![]() Dr. Stacey Reynolds - Pediatric Fever 0-28 days - don't overthink it! - full work up 29-90 days - to tap or not to tap? > If low risk - well appearing child full term with normal physical exam without evidence of focal bacteria infection - then blood cultures, UA (don't trust the dip) - if meets low risk criteria - can either choose to not tap & DC w/o antibiotics or tap, - if no pleocytosis, give dose of abx and DC home (if reliable parents) 3-36 months - does fever exceed 102.5? If not, no further testing is needed!! > Does patient have an obvious source of fever? if so treat. If not & febrile > 102.5 test > UTI - Test all with high risk (prior UTI, high grade VUR, renal abnl); uncircumcised male < 1,circumcised male < 6 months, females < 2 yrs > Bacteremia - If less then 2 prevnar (meaning 2 shots, then 2 weeks after 2nd set of shots) test - CBC, blood cultures - if WBC > 15K, ANC >10K, treat with ceftriaxone - If > 2 prevnar blood cultures at MD's discretion - If hyperpyrexia (temp of 106 or above) blood cultures at MD's discretion (based on small study that showed 10% bacteremia in hyperthermic kids - this was pre Prevnar) > PNA - CXR only needed if evidence of lower respiratory symptoms, hypoxemia, persistent fever, T over 103, WBC > 20K > Herpes - we overtest! (only 2% of what we send comes back positive > 60 day old febrile kid with + UA - to tap or not - data is still out
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![]() FOAM- Free Open Access to Medical Education > Web 2.0 - collaborative info; 2 way connections > Build your filter - feedly, flipboard, pulse > Pitfalls of Social Medial / FOAM - once you post it's hard to get rid of... so always BE PROFESSIONAL!! - peer review? The more partitioners who use FOAM, the better the inherent peer review becomes. - quality can become an issue (know who you are listening to). > Always read and listen with skeptism > Always ask questions before implementing things you learn > When in doubt leave it out > Ask yourself - is this anecdotal? ![]() Pneumococcal Meningitis with HUS Usually serotypes outside of 13-valent vaccine If you suspect, initial treatment with: - Cefotaxime 300 mg/kg/day IV (max 12g/day) in 3 doses OR - Ceftriaxone 100mg/kg/day IV (max 4g/day) in 2 doses PLUS - Vancomycin 60mg/kg/day IV (max 4g/day) in 4 doses Pneumococcal HUS Recognize classic triad: - Microangiopathic hemolytic anemia - Thrombocytopenia - Acute Kidney Injury Sources: - PNA - 70% - Meningitis - 20-30% - Others - Otitis, sinusitis, bacteremia - Not like STEC-HUS - Needs Tx with Abx - Pneumococcal leads to higher M&M Hemoptysis from 5-yr old retained GSW Delayed Pulmonary Hemorrhage from FB - Up to 30 yrs latency reported - Present with intermittent hemoptysis Complications: - Pulm Art or Aortic Pseudoaneurysm - AVMs with R -> L shunts - Embolization - arterial or venous Massive Hemoptysis No universal definition - "Is this life threatening?" Initial ED Management - ID bleeding lung and position dependently - A - Establish airway (8-0 ETT or bigger for bronchoscope) - B - Ensure good gas exchange on vent - C - Stop bleeding! Restore volume, give PRBCs, reverse coagulopathy,etc... Regular Wide Complex Tachycardia
- Consider VT until proven otherwise!!! - 80% is VT by numbers - Algorithms to differentiate SVT are difficult to remember - If you treat for VT, won't harm SVT - Nodal blockers for SVT can send VT into VF -- PLACE PADS with Adenosine! A great analysis of EP and Cardiologist failure in applying Brugada to electrophysiologically proven VT. Two fantastic talks from the ever-salient @amalmattu - VT vs SVT with Aberrancy - Adenosine Sensitive VT ![]() Iron - Metals in salt form cause VOMITING - 2+ ferrous sulfate in absorbable state → 3+ state for storage/transfer Chewable tablets - 10-18mg/tab - Hard to overdose on these - “minimally toxic” Iron carbonyl - elemental iron - low toxicity Iron filings in hand warmers → if ingested, could be toxic Prenatal vitamins - greatest morbidity - look like candy
Injuries
5 stages of toxicity 1. ingestion to 6h - vomiting!! - abd pain - diarrhea - melena/hematemesis - bowel wall necrosis/infarct 2. 6h - 24h - quiescent stage - symptoms appear to resolve - continued worsening acidosis - if ingestion was small → course usually stops here - if ingestion was large → this stage is sometimes skipped and go onto more badness 3. 12h - 48h - crash - CV, Liver, GI, ARDS, CNS lethergy/coma, Acidosis 4. 2d - 3d - independent of severity of stage 3 - fulminant hepatic failure - >1000 iron level 5. weeks later - mucosal injuries/strictures Iron Levels
Workup - electrolytes -- AGMA - coags if bleeding - LFTs if sick - APAP level for intentional ingestion -- think about synergy - x-rays -- abd → see pills sometimes Management
use: hx of sxs, pos xrays, super high iron level 100mg binds 10mg iron IV admin -- 15mg/kg/hr for rate but may not get in enough Side Effects: hypotension, tachycardia, diuresis visual/ototoxicity, abd pain, fever, diarrhea increased risk for yersenia enterocolitica sepsis stop when acidosis resolves Core Concepts: elemental dose is what’s toxic no charcoal for tx look for anion gap metabolic acidosis check an xray for pills, but if it’s negative doesn’t mean pt isn’t sick there’s a quiescent phase of toxicity deferoxamine is an option for iron chelation pay attention to units used to quantify iron --usually in dL ![]() DDX of projectile vomiting
Imaging US - muscle length >17mm positive, width >3mm positive - tips: need true sag, need relaxed muscle UGI - If US not available - string sign ![]() > Up to 100,000 deaths in the US hospitals each yr related to medical errors > Types of errors 1. Affective Errors - idea that we may treat a patient differently because there is something about them or about the circumstance that evokes either a negative or positive emotion - Positive - more time spent; some literature that we may avoid painful procedures - Negative - premature closure, less time, less care, less analgesia 2. Cognitive errors - Faulty knowledge, faulty data gathering, faulty synthesis, affective errors, external factors - Feedback failure - if you don’t know you screw up you don’t change your thought processes or practices = Confirmation bias; want to avoid over recalibration too - System 1 thinking - Illness script - pattern recognition comes from education and experience > Fast but can be unreliable, dependent on experience and not all illness follows illness scripts - System 2 Thinking - Cognitive Checkpoints - specific tests Cognitive Dispositions
- Premature closure = most common error in acute care medicine
Strategies to avoid error a. Admitting you have a problem is the first step b. Improve accuracy of judgements through cognitive aids c. Simulation d. EVERYTHING around you on any given day will influence how you take care of your next patient e. Metacognition - “thinking about thinking” -requires self awareness, ability to be self critical, & ability to introduc deliberate pause during the decision making process Train yourself to do a diagnostic pause - think about serious or alternative diagnosis, evaluate feelings, make sure there’s no extraneous information you’re missing, evaluate if theres anything today that’s impacting your decisions ![]() Myth #1 - "Kids aren't little adults." - Less a myth and more a good idea gone awry. - We don't need to consider kids to be like aliens. - Just take into account the anatomic and physiologic differences, but don't let them frighten you. - They are a unique patient population (similar to all of your other unique patient populations). Myth #2 - "IVF are faster than ORT." --IVF are effective and often expected, but not always easy. --Painful, makes unhappy parents and unhappy patients. --ED LOS: ORT = 225 vs IVF = 358. Myth #3 - "Lidocaine makes LP worse." -- Neonates do feel pain, have greater sensitivity, and are more susceptible to long term effects. -- EMLA is safe, reduces pain during LP. -- Makes your job easier!! (keeps them from wiggling) Myth #4 - "To hold for LP, bend them into a donut." -- Don't do this. -- Hyperflexed neck leads to SUBOPTIMAL AIRWAY ALIGNMENT. -- Best airway position is sitting up with legs flexed and neck neutral. Myth #5 - You can adjust for RBCs in the "Bloody tap." -- Correct with 1:500 for WBC, etc etc -- these formulas don't work. -- When concerned for meningitis, be conservative WBCs. -- Do not adjust the WBC for the RBC in a traumatic LP. Use the total WBC. Myth #6 - "Nebulizers are better than MDI." -- Evidence shows that MDI are AT LEAST as good as nebs, if not better. -- MDI is faster and reinforces good MDI use, which can help prevent patients from needing to return to the ED. TOA
- Has same risk factors as PID - Multiple sexual partners - 15-25 yrs old - History of prior PID 2 forms - Tobuovarian complexes (agglutination of pelvic organs +/- bowel) - Collection of pus - Often begins with DTD, but once abscess forms it is usually polymicrobial > Think about when you have suspicion for PID but are acutely ill, failure of treatment with normal therapy; diffuse abdominal pain > Imaging = US is 1st choice DDX
- septic hip or osteomyelitis, discitis, transient synovitis; trauma, congenital, neoplastic, SCFE, LCPD > Your goal should be to rule out potential catastrophic disease Physical Exam - undress!! - watch gait (antalgic gait - less time in stance phase on injured limb; trendelenberg, leaning over the side of the affected hip) - Evaluate for point of maximum tenderness - Hip pain > think spine - Knee pain > think hips - Range of motion - logroll thigh - gives good range of motion of hip Imaging - plain films are a good place to start - image everything if hard story or difficult to pinpoint pain Labs - ESR, CRP, CBC with diff, blood cultures Diagnosis - Transient Synovitis - get hip XRay - bony landmakrs are normal; may see widened joint space - may have joint effusion on US > Management = Rest and NSAIDs; f/up with ortho vs peds in 24-48 hrs; > Kids can limp on and off for a month > Can look like septic hip, usually follows URI; usually had normal labs > Kocher Criteria - 4 criteria: non-weight bearing on affected side; ESR > 40, Fever, WBC >12K - All 4 = 99%; 3 criteria 93%; 2 criteria = 40%; 1 criteria,3% chance of septic arthritis - Toddlers Fracture - Common in young kids; accidental - Stable; do above knee cast with knee flexed - The developing Bone - thicker periosteum, bone is more eleastic; avulsion before tendon rupture - Allows for unique fracture type: Torus and Bowing - SCFE - widened physis; Kleins line - should have bone on other line of femoral neck (get AP and frog leg views) > Stable - kid can walk (at all) - 90% - DC home; nonweight bearing; f/up with ortho; > Unstable - unable to walk (10%) - higher rate of avascular necrosis - non weight bearing; admit to ortho - Septic Arthritis - Common in large joints; severe pain; muscle spasms; fever - Staph and think Neiserria in sexually active teens > Be aware that little kids (< 3 months) have adjacent osteomyelitis (need MRI); 6mo-2 yrs - 50% will have associated infection > Aspirate and OR (antbx after debridement) - ortho urgency ![]() Infection > 2-7 days post abortion - ascending infection; risk factors include operative intervention, retained POC advanced gestation Retained POC = endometrial stripe >5mm on TVUS > Sx - history, fever (though common to not have a fever), abd pain, discharge, vaginal bleeding, tender uterus, adnexa > Antibitoic regimens - Outpatient - levaquin, flagyl; - Inpatient - vanc, zosyn +/- amp/gent vs vanc and meropenam; Remember tetanus Rh immunization - Rh negative mom, Rh positive fetus - with mixing of maternal and fetal blood; not a lot of great clinical evidence out there so unclear if our Rhogam dosage is correct, unclear how much maternal bleeding is required to have alloimmunization |
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