1. Signs and symptoms of an Upper GI bleed in the pediatric patient
-most common presentation is hematemesis -melena also common presentation -many things mimic GI bleed -> food coloring, raw meats, swallowed blood from oropharynx 2. Differential diagnosis for acute pediatric upper GI bleed -determine if variceal vs nonvariceal -variceal bleed (uncommon but can be life threatening)-> portal HTN from congenital liver pathologies -mucosal bleed -> gastritis, esophagitis, caustic ingestion, foreign body most common in pediatrics 3. ED diagnostic workup for an upper GI bleed in a pediatric patient -CBC, BMP, LFT's, and Type/Cross essential to the workup 4. ED Management of Pediatric Upper GI bleed patient -Place an NG tube -Get GI, Surgery, and Interventional Radiology Involved early -Octreotide and vasopressin are important treatments for variceal bleed -For mucosal bleeds control acid production
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![]() “You get to use the word ‘dizzy’ once.” Andrew Asimos Categories of Dizziness
Posterior Circulation Anatomy Supplies: 1) Brainstem 2) Cerebellum 3) Thalamus 4) Auditory/vestibular structures 5) Visual occipital cortex Neuro Exam for Posterior Circulation
Bias
![]() When should I think about infective endocarditis and septic emboli? -Consider in patients who raise your suspicion for sepsis and have any of these risk factors:
What exam findings are suggestive of IE? -Some are more specific than others. Roth’s spots, Osler’s nodes, and Janeway lesions are relatively rare but are essentially illness defining. More sensitive but less specific findings include cardiac murmors, petechiae, splenomegaly, and splinter hemorrhages. Who gets septic emboli? -Patients with large lesions, unstable/multiple lesions, and left sided lesions are most likely to embolize secondary to higher left sided pressure gradients. Where do the emboli go, and what does that look like? - Right sided lesions (without PFO) go to the lungs, and typically manifest clinically as:
-Left Sided lesions
Take Home Points
![]() ASK, INFORM, and OFFER
Emergency Contraception
Contraceptive emergencies IUD related:
IUD + ectopic:
OCPs:
![]() When managing patients with AG Metabolic Acidosis:
A CAT PILES MUD can help broaden your differential A - Acetaminophen C - CO, CN A - AKA, Starvation ketoacidosis T - Toluene P - Paraldehyde, phenformin, propylene glycol I - Isoniazid, Iron, Ibuprofen, Ischemia L - Lactate elevation E - Ethanol, Ethylene glycol S - Salicylates M - Methanol, Metformin U - Uremia D - DKA ![]() Why is rabies important? Rabies has the highest case fatality rate of any infectious disease, and it is entirely preventable. Although it is rare in the United States, it is very common in the developing world and is the cause of over 20,000 deaths per year in India alone. What is an infectious exposure? The direct exposure of saliva, CSF fluid, or CNS material to exposed wound or mucosa places an individual at risk of infection What is not an infectious exposure? The direct exposure to urine, feces, or blood or exposure of saliva to intact skin does not place an individual at risk of infection. How do we treat an exposure? Post exposure prophylaxis (PEP) includes a combination of local wound care, a one-time dose of human rabies immunoglobulin, and a total of four doses of rabies vaccine (on day 0, 3, 7, 14). When do we treat an animal bite? PEP is indicated in bites caused by bats, raccoons, foxes, skunks, possums, and large rodents (beaver and woodchuck) when the animal cannot be tested within 72 hours after the exposure. PEP is also indicated in bites caused by dogs, cats, or ferrets that cannot be observed for a 10 day period by the local health department. When do we not treat an animal bite? PEP is not indicated in bites caused by dogs, cats, or ferrets that can be observed for a 10 day period by the local health department, herbivores, or small rodents (rats, squirrels, etc.) ![]() • Avoid diagnostic momentum from the prehospital setting and always perform your own cervical spine evaluation. • Patients at risk for cervical spine injuries have a high-impact mechanism (diving, motorized vehicles, surfing, etc.) and/or those who present to the ED with an abnormal physical exam (altered mental status, neurologic deficits). • The risk of delayed ICH in patients on anticoagulants is exceedingly low. • Decision to observe or repeat head CT should be individualized per patient presentation. • Always discuss risks of delayed ICH with patients and their families prior to discharge. ![]()
- AP compression - Vertical shear Resuscitation essentials:
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![]() - Neonate in respiratory distress: remember NRP! - Neonate in respiratory distress with true unilateral absent breath sounds = Congenital Diaphragmatic Hernia??!!-> confirm with CXR Congenital Diaphragmatic Hernia (CDH) - Neonates likely have high risk for pulmonary hypertension! - Do not give PPV -> worsens GI distention/lung compression = worsening pulmonary HTN - In neonates intubate early to prevent hypoxia (hypoxia worsens pulmonary HTN) with low pressure vent settings - Maintain systemic BP to reduce right to left shunting - Older children with CDH, less likely to have significant pulmonary HTN, keep calm and try to avoid intubation - Persistent/worsening cyanotic neonate - think cyanotic congenital heart defect -> Start Prostaglandins - Remember Prostaglandins cause apnea, will likely need intubation - Neonate in extremis = call for back-up early! |
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