and aflutter pts syncopize when convert back into NSR (due to a sinus pause that represents abnormal sinus recovery time) = “tachy brady syndrome,” a type of sick sinus syndrome
-aflutter is difficult to control medically, but responds well to cardioversion (even at low joules)

Diuresis in CHF:
-if pt has poor systolic LV function (low EF) at baseline and presents in pulmonary edema with soft BP, a decrease in preload (diuresis, nitroglycerin) may actually increase CO or at least keep it more or less the same (image below: B –> C)
Screen Shot 2017-11-04 at 2.55.15 PM

Impella = intravascular LVAD
—unlike IABP or VA ECMO, it sucks out volume from LV / unloads the LV -> greatly improving forward flow and preventing backward flow

-the lead most likely to show ST changes = V5 (bc all coronaries have lateral tributaries)
Screen Shot 2017-11-04 at 3.11.36 PM

to diagnose complete heart block, all P waves must march out on time and all QRS complexes must march out on time
-1st degree AV block – can occur either at the AV node or between the SA node and AV node
-posterior fascicle is short and thin, thus much harder to knock out

VT vs SVT with aberrancy or underlying BBB: Brugada criteria, Vereckei criteria
—VT: fusion beats and escape beats (sinus-originating impulses coming through)
—regular
—precordial leads all (+) or all (-)
—RSr’ in V1 – like in RBBB, except first R is larger than second

Management of stable VT: amio push +/- drip, lidocaine push +/- drip, procainamide

-SVT (ex afib) with aberrancy: irregular, old RBBB or LBBB -> beta blocker ok

LVAD indications: cardiogenic shock with forward function refractory to medical therapy, EF <30%???
LVAD complications: infection, thrombosis (causing hemolysis, incr pump power required to maintain flow), dysrhythmias (postsurgical scarring), GIB (AVMs and acquired vWF), low battery, hypotension to MAP<60 (these pts very preload-dependent), high afterload to MAP>90 (obstruction or HTN, if latter choose ACEI or BB), suction event
–exam: precordial “hum” rather than S1/S2, no pulses
–obtain MAP by manual BP = pressure reading when Doppler flow becomes audible
-absence of hum = pump failure
-use relative sizes of RV and LV on echo to narrow differential
-LVAD pts can have walking vfib with fatigue as their only symptom, but will eventually develop heart failure. Give iv amio, lidocaine, procainamide. May cardiovert or defibrillate
-If pt becomes unresponsive with poor perfusion, must begin CPR

Critical Ao stenosis = area <1cm
-these pts have a fixed CO and cannot increase it in compensation
—are at risk of syncope, cardiogenic shock, LV ischemia (hypertrophic wall) and pulmonary edema
—go easy on fluids if pt not crashing
—avoid hypotension bc pts cannot compensate
—avoid any increase in myocardial demand, as pt is at risk for LV ischemia as it is
-these pts need rhythm control if in afib – their LV relies on atrial kick for sufficient filling in diastole
-phenylephrine is vasopressor of choice, norepi is 2nd line
-intubation is high risk given hemodynamic effects of induction agents and positive pressure ventilation – optimize preload prior, have phenylephrine pushes ready, and consider placing A line if there is time

first MI in little old lady – high risk of complications, incl cardiogenic shock, septal wall rupture, free wall rupture, etc. Will need central line and arterial line

How to use axis deviation:
Left Axis Deviation: LAD from VILLA = VT, Inferior wall MI, LVH, LAFB, LBBB
Right Axis Deviation: RAD RALPH = RVH, Anterolateral wall MI, LPFB (hemiblock)
*note that RBBB will NOT cause a coronal axis deviation bc the RV contributes little to the net vector of myocardial depolarization

Bundle Branch Blocks – QRS > 120ms (if <120ms, considered “incomplete” BBB)Screen Shot 2017-11-12 at 11.47.35 AM
RBBB = rSR’ in V1-V3 (right heart leads) that is “M” shaped + widened S wave in V5-V6 (& lateral limb leads)
—R’ = delayed RV depolarization due to the block
no change in coronal or precordial axis as the RV contributes little to the net vector of myocardial depolarization
—V1-V3 have associated T wave inversions
—note that the 2nd R wave is larger than the first, unlike in VT
if V1-V3 also have a humpback appearance, it is Brugada syndrome!
Screen Shot 2017-11-12 at 12.03.38 PM

LBBB = widened S wave in V1-V3 + notched R wave in V5-V6 that is “M” shaped (& lateral limb leads)
—the latter aspect of notched R wave in V5-V6 = delayed LV depolarization due to the block
—left axis deviation (coronal axis) & poor/delayed R wave progression (precordial axis deviation – net vector moves toward RV)
—“appropriate discordance” = the ST segments and T waves point in the opposite direction to the main vector of the QRS complex

How to use R wave progression (precordial axis deviation):
*normal = R > S wave by V4
early R wave progression: posterior wall MI, LPFB???
poor/delayed R wave progression: anterior wall MI, LAFB???, LBBB
*note that RBBB will NOT cause a change in R wave progression bc the RV contributes little to the net vector of myocardial depolarization

Screen Shot 2017-11-12 at 11.33.01 AM.png
*Ant fascicle = anterior & toward right side of LV????
*Post fascicle = posterior & toward left side of LV????

Don’t Miss EKGs
posterior wall MIs: ST depressions in V1, V2, large R waves
—place posterior leads V7-V9
Screen Shot 2017-11-12 at 11.10.35 AM

-**for both inferior and posterior MI, determine whether or not the RV has infarcted
—STE in III > II
—obtain right sided leads…or can just place V4R (opposite of V4), which is most sensitive
–these pts are preload dependent – needs fluids, no nitro or morphine. May have JVD (RV failure) and hypotension

-Wellens: biphasic T

Peds Airway

-upper airway differences: floppier airway, bigger tongue

lung and chest differences: peds pts have much more compliant chest wall (cartilaginous), so have minimal RV (FRC). Ex: as soon as you stop bagging, pt’s chest wall collapses and sats drop fast.

Bagging: slow and hard. Apply PEEP valve to ~10. Kids can tolerate hypercapnia but really need the oxygenation.
-rely on exam: good chest rise and improvement in color (pulse ox lags ~20s)
-#1 = good seal. Bring face up to mask.
-if still see poor chest rise, r/u (floppy) airway obstruction by placing oral airway
-keep pop-off pressure valve open/unlocked to release excess pressure
—the ONLY time to lock it (and deliver high inspiratory pressures >40s) as a last resort if still not getting good chest rise (esp if suspect ARDS

Screen Shot 2017-10-14 at 11.35.46 AM

Intubation:
-if potential airway obstruction, try to avoid paralyzing pt and time insertion of ETT with vocal cord opening
-if lung (rather than airway) problem, can bag indefinitely while call for help
—-it’s ok to take can take first look to get an idea of the airway, then bag back up once sats drop below 90% and then look again. Bag between attempts when SpO2 drops!
-for sticky mucous membranes, *rinse ETT with saline* (rather than use excess lube that may clog up tiny ETT)
-careful not to go too deep with laryngoscope! The blade actually gets in the way impedes your ability to insert the ETT. Put the blade in in superficially and pull up and outward to get your view
-consider using Miller in age <2y

http://www.emdocs.net/the-pediatric-airway-pearls-and-pitfalls/

 

Peds TBI

-key history: +LOC = global cerebral dysfunction (may cause apnea)
—prolonged extraction or intubation at scene (any 2ary injury)

CPP = MAP – ICP

HOB >30 (but <75) – to optimize CPP

Screen Shot 2017-09-27 at 9.49.49 PM.pngClinical signs of herniation:
-decreased MS (“he’s just tired, he hasn’t slept all night”) – RAS in midbrain
-blown pupil(s) = compression of CN3
-Cushing triad = HTN, reflex bradycardia, irregular respiration
-posturing (“he’s agitated”) – deCORticate (limbs go to core, knees flex), decerebrate

Impending herniation on CT: midline shift, effacement of ventricles
-MRI needed to visualize posterior fossa lesions

Salvage therapies (on clinical herniation):
hypertonic saline: good for hypotensive or hemodynamically unstable pts
—-iv pushes in crashing pts: 6.5-10 mL/kg
—-continuous infusion: start at 0.1 mL/kg/h, titrate to effect. Draw Posm.
mannitol: ?localized increased ICP (not supported by lit). 0.5-1g/kg.
hyperventilation (intubated pts) – do NOT hyperventilate prophylactically (worsens cerebral ischemia)

Prevent secondary injury (starting immediately in the ED), specifically:
Screen Shot 2017-09-27 at 9.55.24 PM
^keep head forward-facing (prevent obstruction of venous outflow)
-prevent hypoxemia
-use nicardipine to treat persistently elevated MAPs. Start at lowest dose and titrate to upper limit of MAP goal range
—-goal MAP range is age-specific. Look it up!
-prevent hypo/hypernatremia (goal 135-145)
-avoid fever and hypothermia
-antiseizure ppx (phenytoin) only for supratentorial lesions (not for cerebellar)

Push for ICP monitoring (placement of EVD/External Ventricular Device) regardless of type of bleed.
—in adults, weight risk/benefit of placement for pts on AC