Congenital Pediatric Heart Disease

Congenital Pediatric Heart Disease – Board Review  (PDF with pictures) Basic Pathophysiology Fetal Circulation Have shunts to bypass liquid filled lungs Oxygenated blood from mom goes through placenta into baby via umbilical vein Half the blood goes to liver Half goes to ductus venosus to inferior vena cava where it mixes with deoxygenated blood returning …

Adrenal Crisis Review

Adrenal Crisis, by Dr Nilesh Patel -Also known as acute adrenal insufficiency or Addisonian crisis -No universally accepted definition. Proposed Definition: Acute deterioration in health status associated with hypotension (SBP < 100) or relative hypotension (drop in 20 mmHg from baseline) that resolve in 1-2 hours after glucocorticoid therapy. Generally this occurs in patients with …

Trauma Month!

We love us some trauma here at Joes! Check out our favorite sources of FOMED that supplemented our Tintinalli readings!   Trauma 1 Cant Miss Readings: RebelEM: Ten Commandments of Trauma Resuscitation http://rebelem.com/ten-trauma-resuscitation-commandments/ RebelEM: Spinal Immobilization in Trauma Patients http://rebelem.com/spinal-immobilization-in-trauma-patients/ PEMPlaybook: Multisystem Trauma in Children Part 1: Airway, Chest Tubes, Thoracotomy http://pemplaybook.org/podcast/multisystem-trauma-in-children-part-one-airway-chest-tubes-and-resuscitative-thoracotomy/ Part 2: Massive …

Nitrous Oxide in the Pre-hospital setting

Nitrous Oxide in the Pre-hospital Setting Nitrous Oxide in the Pre-hospital Setting By: Gregory Cassidy M.D., PGY3 Nitrous oxide is a colorless, tasteless gas that is administered in combination with oxygen, often referred to as “laughing gas”.  It is absorbed via the pulmonary vasculature following inhalation through a facemask.  The patient may self-administer the gas …

Resiliency

Resiliency is the human character trait to suffer an insult and return to a state of dis-despair, to return to one’s homeostatic equilibrium. In life we all will encounter problems, errors, disasters. How we deal with it, is how we come to be resilient. As physicians, we must take our own advice and practice what …

Pediatric Pearl – Anaphylaxis

ANAPHYLAXIS By: Hima Khamar, PGY3 4-year-old female presents to ED with parents due to 1 week of cough, fever, congestion, irritability, and decreased PO intake. CXR shows RLL pneumonia, patient is started on Ceftriaxone. 5 mins after the initiation of Ceftriaxone infusion, patient begins to complain of itchy scalp, starts coughing uncontrollably (much worse than …

Pediatric Pearl: UTI (February)

FEBRUARY UTI – Hima Khamar Pediatric Urinary Tract Infection By: Hima Khamar, PGY3 In a previous pediatric pearl, we discussed how to treat febrile infants below 60 days. This pearl discussed management of pediatric urinary tract infection (UTI), but also discusses patients above the age of 60 days with a fever with no obvious source …

COW

Presenting Resident: Katrina D’Amore, PGY4 Chief  Complaint: Palpitations Brief HPI: 36 y/o F G4P2012 at 18 weeks gestation presents complaining of palpitations that began this morning. Patient reports a history of “SVT” multiple times in the past and she even underwent ablation in 2012.  Patient states that “Adenosine never ever works for me.” Patient  denies …

TRANEXAMIC ACID (TXA)

TRANEXAMIC ACID (TXA) By: Hima Khamar M.D., PGY3 Tranexamic acid (TXA) has become a huge asset in the world of emergency medicine when it comes to controlling hemorrhage. The main use in the ED is in traumatic hemorrhage, but there are many other uses for TXA. In this article, I will discuss some of the …

Pediatric Pearl

Pediatric Pearl – January PAIN MANAGEMENT & VASO-OCCLUSIVE CRISIS IN SICKLE CELL DISEASE By: Hima Khamar, PGY3  &  Dr. Patel, PGY16 Sickle cell disease (SCD) is a common disease process we encounter in the ED. There are multiple complaints related to SCD that patients present with such as: pain, fever, stroke like symptoms, anemia. In this …

Physician burnout

As physicians, we all decided to help others. Those of us in Emergency Medicine decided to help others at their most ill, at the most traumatic moment in their lives, or at their wits end as far as where to seek answers. Sometimes we can help, and sometimes we cannot. Regardless of what their reason …

Case of the Week COW #20

Resident: D’Amore/Clayton CC: “My heart is racing.” HPI: 26 year old male with no past medical history presents to the Emergency Room with complaints of palpitations. Patient states that while exercising at the gym just prior to arrival, he suddenly developed palpitations along with associated lightheadedness. He reported one similar episode in the past that …

Pediatric Pearl

OCTOBER Foreign Body Ingestion – Hima Khamar

FOREIGN BODY INGESTION

By: Hima Khamar M.D., PGY3

HISTORY
WITNESSED or UNWITNESSED
Time of ingestion
Description of object: Size, Shape, Length, Width Sharp end, similar object for comparison
Last meal time
History of GI anomaly, surgery or disease

Symptoms:
FB sensation
Refusing oral intake
Drooling, dysphagia, gagging
Choking or coughing with PO intake
Respiratory symptoms: Stridor, Hoarseness
Chest pain
Abdominal pain, vomiting (signs of perforation, obstruction)
GI Bleeding

PHYSICAL EXAM
Vital signs
Drooling, oral lesions
Tripod position
Neck crepitus, stridor
Wheezing, unequal breath sounds
Check ears and nose, especially if FB not confirmed on X-ray
Signs suggesting acute abdomen

 IMAGING TIPS

AP and lateral view of chest, neck, and abdomen

Flat object location on AP:
-Esophagus: Coin appears circular
-Trachea: Coin appears as a slit

Batteries:
-Double ring on AP view
-Step-off between the anode and cathode on lateral view

Magnets:
-Difficult to reliably distinguish single from multiple magnets

Non-radiopaque FB:
-Avoid GI contrast studies for suspected esophageal FBs: May obscure visualization on endoscopy and also increases the risk of aspiration if there is an esophageal FB
-Endoscopy favored

-CT scan may be considered in special circumstances

WHO NEEDS ENDOSCOPY & WHEN 

EMERGENT URGENT NON-URGENT
Esophageal location
-Button battery – NO DELAY
-Obstructive symptoms
-Respiratory distress
-Significant pain
-Sharp pointed objects
-Multiple magnetsStomach location
-Multiple magnets
Esophageal location
-Minimal symptoms
-Sharp longer objects in stomach with no symptoms
Stomach location
–        FB > 2cm wide
–        FB > 5cm long

BUTTON BATTERY INGESTION

Button Battery Facts
-Serious burns can occur within 2 hrs of ingestion
-Symptoms may be delayed
-If mucosal injury is present after removal, observe for delayed complications (esophageal perforation, TEF, vocal cord paralysis, tracheal stenosis, mediastinitis, aspiration pneumonia, perforation into a large vessel)
-Complications may be delayed weeks, months
-Lithium cell batteries are most frequently involved in esophageal injuries
-Determination of battery diameter prior to removal or passage is unlikely in at least 40% of cases
-Assume hearing aid batteries are < 12 mm
-X-ray overestimates the diameter

Coins/Blunt Objects Facts
-Items within the stomach:
—Width > 2 cm, length > 5 cm (less likely to pass pylorus/duodenum)
—Repeat X-ray:
Within 2-3 weeks if Age < 2 yrs or Quarter
Within 1 week if Cylindrical battery
Sooner if symptomatic

Items beyond the stomach:
-Return if symptoms

Coins usually appear larger on the X-ray due to magnification
-Quarter à 24 mm
-Nickel à 21 mm
-Penny à 19 mm
-Dime à 18 mm

 COINS/BLUNT OBJECTS INGESTION

MAGNETS INGESTION
 

RADIOPAQUE/SHARP RADIOTRANSLUSCENT OBJECT INGESTION