UMEM Educational Pearls

Title: ALTE

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

Posted: 7/14/2007 by Sean Fox, MD (Updated: 3/6/2025)
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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.

Title: Acetaminophen Toxicity

Category: Toxicology

Keywords: acetaminophen, hepatic failure, hepatitis (PubMed Search)

Posted: 7/14/2007 by Fermin Barrueto (Updated: 3/6/2025)
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Acetaminophen Toxicity Hepatoxicity defined by AST >1000 King s College Criteria to prognosticate hepatic failure and need for transplant: o pH <7.3 o Creatinine >3.4 mg/dL o INR >6.5 o Hepatic encephalopathy Grade III or IV Low phosphate (<1.2 mmol/L) may be predictor of survival and elevated may be indicator of impending hepatic failure. (Especially 48 96 hrs post-ingestion) o Theory is phosphate used in regeneration/healing liver Gow PJ, Sood S, Angus PW. Serum phosphate as a predictor of outcome in acetaminophen-induced fulminant hepatic failure. Hepatology. 2003; 37(3):711.

Title: Toxic Alcohols

Category: Toxicology

Keywords: Ethylene glycol, methanol, toxic alcohol (PubMed Search)

Posted: 7/14/2007 by Fermin Barrueto (Updated: 3/6/2025)
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Toxic Alcohols Unexplained anion gap metabolic acidosis => give fomepizole (antidote) Hypokalemia, hypocalcemia, elevated creatinine => think ethlylene glycol Visual disturbances => think methanol Ketosis without acidosis and high osmol gap => think isopropanol If osmol gap is >70; high specificity for a toxic alcohol ingestion

Title: Hydrofluoric Acid (HF)

Category: Toxicology

Keywords: hydrofluoric acid, hypocalcemia, burn (PubMed Search)

Posted: 7/14/2007 by Fermin Barrueto (Updated: 3/6/2025)
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Hydrofluoric Acid (HF) Used in glass etching, brick/porcelain cleaning and available in hardware stores Death has been reported after JUST 2-3% body surface area exposure! Systemic toxicity: hypocalcemia, hyperkalemia and hypomagensemia Local effects: paucity of skin findings with tremendous pain Treatment: skin decontamination, correct electrolyte abnormalities and topical calcium gel for local pain Mayer TG, GrossPI. Fatal systemic fluoride due to hydrofluoric acid burns. Ann Emerg Med 1985; 14: 149-153.

Title: Cyanide

Category: Toxicology

Keywords: cyanide, poisoning, hydroxycobalamin (PubMed Search)

Posted: 7/14/2007 by Fermin Barrueto (Updated: 3/6/2025)
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Cyanide Presents with arterialization of venous blood (venous blood draw looks like ABG) Reason: o Hemoglobin is not able to offload oxygen o CN poisons cytochrome c oxidase preventing conversion of oxygen to water and thus production of ATP Old antidote: sodium thiosulfate New antidote: hydroxycobalamin binds CN producing cyanocobalamin (Vit B12) When you give it expects a dip in pulse because of its blue color. Remember CN will give you a beautiful 100% pulse all the way to death. Lee J, et al. Potential interference by hydroxocobalamin on cooximetry hemoglobin measurements during cyanide and smoke inhalation treatments. Ann Emerg Med. 2007 Jun;49(6):802-5. Epub 2007 Jan 8.

Title: Heavy Metal Poisoning Clues for Diagnosis

Category: Toxicology

Keywords: metal, poisoning, thallium (PubMed Search)

Posted: 7/14/2007 by Fermin Barrueto (Updated: 3/6/2025)
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Heavy Metal Poisoning Clues for Diagnosis Mees lines, indication of arrested nail growth, occurs in lead, arsenic and others Most heavy metals will cause a proteinuria Microcytic anemia and basophilic stippling seen in lead, arsenic, mercury Peripheral neuropathies in otherwise healthy person Thallium causes classic painful paresthesias in lower extremities

Title: Acute Otitis Media

Category: Pediatrics

Keywords: Acute Otitis Media, Amoxicillin, insufflation, Delayed treament (PubMed Search)

Posted: 7/14/2007 by Sean Fox, MD (Updated: 3/6/2025)
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Acute Otitis Media Make the Diagnosis Properly ==> Acute Onset of Symptoms ==> Signs of Middle Ear Infection (1) Buldging TM, poor mobility c insufflation, otorrhea, air-fluid level ==> Signs of Middle Ear Inflammation (1) TM erythema or otalgia (that interferes with nl activity) Can you wait on the Abx? ==> Older than 6months ==> No severe infections (T>39 C) ==> If yes to both, may hold Abx for 48 hours. Treat Appropriately ==> High-Dose Amoxicillin (80-90mg/kg/D) is 1st line If the decision is made to observe without antibiotic therapy, the parents can be given a prescription for Abx with instructions to fill it if the child does not improve in 48 to 72 hours, or see the PMD in 2 days. (Spiro, D. Tay, K. Wait-to-see prescription for the treatment of acute otitis media. JAMA 2006, 1235.)

Title: Pediatric Thoracic Trauma

Category: Pediatrics

Keywords: Thoracic, Trauma , Traumatic Asphyxia, Pulmonary Contusion (PubMed Search)

Posted: 7/14/2007 by Sean Fox, MD (Updated: 3/6/2025)
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Pediatric Thoracic Trauma 2nd leading cause of death in Peds Trauma Most injuries in Peds are Blunt Kids are Different ==> More Pliable Chest Walls → Pulm Contusion more likely than rib Fx ==> More Mobile Mediastinum → more susceptible to develop tension ptx ==> More Likely to Hyperventilate → Swallowed Air → compromise Respiratory status ==> Can compensate for significant volume loss with tachycardia Traumatic Asphyxia ==> Primarily in younger children ==> Due to the more pliable chest wall ==> Sudden, severe crushing blow to the chest when the glottis is closed. ==> Petechial Hemorrhages of sclera and skin of the head and upper extremities ==> Neuro deficits and coma due to cerebral edema can occur, although rare Pulmonary Contusion ==> Most Common thoracic Injury in kids ==> Alveolar Hemorrhage, Consolidation, Edema ==> Leads to: (1) V/Q mismatch (2) Decreased Compliance (3) Hypoxemia (4) hypoventilation

Title: Neonatal Resuscitation

Category: Pediatrics

Keywords: Neonatal Resuscitation, Newborn, Transilluminate, Meconoium Aspiration, Zip Lock Bag (PubMed Search)

Posted: 7/14/2007 by Sean Fox, MD (Updated: 3/6/2025)
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Neonatal Resuscitation 3 Key Questions to ask of your pregnant patients: ==> Are you having twins (or more)? ==> When is your due date? ==> What color is the fluid? Magic numbers for Neonatal Resuscitation: ==> HR < 100 (or persistent central cyanosis or apnea) = positive pressure ventilation ==> HR < 60 = chest compressions +/- epinephrine If there is meconium present and ==> The infant is depressed, then use meconium aspirator (aspirate the airway via the ETT) ==> The infant is vigorous, then resuscitate as usual (dry, clear airway, assess circulation/color) When resuscitating an infant who is <28wks GA, do not dry with towels as you would an older neonate, instead ==> Place the child in a food grade polyethylene bag (Zip Lock bag), to prevent heat loss and avoid losing valuable time during the resuscitation. For infants not responding to resuscitation, TRANSILLUMINATE the chest to determine if there is a pneumothorax.

Title: Intussusception

Category: Pediatrics

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

Posted: 7/14/2007 by Sean Fox, MD (Updated: 3/6/2025)
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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

Title: Shoulder Dystocia Legal Pearl

Category: Obstetrics & Gynecology

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

Posted: 7/14/2007 by Michael Bond, MD (Updated: 3/6/2025)
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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.

Title: SCIWORA

Category: Pediatrics

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

Posted: 7/14/2007 by Sean Fox, MD (Updated: 3/6/2025)
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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.

Title: NewBorn Resuscitation

Category: Pediatrics

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

Posted: 7/14/2007 by Sean Fox, MD (Updated: 3/6/2025)
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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.

Title: Kawasaki s Disease

Category: Pediatrics

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

Posted: 7/14/2007 by Sean Fox, MD (Updated: 3/6/2025)
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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.

Title: Leukokoria

Category: Pediatrics

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

Posted: 7/14/2007 by Sean Fox, MD (Updated: 3/6/2025)
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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.

Title: Pediatric Fever / UTI

Category: Pediatrics

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

Posted: 7/14/2007 by Sean Fox, MD (Updated: 3/6/2025)
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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.

Title: Syncope

Category: Pediatrics

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

Posted: 7/14/2007 by Sean Fox, MD (Updated: 3/6/2025)
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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.

Title: Bacterial tracheitis

Category: Pediatrics

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

Posted: 7/14/2007 by Sean Fox, MD (Updated: 3/6/2025)
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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.

Title: Inborn Errors of Metabolisn

Category: Pediatrics

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

Posted: 7/14/2007 by Sean Fox, MD (Updated: 3/6/2025)
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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

Title: Pulmonary Embolism Rule Out

Category: Vascular

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

Posted: 7/14/2007 by Rob Rogers, MD (Updated: 3/6/2025)
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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.