![]() Kids are Different - Larger heads, tongues, smaller nostrils - Cricoid ring determines size of ET tube - Bradycardia is a BAD SIGN. Signs of Increased Respiratory Effort - Assumed position - Bobbing head - If kids are pulling off their mask, they might need to be intubated. Positioning - sniffing position, sometimes achieved without any padding - jaw thrust is preferred to chin tilt - always use an oral airway, measure from angle of mouth to angle of jaw DOPE for ETT problems - Check ETCO2 waveform - Dislodged - Occluded - PTX - Equipment Pitfalls Not recognizing compromise early! Not thinking to clean out the nose! Not thinking in terms of axis alignment!
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![]() Timing Matters 1. Single episode - concerning for impending airway compromise - get help! a. Febrile? - tonsills, abscess, mono, croup, tracheitis, epiglottitis, bronchiolitis b. Afebrile? - airway foreign body 2. Recurrent a. Inspiration - obstruction is above the level of the vocal cords; - Ex, laryngomalacia - from bith; worse with supine. eating or upset b. Expiration - below the vocal cords; - Ex, tracheomalacia in hypotonic kids; vascular anomalies c. Biphasic - at the level of the cords (or just below) - Ex, subglottic stenosis/ hemangioma (get bigger over the first year of life before they start to shrink); vocal cord dyfunction; esophageal foreign body ![]() The Return ED Visit
"BB" Shot to Right Groin...
- Bullet embolism is extremely rare. - Requires multidisciplinary management. - Consider possibility if missile lays next to major vessels or bullets are found in unexpected locations. - Venous more common than arterial FLU 1st presentation - viral symptoms. 2nd presentation - viral symptoms. 3rd presentation (within 24 hours) - SHOCK with Resp Failure
Tamiflu is not magic...
![]() TRAUMA PATIENTS - CT if there is abdominal tenderness or a seatbelt sign - Seatbelt sign- Not just abrasions! They have bruising / ecchymoses. - With Seat Belt Sign, incidence of hollow viscus injuries (17%); splenic injuries (10%) - Things that are easy to miss on CT scan - Diaphragm injuries - think about in abdominal pain w/ dyspnea or chest pain - GI tract injuries - free fluid; bowel in discontinuity - Pancreatic injuries - difficult to tell difference between contusion and ductal injury - - Important because these need intervention and waiting will be detrimental; - ERCP or MRCP - definitive diagnosis ABDOMINAL PAIN IN THE ELDERLY - Have a low threshold for imaging elderly patients with abdominal pain - Abdominal pain in elderly - 60-70% admitted; 30% with surgical process; 10% with return ED visits; 5% mortality - Exam is not as reliable!! - CT: diagnostic in 85% of people who had emergent surgical process - Contrast? IV/ PO/ both/ CTA?- if concerned about vascular - get CTA > Contrast allergy - only true contraindication - airway compromise > CIN - Cr rising >0.5 mg/dL or 25% from baseline; > Most elderly people have risk factors Cr > 1.5-2.0 > Consider no contrast - if giving contrast - HYDRATE - Metformin > Manufacture warning - no metformin 48 hrs before or after IV contrast; > Increased risk - contraindications to metfomin, preexisting renal dysfunction BOWEL OBSTRUCTION - Diagnosis - Dilated loops of small bowel - diameter > 2.5 cm; - >50% difference in caliber before and after transition - Acute Obstruction Series X-rays - help if diagnostic; not so much if "normal" or "non-specific" - If an obstruction series is nondiagnostic and you suspect bowel obstruction, get a CT - PO contrast may add functional info, but often difficult to get into the patient... and not necessary. - PO contrast is almost never needed in CT scanning OTHERS - Diverticulitis - fat stranding; bowel wall thickening - CT with IV contrast best image - Appenditicits - senstivity 90% with no contrast; 100% with contrast - Mesenteric ischemia - CT angio is the best - Acute cholecystitis - cholesterol vs pigment stones can be seen on CT - Ultrasound is the first best test for suspected gallbladder pathology - Pancreatitis - Generally don't need imaging. - Consider imaging if changing clinical picture; not typical; no classic pancreatitis risk factors (to r/o malignancy) ![]() Hemophilia A/B - Hemophilia A much more common than hemophilia B - present with delayed bleeding - severity: severe( spontaneous bleeding), moderate( occasional bleeding), mild - inheritance: X linked recessive, 30% spontaneous - Dx- often done early in life, can get PT, PTT, BT, platelet count if no Dx and bleeding Hemathroses: - ankles, elbow, knee - 15-40x risk septic arthritis, arthrocentesis only if concern for septic joint or no improvement in 24 hr- Treat with major dose factor if obvious effusion (if not, just routine dose), RICE, crutches, follow up with hematology Muscle bleeds: - Dx with US, CT, MRI - Watch out for compartment syndrome (especially iliopsoas) or airway compromise CNS hemorrhage: - Give factor prior to getting CT. Therapies: - Factor 8 major dose: 50 U/kg, Routine dose 25 U/kg - Factor 9 major dose: 80-100 U/kg, Routine dose 50 U/kg - talk to family and patient, use their factor if available, needs it's own IV, avoid IM injections - Factor must be reconstituted, 30 minute turnaround call pharmacy ahead of time - DDAVP release Von willebrand ( 0.3 mcg/kg) - cryo, antifibrinolytics, fibrin glue ![]() CORE CONCEPTS
Special Circumstances:
1. Spearing injury - duodenal injuries, rectus injury with hernia, pancreatic injury - handlebar, ski pole, - duodenal hematoma- CT with oral contrast - pancreatic injury - get lipase (usually presents in delayed fashion) 2. Seatbelt sign - Ecchymosis / Bruises ... not just abrasions - get CT, give good return precautions or have them come back for check 3. Geriatric - VS misleading, abdominal exam insensitive, lactate > 2( sensitive to occult shock) - liberal role for CT - low threshold for admit PECARN Rules: get CT if, - Abdominal wall trauma, seatbelt sign - GCS< 14 - Tenderness - Chest wall trauma - Intoxication, - Hematuria - Elevated LFT - Painful distracting injury ![]() Pediatric Tracheal Injury - Trach injuries- 15-50% mortality in 1st hour - Goals- control airway, ensure respiratory sufficiency - Anatomic differences- large mandible, head and short neck Indications for Intubation after Neck Trauma - stridor, dyspnea, hypoxia, expanding hematoma, - If pt is "stable," call anaesthesia, tube in OR with bronch - If more critical; try awake or minimally sedated intubation (Ketamine and no paralytic), prep surg airway, fiberoptic scope INTUBATION CAN GO BADLY... so be careful! You can disrupt tenuous attachment of trachea and it will retract back into chest (super bad). Immunodeficiency
- Primary: hereditary or genetic causes antibody related, B and T cell deficiency - Secondary- acquired - Red flags for primary immunodeficiency - family hx, FTT, IV abx and hospitalization to clear infection, recurrent candidiasis, recurrent abscesses, chronic diarrhea - >6 infections/yr, >2 serious sinus infxn or pneumonias, >2 sepsis/meninigitis in lifetime ![]() Finger Infections - Paronychia- disruption of nail fold/ plate, mixed flora + staph - erythema swelling tender, can extend into eponychium - tx- warm soaks, po abx, I&D - Felon- infection of hyponychium, progressing to pulp - tx- soaks, elevation, abx; surgical- incision options for i&d - may use transverse incision here, must disrupt all septae, - wick/drain that is changed at 24hrs, - abx- iv in ed - Flexor Tenosynovitis- infx of synovial sheath around flexor tendon, - mechanism is penetrating injury, may be direct spread from other area; - s. aureus; - kanaval signs - flexed posturing, pain with passive extension, fusiform swelling of digit; TTP over palmar aspect of digit - tx- early- admit, obs, abx but will usually go to OR Nail Bed Injuries - get an xray, 50%with tuft fracture - repair: removal of plate, elevate proximal nail fold if needed; wash out; closure 5-0 chromic, 4-0 nylon for surrounding skin - protection of repair- native nail is ideal, or silicone, aluminum; secure with suture; protect scaring of nail fold down Tip Amuptations - Preserve fxnal length, durable coverage - <1cm squared can be healed by 2ndary intention; 4-5 weeks to heal, pain control, abx, tetanus; - Find digital nerves, pull out, trim to avoid neuromas. - Exposed bone- need rongeurs, bone cutters, take joint surface off - If you close primarily, space out sutures - Dressings non-circumferntial, loose2x2, cast padding, bias Finger Dislocations - palmar dislocation - recreated deformity then volar force - no splint needed, buddy tape - volar dislocations - hyperflex, dorsally reduce, splint in extension ![]() * Propofol is used in >95% of residency training programs - well established to be safe & effective* > Propofol - Fast onset (2-5 min) fast recovery (5-10 min) - Great for short painful procedures - fracure DL, I&D, etc - Possible ADR - hypoventilation, partial obstruction, apnea, hypotension, bradycardia - No analgesia - however most patients do not recall or report pain; if you give additional opiods - taper propofol dose > Get equipped! {These are specific for CMC at current date} 1. Oral & nasal airways, O2, ambu bag with mask, direct or video laryngoscopes, ET tubes, suction, ECG monitoring with pulse ox, End tidal CO2 , code cart, narcan and flumazenil 2. For ASA class 1 & 2, Mallampati class <3 - consult anesthesia if outside these guidelines or pregnant 3. NPO for 2 hrs from clear liquids, 6 hrs nonclear liquds & food; deviation MUST be justified by attending physician 4. Need 2 physicians - attending needs to push meds 5. QA review - things that must be documented - apnea > 15 sec, ETT PPV, O2 dsat < 90% for > 90 sec, vomiting, unexpected change in vital signs, use of reversal agent, emergent anesthesia consultation, NPO guideline deviation 6. Nurses CANNOT push; only attending can push or a resident under direct supervision of attending not also doing the procedure (required 3 docs at bedside) 7. Doses - 0.25 - 1 mg/kg bolus (adults and peds) then q3-5 min can give 0.2-0.5 mg/kg; - Draw up 1 mg/kg & infuse slowly over 3-5 min 8. Consider lidocaine or fentanyl predosing to help ease pain at injection site (fentanyl 1mcg/kg IV in same line you're giving propofol) ![]() Wide Complex Tachycardia... and Overthinking If it is a Wide Complex Tachycardia... DON'T OVERTHINK IT!! Treat it as VTACH! > Wide complex tachycardia - vtach 80% of the time; but also consider SVT with aberrancy or preexcitation, toxic metabolic (hypomag, hyperk, TCAs IC antiarrythmics) or pacemaker related > Regular wide complex tachycardia - Unstable - synchronized cardioversion > Cardioversion may be resistant if tox/metabolic > Consider bicarb if resistant > If recurrent start amio, procainimaide or lidocaine - If stable - procainamide; amio/lido |
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