Happy Holidays!
Lovell Study Guide Peds 3
Congenital adrenal hyperplasia: These kids need dextrose, saline, and hydrocortisone.
Dextrose dosing: %Dextrosex ml/kg should always equal 50
Adult D50: 50% dextrose X 1ml/kg=50
Child D25: 25% dextrose X 2ml/kg
Neonate/Infant: D10: 10% dextrose X 5ml/k=50
CAH occurs when the adrenal glands do not produce enough cortisol and aldosterone hormones, and instead produce too much of the male-like hormones, androgens.
The overproduction of male-like hormones can affect a baby before it is born. Girls with CAH may have an enlarged clitoris at birth, and may develop masculine features as they grow, such as deepening of the voice, facial hair, and failure to menstruate or abnormal periods at puberty. Girls with severe CAH may be mistaken for boys at birth. Boys with CAH are born with normal genitals, but may soon become muscular, develop pubic hair, an enlarged penis and a deepening of the voice sometimes as early as two to three years of age. The testicles of boys with untreated CAH cannot function well and may not make sperm normally.
Children’s growth also may be affected. Their long bones have growth plates at the ends. These plates allow for growth and eventually “close” when normal adult height is reached. High levels of androgens may cause rapid early growth. However, if these high levels of male-like hormones continue, the growth plates may “close-up” too early resulting in a very short adult.
In its most severe form, called salt-wasting CAH, a life-threatening adrenal crisis can occur if the disorder is not treated quickly. An adrenal crisis can cause dehydration, shock, and death within 14 days of birth. Other forms include Simple Virilizing CAH and milder forms. (Texas Department of Health Reference)
*Torus Fracture
*Kerion needs 8 weeks of oral griseofulvin. Don’t I&D this!
*Red Flags for Syncope in Kids. We also discussed the minimal work up in the ED for syncope is listening for a murmur, check a glucose, and get an EKG.
*Eczema Herpeticum. This is a complication of eczema. If you see vesicles where the patient normally has eczema then treat with anti-viral and admit. These kids usually look somewhat ill.
*Crash and Burn mnemonic for Kawasaki’s(Thanks to John Meyers)
The leading cause of death in sickle cell disease is infection. Sickle Cell patients have functional asplenia. Consult with hematology for kids with fever and sickle cell disease. Get a blood culture and give ceftriaxone. Some kids with sickle cell disease and fever can go home on a case by case basis if well appearing and OK’d by Hematology.
For sickle cell pain crises don’t give a lot of IVF. Over-aggressive IV fluids can increase the risk of acute chest syndrome. If kids can drink then let them just drink. Elise was OK with maintenance fluids but felt that boluses were not indicated. In a similar fashion don’t give O2 unless the patient is hypoxic.
*MEmnemonic for Salter Harris Fractures
Christine made the point that on a recent EMRap podcast, there is a growing sense that Salter 1 injuries generally do very well and don’t necessarily need a post mold. Elise felt that it depended on the level of pain and mechanism of injury. Harwood made the point that Salter 5 fractures are a serious problem for kids. You don’t want to miss these injuries. Salter 5 injuries will look on xray like the growth plate is compressed or absent in comparison to the other side. Kids with Salter 5 fractures will have arrested limb growth and will have assymetric limb lengths making it difficult to walk or use their arms
For hemophiliacs get Factor 8 into them as soon as possible. Give the Factor before diagnostic studies. For head injury give 50u/kg to attain 100% activity. For hemarthrosis give 25u/kg to attain 50% activity.
*Toddler’s Fracture is a spiral fracture of the distal tibia in a toddler. It is not a fracture of abuse.
Bonder M&M
I will not include details of the case to maintain confidentiality. I will only give the teaching points.
Steroids have never shown any functional improvement in patients with spinal cord injury. Since 2013 steroids are no longer recommended for spinal cord injury.
Surgery is still indicated for spinal cord injury if there is a possibility of decompression o the cord or stabilization of spine.
It is important to re-evaluate all patients in the ED. Assess them carefully if they have any new complaints. Document your re-evaluations in the chart.
Be cautious of cognitive biases that alter your thinking about the patient. Our normal human responses to patients’ behavior can sometimes cause us to not evaluate them optimally.
McDowell Thrombolytics in Sub-massive PE
Case: 30yo male with PE. Patient has enlarged RV on echo. BP is 110 systolic. HR is 112. BNP and Troponin are both elevated. EKG has signs of right heart strain.
*Definition of Sub-massive PE. Massive PE has hypotension, shock, or arrest.
*Daniels Score for EKG findings of right heart strain in the setting of PE.
Ekos Catheter is a catheter that goes into the pulmonary artery. It gives off sound waves that weaken fibrin strands of clot and the catheter also gives intra-arterial thrombolytic in a smaller dose than intravenous thrombolytic.
Back to the case, we discussed the management of the initial patient. Elise, Erik, and Harwood made the point that there is no consensus on how to manage this patient. The benefit of thrombolytic treatment is that it prevents post-PE pulmonary hypertension. This seems to be more important in younger patients who are more active, need towork and have longer lives ahead of them. However whether you choose heparin, LMWH, TPA, or Ekos catheter it is on a case by case basis. Erik felt that for sub-massive PE he would lean toward TPA if the bleeding risk was low. He would definitely give TPA for massive PE regardless of the bleed risk.
*Management of PE
Alexander Pediatric TraumaSafety Lecture
*Children are not just small adults. It’s worth reading this slide.
We discussed a proposed Pediatric Trauma Protocol with defined roles for EM/PICU/Surgery responders at the Trauma Resuscitation.
There seemed to be consensus that there should be the same number of people responding to Pediatric Trauma Codes every time. That number of responders should be capable of a maximal response for severe trauma cases. The team captain can dismiss responders rapidly if the patient is not severely traumatized. Also there was consensus that assigned roles and assigned locations around the bed were good ideas.
*Trauma Team Assignments
Iannitelli M&M
I will not include details of the case to maintain confidentiality. I will only give the teaching points.
Comfort measure for a terminally ill patient who is DNR: 2mg of morphine Q 1 hr PRN dyspnea/tachypnea/respiratory rate >24.
If a patient has a public guardian, call the public guardian to find out about the patient’s medical problems and their DNR wishes.
Make a copy of the DNR/POLST form and affix it to the patient’s bed.
If you are admitting a patient for Hospice, call the physician who will be writing the admit orders to be sure there will be no confusion about DNR status.
West comment: If you have an elder family member who has specific DNR wishes, have the DNR form on every entrance to the home and on the wall above their bed.
Samir Patel comments: I always give the family a clear picture of what the patient’s life will be expected to be like for the next six months. The most common response of families to a patient who will not be independent is to “just make the patient comfortable and do heroic interventions”.
A Healthcare Power of Attorney can overturn a DNR form.
Munoz Safety Lecture Medication Errors
Medication errors are the most common type of safety events.
In the ED we have time pressure, multiple patients, patients are strangers, we use high-risk mediations and deal with high risk populations (elderly, pediatrics, pregnancy, comorbidities), and we have multiple distractions and interruptions. We work in the almost perfect ecosystem for error.
*Phases of Medication Dispensing
*Errors in Medication Dispensing
Most medication errors occur in the prescribing stage: wrong medication, wrong dosing, lack of knowledge about medication.
Avoid trailing 0’s when writing drug dosing. It can result in over-dosage.