Episodes

Sepsis guidelines are constantly changing. Refer to your national guidelines or institutional protocol for most up to date treatment information. Introduction * Sepsis is bad and needs to be treated aggressively* Confusion around multiple conflicting guidelines and requirements* Surviving Sepsis Campaign recommendations* CMS requirements* Sepsis-3* SOFA/SIRS/qSOFA* Institutional protocols Sepsis-3 Proposed Recommendations * Screen for sepsis by applying qSOFA instead of SIRS criteria* qSOFA ...

Physiology * RBC hemoglobin breakdown -> unconjugated (indirect) bilirubin* Unconjugated (indirect) bilirubin -> liver -> conjugated (direct) bilirubin* Conjugated (direct) bilirubin -> Eliminated in stool Causes of Hyperbilirubinemia * Increased RBC turnover* Sepsis* Rh incompatibility* RBC disorders* Maternal diabetes* Scalp hematoma* Decreased/slow conjugation by the liver* Peaks around day 5 of life* Congenital liver disorders* Gilbert/Crigler Najjar Syndromes* Breast milk jaundice* Breas...

Clinical Presentation * Incidental finding on routing CBC* Petechiae/purpura* Mucosal bleeding* Epistaxis* Gingival bleeding* Hematuria* Vaginal bleeding 5 Major Causes of Thrombocytopenia * Thrombotic Thrombocytopenic Purpura (TTP)* Clinical presentation (pentad)* Thrombocytopenia* Fever* Microangiopathic hemolytic anemia* “schistocytes”* Neurologic abnormalities* Renal dysfunction* Physiology* Low ADAMTS13 results in impaired vWF breakdown* Widespread “platelet plugs”* Treatment* Plasma exc...

The hardest part about this chief complaint is expanding your differential beyond gastritis!!! Step 1: Expand Your Differential Diagnosis * Early appendicitis* Bowel obstructions* Myocardial infarction* Elevated ICP* Diabetic Ketoacidosis Step 2: Give a Testing Plan * High yield tests to consider* EKG – older adults* Pregnancy test – women of child bearing age* Electrolytes – most patients* Other tests to consider* CBC* LFTs/Lipase* Urinalysis Step 3: Give a Treatment Plan * IV fluids (1L ...

Organ Failure Complications * Hepatorenal syndrome (renal failure)* Decreased urine output* Labs show elevated creatinine* Admit to hospital (high mortality)* Hepatic encephalopathy (brain failure)* Introduction* Liver clears ammonia from body* In advanced liver failure, ammonia increases* Symptoms* Altered mental status/confusion* Asterixis* Treatment* Lactulose* Binds ammonia and is excreted* Rifaximin* Eliminates bacteria responsible for producing ammonia Portal Hypertension Complications ...

Non-Accidental Trauma * Estimated 10% of pediatric patients are victims of abuse* Sexual abuse* Physical abuse* Neglect* Common red flags* Changing story* Story that doesn’t make since* Delays in seeking care* Unusual bruising locations* Torso* Ears* Neck* Common tests if non-accidental trauma suspected* Skeletal survey x-rays* Head CT* Especially if altered mental status* Abdominal CT* Especially if abdominal trauma* Report to child protective services (CPS) Tummy Ache * Necrotizing enteroco...

Don’t be overwhelmed knowing/memorizing each inborn error of metabolism. The basic approach is actually quite easy!!! Inborn Errors of Metabolism (IEM) * Almost always result in one of the following three clinical abnormalities* Buildup of toxins* Ammonia* To test for this, obtain an ammonia level* Buildup of acids* Methylmalonic acidemia* To test for this, obtain electrolyte panel and look for decrease CO2* Shortage of glucose* Glycogen storage disorders* To test for this, obtain a blood gluc...

Common Chief Complaints * Cyanosis* Difficulty feeding* Failure to thrive Cyanotic Heart Lesions * Truncus arteriosus* Aorta and pulmonary artery are fused* Single vessel comes from both ventricles* Transposition of great vessels* Aorta comes off RIGHT ventricle* Pulmonary artery comes off LEFT ventricle* Tricuspid atresia* Blood unable to get from right atrium to right ventricle* Tetrology of fallot* Overriding aorta* Ventricular septal defect* Right ventricular outflow tract obstruction* Hy...

Pediatric “Sepsis” * Consider in any toxic appearing child/neonate* Especially with fever (or hypothermia)* Treatment* Early antibiotics* Fluid bolus “Serious Bacterial Infections” (SBI) * Consider in any baby with fever* Three classic categories* Age <30 days* Introduction* Weak immune system* No immunizations* Very high risk for serious bacterial infections* Require a significant amount of testing* Urinalysis with Urine Culture* Blood Cultures* Lumbar Puncture with CSF Cultures* Chest X-Ray...

Introduction * In pediatric patients, have a low threshold to check blood sugar* Undiagnosed diabetics commonly identified in ED during first episode of DKA* HYPOglycemia is very common in multiple conditions, especially in ill children Hyperglycemia * DKA is different in kids* They get cerebral edema* Increased intracranial pressure with rapid fluid administration* Common symptoms* Headache* Altered mental status* Neurologic deficits* Cushings triad* Hypertension* Bradycardia* Irregular brea...

Applying oxygen is one of the first steps in treating any crashing child!!! Airway Emergencies * Foreign body (FB)* Patient presentation* Stridor* Choking episode* Testing* CXR* May directly show foreign body* May show secondary effects of a foreign body* Hyperinflated/collapsed lobes of the lung* Patient needs bronchoscopy if suspicion is high* Peritonsillar abscess* Visible in the pharynx* Bacterial tracheitis* HIDDEN IN the airway* Epiglottitis* HIDDEN ABOVE the airway* Retropharyngeal absc...

When you have a critically ill child in front of you, always remember, OH SHIT, Grab the Broslow!!! Oxygen- Apply Oxygen and Consider Airway/Respiratory Emergencies * Foreign body* Peritonsillar abscess* Bacterial tracheitis* Epiglottitis* Retropharyngeal Abscess* Bronchiolitis* Asthma* Croup* Pneumonia* Cystic Fibrosis Hyper/Hypoglycemia- Check Blood Glucose * Hypoglycemia* DKA Sepsis- Consider Sepsis and Serious Bacterial Infections * Pediatric sepsis* Fever <30 days of age* Fever 30-60 ...

These are most important in trauma patients!!! Platelet Disorders * Symptoms of SUPERFICIAL bleeding* Mucosal bleeding* GI bleeding* Recurrent epistaxis* Thrombocytopenia* When the platelets ARE LOW* Refer to THIS episode* Von-Willebrand disease* When the platelets CAN’T BIND* Treatment * Desmopressin (DDAVP)* Causes increase in amount of von-willebrand factor (vWF) available* Also causes free water retention* Treatment of diabetes insipidus* Replace vWF* Transfuse factor VIII* Contains vWF (f...

Always remember…1, 2, 3, get an old EKG!!! Step 1: Identify the Rate and Rhythm * Is it sinus rhythm?* P wave before every QRS* Is it one of the tachycardias? (Refer to THIS episode)* Is it one of the bradycardias? (Refer to THIS episode) Step 2: Look for Signs of Ischemia * Most consistent way is to examine by anatomic region of the heart* II, III, and aVF are “inferior” leads* I, aVL, V5, V6 are “lateral” leads* V1 and V2 are “septal” leads* V3 and V4 are “anterior” leads* Check for Q wave...

Mnemonic: ABCDEF Appearance * The ‘A’ in the pediatric assessment triangle* Interactive vs distant* Good tone vs floppy* Calm and happy vs inconsolable Breathing * The ‘B’ in the pediatric assessment triangle* Signs of respiratory distress* Nasal flaring* Retractions* Abnormal respiratory sounds Color/Circulation * The ‘C’ in the pediatric assessment triangle* Pink = good* Abnormalities* Pallor* Cyanosis* Mottling Distraction * Almost impossible to do a good peds exam in a crying kid* Ea...

Always ask about pediatric patient’s ‘P-I-S-S’ status!!! Core Function Questions (P-I-S-S Status) * Peeing* Evaluates for dehydration* Number of wet diapers per day?* Same number as usual?* Intake* Rule of 3s* Estimates how much milk/formula an average infant should be taking* 3oz of milk or formula every 3 hours* Sleeping* Is the patient sleeping MORE than usual?* LESS than usual?* Stooling* Normal stool* Changes from dark meconium to tans/yellows Pediatric Medical History * Prebirth* Did t...

If a returning traveler has a fever, think malaria malaria malaria!!! Step 1: Ask your patient if they have traveled within the last year * If yes… You should at least CONSIDER malaria Step 2: If patient says yes, take a travel history * When did they go* Where did they stay* Where they exposed to anything concerning* Mosquitos* Animals* Weird foods* Sexual partners* Sick people* Where they in developed/tourist areas or “off the trail” Step 3: Ask about prophylaxis * Did they see a doctor ...

If the patient is completely non-toxic and doesn’t have any red flags, they can usually go home without further testing!!! 3 Big (Non-Viral) Causes of Diarrhea * The Icky ‘I’s* Ischemia* Frequently require surgery consult* Infection* Frequently require antibiotics* Inflammatory bowel disease* Frequently require GI consult, steroids, or salicylates 5 Red Flags * Is it bloody? * Consider performing a guaiac test* Bloody diarrhea usually isn’t “just a virus”* Is it severely painful? * (Viral ga...

Patients rarely have the “classic” presentation of appendicitis. Frequently it is misdiagnosed as GASTROENTERITIS!!! Three Stages of Appendicitis * Stage 1: ~12 hours of “gastroenteritis” like symptoms* Stage 2: Direct somatic irritation* This is when pain over McBurney’s develops!* Stage 3: Perforation* Patient is now sick and septic Approach to Appendicitis * Step 1: Consider getting labs* Always remember “The white blood cell count is the last refuge of the intellectually destitute”* The ...

Common Complaints * Red Eye* Decreased Vision* Trauma to the Eye Approach to a Vision Complaint * Step 1: Assess visual acuity* Visual acuity is the “vital sign of the eye”* Snellen eye chart is best* If patient unable to see chart…* Count fingers?* Able to see light?* Step 2: Examine the conjunctiva/cornea with fluorescein* How to apply fluorescein* Recline patient 45 degrees* Pull down on lower eyelid to create pocket* Place anesthetic eye drops in pocket (ex. tetracaine) * Wet the fluoresc...

Differential Diagnosis * Mnemonic: HE DIES* Hypothyroidism* Elevated intracranial pressure (ICP)* Cushings reflex* Bradycardia* Increased blood pressure* Irregular breathing* Drugs* Beta blockers* Calcium channel blockers* Digoxin* Ischemia* Electrolytes* Especially potassium!!!* Sick Sinus Syndrome Approach to Bradycardia * Step 1: Get an EKG* Ischemia?* Heart block?* 1st degree = PR interval >200ms (5 small boxes)* 2nd degree type 1 = PR gradually prolongs until dropped beat* 2nd degree typ...

Airway and Epi! Airway and Epi! Airway and Epi! Introduction * Anaphylaxis is caused by massive uncontrolled release of chemicals after exposure to “antigen”* The antigen causes extensive mast cell and basophil cross-linking/activation* Common antigens* Foods* Drugs* Insect venoms Basic Approach * Step 1: Diagnose anaphylaxis* Consider anaphylaxis if the patient has TWO body systems involved* Dermatologic symptoms* Flushing* Rash* Urticaria* Pulmonary symptoms* Shortness of breath* Wheezing*...

Basic Approach * Step 1: Is this SINUS tachycardia? * P before every QRS? * Treat the underlying condition* Step 2: Is this a NARROW and REGULAR rhythm?* SVT* Treat with vagal maneuvers or adenosine* Another new trend is treating with calcium channel blockers!! * ORTHOdromic Wolf Parkinson White* Treat with adenosine* Atrial flutter with fixed block* Treat with AV blockers (diltiazem)* Slows the heart rate* Step 3: Is this a NARROW and IRREGULAR tachycardia?* Almost always atrial fibrillation* ...

Introduction * Simple seizure* Seizure ends in <5 minutes AND* Patient wakes up before next seizure* No meds required* Status epilepticus* Seizure lasts >5 minutes OR* Patient has a 2nd seizure before waking up from 1st* Initiate status epilepticus pathway Approach to Status Epilepticus * Step 1: Give a benzodiazepine* Lorazepam (IV)* Diazepam (IV or PR)* Midazolam (IV or IM)* Step 2: Give an anti epileptic* Levetiracetam (Keppra)* Fosphenytoin* Valproic Acid* Step 3: Continue attempting agen...