UMEM Educational Pearls

Title: Inborn Errors of Metabolisn

Keywords: Inborn Errors of Metabolism, Hypoglycemia, organomegaly (PubMed Search)

Posted: 7/14/2007 by Sean Fox, MD (Emailed: 7/8/2007) (Updated: 7/16/2024)
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Inborn Errors of Metabolism For the child with neurologic abnormalities, vomiting, acidosis, hypoglycemia, organomegaly, or cardiopulmonary arrest remember to consider Inborn Errors of Metabolism (IEM) on your DDx. There are over 300 disorders of the various biochemical pathways, and while the individual incidence for each disorder may be rare, the collective incidence for IEM is 1-2 / 1,000 births. Treat dehydration and hypoglycemia promptly but FIRST, draw EXTRA blood samples (at UMMS, two adult Green Tops and one adult Red Top) in addition to the basic labs. ==> Once you begin therapy to correct the acid/base disturbance, hypoglycemia, and dehydration the abnormal metabolites present in their serum will be reduced and possibly confound the diagnosis. ==> Draw the extra blood, before your give the NS bolus or the Dextrose! ==> Basic Labs (1) ABG, BMP, Ammonia, U/A are helpful immediately (2) CBC, Blood and Urine Cultures (look for concurrent infection, possibly the inciting event) (3) Urine Reducing Substances, serum organic acids, urine and serum amino acids are also useful

Category: Pediatrics

Title: Intussusception

Keywords: Intussusception, Abdominal Pain, bloody stools, vomitting, change in mental status (PubMed Search)

Posted: 7/14/2007 by Sean Fox, MD (Emailed: 7/8/2007) (Updated: 7/16/2024)
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Intussusception Age: 3months to 6 years, most common among 3-12 months The classic triad: colicky abdominal pain, vomiting, and red currant jelly stools ==> Occurs in only 21% of cases. ==> Currant jelly stools are observed in only 50% of cases. ==> 75% without obviously bloody stools will have positive occult blood. A child vomiting without diarrhea should raise suspicion. Consider it in infant/toddler with change in mental status/lethargy (TIPS AEIOU one of the I s is for Intussusception). Choice of Radiographic Evaluation is often based upon your institutional resources ==> U/S is the modality of choice for imaging, but cannot treat. ==> Air contrast enema (now preferred over saline contrast) is useful for diagnosis and treatment. ==> Both are operator dependent

Category: Pediatrics

Title: ALTE

Keywords: ALTE , Apparent Life Threatening Events, color change, apnea, SIDS, Seizure (PubMed Search)

Posted: 7/14/2007 by Sean Fox, MD (Emailed: 7/8/2007) (Updated: 7/16/2024)
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ALTE (Apparent Life Threatening Events) Defined as an episode characterized by some combination of apnea, color change, change in tone, choking, and/or gaging. Vast DDx ==> Get Bedside Glucose Early (should be part of vital signs) ==> Keep Non-accidental Trauma on the list ==> ~50% are classified as Idiopathic Risk Factors associated with Increased Mortality: ==> Sleep Onset ==> Prior Similar Episode ==> Sibling a Victim of SIDS ==> Development of Seizure D/O during monitoring 7.8% of ALTE pt s with a Normal ED evaluation required medical intervention during hospitalization. -Oren, J., D. Kelly, and D.C. Shannon, Identification of a high-risk group for sudden infant death syndrome among infants who were resuscitated for sleep apnea. Pediatrics, 1986. 77(4): p. 495-9. -De Piero, A.D., S.J. Teach, and J.M. Chamberlain, ED evaluation of infants after an apparent life-threatening event. Am J Emerg Med, 2004. 22(2): p. 83-6.

Category: Pediatrics

Title: SCIWORA

Keywords: SCIWORA, Spinal Cord Injury Without Radiographic Abnormality, MRI, steroids (PubMed Search)

Posted: 7/14/2007 by Sean Fox, MD (Emailed: 7/8/2007) (Updated: 7/16/2024)
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SCIWORA (Spinal Cord Injury Without Radiographic Abnormality) Children <8yrs old can have their spinal cord stretched up to 5cm before rupture. Their cervical spinal columns are more mobile and held together with less stable ligaments allowing for horizontal movement of the vertebrae. The mobility of the spinal column allows for spontaneous reduction of subluxated vertebrae; therefore, CTs and plain radiographs will often appear normal at the time of ED evaluation. Any child with neurologic deficits or a concerning mechanism of injury deserves an MRI to evaluated for SCIWORA. No studies of the utility of steroids in children with spinal cord injury exist; current recommendations are to reserve methylprednisolone for those children who present with persistent or progressive neurologic deficits.

Category: Pediatrics

Title: NewBorn Resuscitation

Keywords: NewBorn Resuscitation, Neonate, Transilluminate, Bradycardia (PubMed Search)

Posted: 7/14/2007 by Sean Fox, MD (Emailed: 7/8/2007) (Updated: 7/16/2024)
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NewBorn Resuscitation Important numbers to remember: ==> HR <100, start Positive Pressure Ventilation ==> HR <60, start Chest Compressions Bradycardia and Hypotonia are symptoms of Poor Ventilation and Acidosis With an infant who is not responding to resuscitation measures, TRANSILLUMINATE the chest to help detect a pneumothorax.

Category: Pediatrics

Title: Kawasaki s Disease

Keywords: Kawasaki s, Coronary Artery Aneurysm, fever (PubMed Search)

Posted: 7/14/2007 by Sean Fox, MD (Emailed: 7/8/2007) (Updated: 7/16/2024)
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Kawasaki s In the US, Kawasaki Disease is the leading cause of Acquired Heart Disease in Children (surpassing Acute Rheumatic Fever). ==> 15-25% of untreated pts develop coronary artery aneurysm or ectasia. Diagnosis is a clinical one. ==> 5 days of fever PLUS 4/5 clinical features (rash, inflammation of lips/mouth, bilateral conjunctivitis, edema or erythema of hands/feet, and peeling of fingers/toes). No lab values are diagnostic; however, they can strengthen clinical suspicion. ==> CRP and ESR are usually elevated. Thrombocytosis is also common after 1 week of illness. Symptoms are often transient and require careful history. Considered it in the DDx of every child with fever of at least several days duration, rash, and nonpurulent conjunctivitis, especially in children <1 year old and in adolescents, who often have incomplete Kawasaki Disease and are likely to be missed. Newburger, JW. Diagnosis, Treatment, and Long-Term Management of Kawasaki Disease. Circulation. 2004;110:2747-2771.

Category: Pediatrics

Title: Leukokoria

Keywords: Leukokoria, white pupil, retinoblastoma (PubMed Search)

Posted: 7/14/2007 by Sean Fox, MD (Emailed: 7/8/2007) (Updated: 7/16/2024)
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Leukokoria The White Pupil Leukokoria is seen in 50-60% of the patients with retinoblastoma Retinoblastoma is the most common intraocular malignancy in children, usually detected in the primary care clinic (which the ED often is now) Median age of diagnosis: unilateral = 24 months; bilateral = 12 months Metastatic disease: direct extension to CNS, hematogenous to bones, lung, and brain When detected early, it is one of the most curable childhood cancers Untreated, almost all will die within 2 years Refer anyone without a normal red reflex to an ophthalmologist within 1 week. WG Wilson, JR Serwint. Retinoblastoma. Pediatrics in Review. 2007;28:37-38 Melamud A, Palekar R, Singh A Retinoblastoma. Am Fam Physician. 2006 Mar 15;73(6):1039-44.

Category: Pediatrics

Title: Pediatric Fever / UTI

Keywords: Fever, UTI, Vesicoureteral Reflux, VCUG (PubMed Search)

Posted: 7/14/2007 by Sean Fox, MD (Emailed: 7/8/2007) (Updated: 7/16/2024)
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Pediatric Fever / UTI UTI is one of the most frequent bacterial infections in children. ==> Vesicoureteral Reflux is diagnosed in 30-40% of children found to have a febrile UTI. ==> Vesicoureteral Reflux can lead to recurrent UTIs and Renal Scarring, which can then lead to hypertension and renal insufficiency. Instruct newly diagnosed patients and families to f/u with PMD to schedule renal imaging (renal ultrasound and VCUG). American Academy of Pediatrics, Committee on Quality Improvement, Subcommittee on Urinary Tract Infection. Practice parameter: the diagnosis, treatment, and evaluation of the initial urinary tract infection in febrile infants and young children Pediatrics. 2000;105:141.

Category: Pediatrics

Title: Syncope

Keywords: Syncope, Brugada, WPW, Prolonged QTc (PubMed Search)

Posted: 7/14/2007 by Sean Fox, MD (Emailed: 7/8/2007) (Updated: 7/16/2024)
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Pediatric Syncope 15-25% of children experience at least one syncopal episode by young adulthood Heart Disease has been the attributed etiology in as high as 10-28% of these cases ==> Historical features suggestive of Cardiac etiology (similar to adults): (1) Onset with exertion (2) No prodome or premonitory symptoms; Resulted in bodily injury (3) Incontinence, Seizure-like activity (4) Abnormal Cardiac Structure or previous cardiac surgery (5) Family Hx of unexplained Death or Accidents (MVC) (6) Required CPR (7) Resulted in neurological insult ==> Get the EKG! Look for (1) WPW (2) Prolonged QTc (3) AV blocks (4) BRUGADA Syndrome Yes, even in kids! Johnsrude, C.L., Current approach to pediatric syncope. Pediatr Cardiol, 2000. 21(6): p. 522-31.

Category: Pediatrics

Title: Bacterial tracheitis

Keywords: Bacterial tracheitis, stridor, croup, epiglottitis (PubMed Search)

Posted: 7/14/2007 by Sean Fox, MD (Emailed: 7/8/2007) (Updated: 7/16/2024)
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Bacterial Tracheitis Considered bacterial tracheitis in a patient who has fever, stridor, and symptoms that do not respond to therapy for croup (racemic epinephrine and steroids). The epidemiology of acute infectious upper airway disease in pediatrics has been altered with immunization against Haemophilus influenza- b and the widespread use of corticosteroids for the treatment of viral croup. Bacterial Tracheitis has replaced epiglottitis and croup as the most common cause of acute respiratory failure. One study found it to be 3 times more likely to cause respiratory failure than croup and epiglotittis combined. The mortality rates had been reported as high as 18% to 40%. Hopkins, A., et al., Changing epidemiology of life-threatening upper airway infections: the reemergence of bacterial tracheitis. Pediatrics, 2006. 118(4): p. 1418-21.

Category: Airway Management

Title: Bougie-Facilitated Intubation

Keywords: Intubation, Bougie, Difficult Airway, Wound Care, Irrigation (PubMed Search)

Posted: 7/10/2007 by Michael Bond, MD (Emailed: 7/8/2007) (Updated: 7/16/2024)
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Bougie-Facilitated Intubation Using the Bougie as a rescue device can sometimes be complicated with difficulty advancing the endotracheal tube as the tip can get hang up at the level of the glottis. Two things that can help advance the tube: Rotate the tube 90 degrees counterclockwise. Stop holding Cricoid Pressure, especially in female patients A recent study looking at cricoid pressure showed that the frequency of impingement was 38% with sham pressure and 60% with true cricoid pressure. This statistically significant difference was entirely attributable to an effect in female patients. Original Article: McNelis U et al. The effect of cricoid pressure on intubation facilitated by the gum elastic bougie. Anaesthesia 2007 May; 62:456-9. Forget about Sterile Saline and Use Tap Water Irrigation In a multicenter prospective trial of 715 patients, Moscati et al have shown that rates of wound infection were similar (3.3% compared to 4.0%) in patients that received clinician-administered sterile saline irrigation or at least 2 minutes of self-administered tap-water irrigation. The amount (volume) of irrigation is more important than whether the irrigate is sterile or not. Moscati RM et al. A multicenter comparison of tap water versus sterile saline for wound irrigation. Acad Emerg Med 2007 May; 14:404-9.

Category: Vascular

Title: Pulmonary Embolism Rule Out

Keywords: D-Dimer, PE, Well's (PubMed Search)

Posted: 7/14/2007 by Rob Rogers, MD (Emailed: 7/8/2007) (Updated: 7/16/2024)
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Update on the Wells Criteria for PE-patients with a score of 4 or less (which means low to moderate probability) can be considered for a "d-dimer negative" rule out approach. This is a bit of a change from the low risk only approach. Additionally, the British Thoracic Society guidelines support the low and moderate risk group patient rule out strategy. So, if you have a low or even moderate risk patient, you can use the approach of obtaining a highly sensitive d-dimer and if it is negative, the hunt for PE is over.

Category: Obstetrics & Gynecology

Title: Shoulder Dystocia Legal Pearl

Keywords: Erb's Palsy, Dystocia, Legal (PubMed Search)

Posted: 7/14/2007 by Michael Bond, MD (Emailed: 7/8/2007) (Updated: 7/16/2024)
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In follow up to my Shoulder Dystocia Pearl

Dr. DePriest Whye has some legal pearls for us:

Erbs Palsy( Brachial Plexus Injury) is a known complication of shoulder dystocia and is due to traction on the arm that causes stretching of the brachial plexus.

Should an Erb's Palsy result as a consequence of a shoulder dystocia, a medical malpractice suit is inevitable.
The medical record documentation is particularly critical in defending the medical care rendered.
The medical record should reflect timely recognition of the shoulder dystocia.
It is important that appropriate implementation of the maneuvers described last week are done in a timely fashion.
Vital documentation should describe the amount of traction placed if any.
Terms such as minimal or mild or light traction should be used.
Terms such as strong, forceful, significant traction should be avoided.
Never state in the record that uterine pressure was used as opposed to suprapubic pressure.
Uterine pressure is contraindicated.

Erb's Palsy cases are difficult to defend. They are impossible to defend with improper documentation.

Category: Obstetrics & Gynecology

Title: OB Pearls

Keywords: Pre-eclampsia, eclampsia, HELLP (PubMed Search)

Posted: 7/12/2007 by Michael Bond, MD (Emailed: 7/8/2007) (Updated: 7/16/2024)
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The best known peripartum complications are pre-eclampsia and eclampsia. However, do not forget about HELLP syndrome which occurs in approximately 0.2 to 0.6 percent of all pregnancies. HELLP is an acronym for: Hemolysis Elevated Liver Enzymes Low Platelet Treatment consists: 1. Seizure prophylaxis with magnesium 2. Blood pressure control 3. Corticosteriods and plasmapheresis may be helpful in severe causes 4. Supportive care. 5. Early delivery of child.

Category: Airway Management

Title: Airway Management Pearls

Keywords: Intubation, Airway (PubMed Search)

Posted: 7/12/2007 by Michael Bond, MD (Emailed: 7/8/2007) (Updated: 7/16/2024)
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1. 30% of all ETT placed in the field by EMS are esophageal. 2. Patients that will rapidly desaturate - think "POPS" ie Pregnancy, Obesity, Pediatric, Smoke inhalation. 3. In the adult the only absolute contraindication to performing a cricothyroidotomy is a fractured larynx. 4. Post intubation desaturation think "DOPE" ie Displacement, Obstruction, PNTX, Equipment failure.

Category: Orthopedics

Title: Supracondylar Fractures

Keywords: Supracondylar, Fracture, Pediatric, Ossification (PubMed Search)

Posted: 7/12/2007 by Michael Bond, MD (Emailed: 7/8/2007) (Updated: 7/16/2024)
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Supracondylar fractures in children: To assess the likelihood of a supracondylar fracture in a child look at the anterior humeral line. This is a line drawn down the anterior portion of the humerus on the lateral view of the elbow. This line should pass through the center of the capitellum in the distal humerus. If the line does not pass through the center there is a very high likelihood of a supracondylar fracture. Review of the Appearance of Ossification Centers in Children's Elbows CRITOE Capitellum 1 to 8 months Radial Head 3 to 5 years Medial (Internal)Epicondyle 5 to 7 years Trochlea 7 to 9 years Olecranon 8 to 11 years Lateral ( External) Epicondyle 11 to 14 yeras

Category: Infectious Disease

Title: Tuberculosis Screening

Keywords: TB, PPD, Conversion (PubMed Search)

Posted: 7/12/2007 by Michael Bond, MD (Emailed: 7/8/2007) (Updated: 7/16/2024)
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PPD is considered positive: >= 15 mm Induration: Anybody >= 10 mm induration: Born in a high-revalence country, are in a medically underserved population ( e.g.:Blacks, Hispanics, and Native Americans), individuals with a medical condition that increases risk of TB (e.g.; silicosis, gastrectomy, chronic renal failure, immunosuppressant therapy, malignancy, IV drug abusers, and those that work in the medical field. >=5mm induration: HIV or suspected HIV-positive, close contacts of newly diagnosed TB Cases (everybody on the plane), and abnormal CXR with fibrotic changes suggesting old TB MMWR September 08, 1995/ 44(RR-11);18-34

Category: Airway Management

Title: Airway Pearls

Keywords: Airway, Intubation (PubMed Search)

Posted: 7/12/2007 by Michael Bond, MD (Emailed: 7/8/2007) (Updated: 7/16/2024)
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1. Hyperventilation in the pediatric HI causes an increase in cerebral ischemiaand increases in ICP 2. Cuffed tubes can be used in the pediatric airway 3. The most common cause of bradycardia in pediatric RSI is hypoxia and this is NOT prevented with atropine 4. Patients with an underlining neuromyopathy have an upregulation of neuroreceptors (they actually have more in number) the risk if hyperkalemic cardiac arrest is significant if succynlcholine is administered. 5. During Direct Laryngoscopy; the Mac blade can also be used as a Miller negating changing the blades. 6. Intubation is now a bimanual procedure as the use of External Laryngeal Movement (ELM) significantly increase the intubators view.

Category: Obstetrics & Gynecology

Title: Imminent Delivery

Keywords: Delivery, Imminent, Dystocia (PubMed Search)

Posted: 7/10/2007 by Michael Bond, MD (Emailed: 7/8/2007) (Updated: 7/16/2024)
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If you are facing the imminent delivery of a newborn with shoulder dystocia remember the mnemonic HELPERR. * Help. Call for it. * Episiotomy. o Necessary only to make more room if rotation maneuvers are required. * Legs (the McRoberts maneuver) o This procedure involves flexing and abducting the maternal hips, positioning the maternal thighs up onto the maternal abdomen. * Pressure, Suprapubic o The hand of an assistant should be placed suprapubically over the fetal anterior shoulder, applying pressure in a cardiopulmonary resuscitation style with a downward and lateral motion on the posterior aspect of the fetal shoulder. This maneuver should be attempted while continuing downward traction. * Enter maneuvers (internal rotation) o Attempt to manipulate the fetus to rotate the anterior shoulder into an oblique plane and under the maternal symphysis. * Remove o Remove the posterior arm. * Roll the patient. o Rolling the patient on all-fours will often dislodge the shoulder, and the position change allows gravity to aid in the disimpaction of shoulder. Baxley EG, Gobbo RW. Shoulder Dystocia, Am FamPhysician. 2004;69(7):1709-1714.

Category: ENT

Title: Epistaxis Control

Keywords: Epistaxis, Nose, Bleeding (PubMed Search)

Posted: 7/10/2007 by Michael Bond, MD (Emailed: 7/8/2007) (Updated: 7/16/2024)
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Direct Pressure: Can be held with two fingers pinching the nares, or you can tape 4 tongue blades together and make your own "clothes pin" that can then be used to pinch the nares. Vasoconstrictor and Anesthesia: Use a 1:1 mixture of topical lidocaine 4% and oxymetazoline can often be mixed together in the same oxymetazoline spray container and then just spray it into the nares. Some IV/IM narcotic pain medication will also help increase patient cooperation. Visualize the bleeding site: Use a HEAD LAMP with an appropriate sized nasal speculum. You may look like Marcus Welby, MD but nothing works as well to see into the nose. Cauterization It is best to cauterize circumferential around the bleeding site prior to directly cauterizing the actual site. Be careful with electrical cautery so has not to perforate the septum. Nasal Packing: Instead of surgilube use Muprion, Bactroban or Bacitracin ointment to lubricate the packing. This will reduce the chance of Toxic Shock Syndrome.