Pediatric EM Morsels

SEPTEMBER 22, 2023

Negative E-FAST and no signs of long bone injuries should raise concern for neurogenic shock in the hypotensive trauma patient with suspected spinal injury. Alpha 1 agonists are necessary to maintain appropriate blood pressure. Tenenbein M, Macias CG, Sharieff GQ, et al, eds. 2011;46(9):1771. 5 th Edition. J Pediatr Surg.

E-9-1-1 304

E-9-1-1 Epinephrine ALS EMS 304

ALiEM

AUGUST 9, 2023

Technique Positioning and Probe Figure 1: Younger children can sit in their parent’s lap and give a hug for lateral and posterior lung scanning. The patient should be in a position of comfort: supine, sitting, or in parent’s lap (Figure 1). Identify anatomical landmarks on ultrasound (Figure 3, Video 1). Balk et al.,

E-9-1-1 246

E-9-1-1 Emergency Department ALS OR 246

ALiEM

MARCH 7, 2024

Ultrasound probes from left to right: linear (nenoates), phased array (infants/younger children), and curvilinear (older children/adolescents) Pro tips for performing renal/bladder POCUS on a child [1] Addressing potential anxiety leads to a more efficient and comfortable examination.

E-9-1-1 177

E-9-1-1 Emergency Department ALS ED 177

ALiEM

MAY 13, 2024

Her symptoms started 1 week ago as a scratch which progressively got more red and painful. Pediatric Soft Tissue POCUS Ultrasound Technique Figure 1. Cellulitis with cobblestoning Video 1. Abscess with irregular borders and surrounding cellulitis E. Superficial abscess with well-circumscribed borders Table 1.

E-9-1-1 161

E-9-1-1 ALS Emergency Department OR 161

Dr. Smith's ECG Blog

OCTOBER 3, 2024

I agree, however: 1) I don't think you can get a good enough ech o without bubble contrast. 3) E cho is another step that takes time. I had only 9 false positives but I missed 2 OMI. 2) To be presented at AHA conference in Chicago in 2 weeks: Sharkey SW et al. 2) You need to be just as expert at echo as I am at the ECG.

E-9-1-1 122

E-9-1-1 Coronary ALS ED 122

Dr. Smith's ECG Blog

DECEMBER 19, 2023

link] A 62 year old man with a history of hypertension, type 2 diabetes mellitus, and carotid artery stenosis called 911 at 9:30 in the morning with complaint of chest pain. Challenge QUESTION: The relative change in T-QRS-D is not the only thing that changes during period of time that passed between recording of the 2 ECGs shown in Figure-1.

E-9-1-1 126

E-9-1-1 Coronary ACS BLS 126

ALiEM

AUGUST 16, 2023

Common agents include local anesthetics, dapsone, quinones, sulfonamides, phenazopyridine, and nitrites [1, 2]. Treatment for methemoglobinemia in G6PD deficiency may consist of ascorbic acid, exchange transfusion, and hyperbaric oxygen [7, 9]. PMID 23953868 Mack E. Nelson, et al., Nelson, et al., 1971;75(1):83-86.

E-9-1-1 130

E-9-1-1 ALS OR 130

Pediatric EM Morsels

NOVEMBER 17, 2023

Bibl K, Pracher L, Küng E, Wagner M, Roesner I, Berger A, Hermon M, Werther T. 1994 Jul;125(1):57-62. 2019 Sep;74(9):1186-1190. 2016 Feb;30(1):3-11. Differences in intubation outcomes for pediatric patients between pediatric and general Emergency Departments. Paediatr Anaesth. 2021 Jun;31(6):713-719. doi: 10.1111/pan.14185.

E-9-1-1 187

E-9-1-1 Operating Room Emergency Department ALS 187

Don't Forget the Bubbles

AUGUST 30, 2023

The parents of 9-month-old Josie bring her into the Emergency Department with coryzal symptoms and difficulty breathing. Among those who do not always obtain a CXR, one-fifth still routinely obtained them under a certain age (2 weeks to 12 years, median of 1 year). Take home points References Allie EH, Dingle HE, Johnson WN, et al.

E-9-1-1 131

E-9-1-1 Emergency Department ALS OR 131

Dr. Smith's ECG Blog

SEPTEMBER 23, 2024

Here is lead I from ECGs 1 and 2 shown side-by-side to highlight the change in axis from borderline right to completely normal. Consider the following: We become attuned to looking for acute coronary occlusion in patients who present with acute symptoms to the ED ( E mergency D epartment ).

E-9-1-1 126

E-9-1-1 Coronary STEMI ALS 126

Broome Docs

SEPTEMBER 3, 2024

In a surprise to no one who reads First10EM, clinical judgment is better than all decision tools for sepsis Knack SKS, Scott N, Driver BE, Prekker ME, Black LP, Hopson C, Maruggi E, Kaus O, Tordsen W, Puskarich MA. Epub 2024 Apr 9. 2024 Mar;27(1):26-29. Cook D, Deane A, Lauzier F, et al. 2024 Jul 4;391(1):9-20.

E-9-1-1 95

E-9-1-1 Emergency Department ICU ALS 95

This Podcast Will Kill You

JULY 23, 2024

Official journal of the American College of Gastroenterology| ACG , 118 (1), pp.59-76. Annals of internal medicine , 172 (1), pp.ITC1-ITC16. Caio, Giacomo, et al. ” BMC medicine 17 (2019): 1-20. . ” BMC medicine 17 (2019): 1-20. Cenit, María Carmen, et al. Gastroenterology , 160 (1), pp.63-75.

E-9-1-1 98

E-9-1-1 ALS OR 98

Dr. Smith's ECG Blog

AUGUST 14, 2024

R waves 6 through 9 have no preceding P waves and are suspiciously regularly spaced. Depolarization wavefronts exit the sinus node through one or several sinoatrial conduction pathways (SACP) as seen in the histology section below taken from Li et al. Impulses E, F, G, H, and I were blocked. This is consistent with sinus rhythm.

E-9-1-1 110

E-9-1-1 OR ALS 110

Dr. Smith's ECG Blog

DECEMBER 27, 2023

Written by Willy Frick A man in his 50s with a history of hypertension, dyslipidemia, type 2 diabetes mellitus, and prior inferior OMI status post DES to his proximal RCA 3 years prior presented to the emergency department at around 3 AM complaining of chest pain onset around 9 PM the evening prior. ECG 1 What do you think? Grines, C.

E-9-1-1 129

E-9-1-1 OR Coronary ACS 129

EMDocs

FEBRUARY 20, 2024

Fluids in Pancreatitis #1 : de-Madaria E, Buxbaum JL, Maisonneuve P, et al; ERICA Consortium. 2: Li XW, Wang CH, Dai JW, et al. 2023 Mar 22;27(1):122. These videos will cover post summaries, take homes on clinical condition, and EBM/guideline literature updates. Today we focus on pancreatitis. N Engl J Med.

E-9-1-1 98

E-9-1-1 ICU ALS OR 98

EMDocs

MAY 11, 2024

CT head without contrast 1 is performed and reveals the following: Question: What is the diagnosis? Rosh Review Website Link Further Reading: FOAMed: [link] [link] [link] [link] [link] [link] [link] References : Turi B, Smith D, Kusel K, et al. Updated November 9, 2023. link] Sharma R, Gaillard F, Bell D, et al.

EMS 111

EMS E-9-1-1 ALS OR 111

ACEP Now

NOVEMBER 8, 2024

1 Prehospital endotracheal intubation and EGAs are typically placed without paralytics and are reserved for unconscious, apneic, and out-of-hospital cardiac arrest patients. 9 LMAs use an inflatable mask expanded using a similar technique to the endotracheal tube cuff. Benger JR, Kirby K, Black S, et al. 2014;4(1):77-87.

E-9-1-1 40

E-9-1-1 Emergency Medical Services Emergency Medical Technician AEMT 40

EMDocs

NOVEMBER 29, 2023

EBM Update: Fluids in Pancreatitis, Hypertriglyceridemic Pancreatitis #1: de-Madaria E, Buxbaum JL, Maisonneuve P, et al; ERICA Consortium. 2: Li XW, Wang CH, Dai JW, et al. 2023 Mar 22;27(1):122. These videos will cover post summaries, take homes on clinical condition, and EBM/guideline literature updates.

E-9-1-1 93

E-9-1-1 ICU ALS OR 93

REBEL EM

AUGUST 30, 2023

Epidemiology 1 to 2.4 cases per 100,000 people ( Zimmerli 2010 ) More common in males with M:F of 3:1 Rate is also increasing due to increased number of spinal procedures Typically affects adults, with most cases occurring in patients over 50 years old. Other pathogens include: E. PMID: 26316526 Boody B, et al.

E-9-1-1 96

E-9-1-1 ALS ED OR 96

EMS 12-Lead

AUGUST 22, 2022

Question 1: What is the rhythm? Beat 1 : Sinus, narrow QRS complex. The assumption is that a premature complex discharged prior to Beat 1, which prolonged its respective refractory period in the same manner as Beat 5. We can, therefore, put down the defibrillation pads, set aside the amiodarone, and look further at the ECG.

E-9-1-1 130

E-9-1-1 Coronary ALS ICU 130

Don't Forget the Bubbles

SEPTEMBER 20, 2023

2012;161(1):44–50.e502. DOI: [link] Freedman SB, Rodean J, Hall M, et al. DOI: [link] Freedman SB, Thull-Freedman J, Manson D, et al. 2014;164(1):83-88.e2 2020;15(9):557-559. 3387 Kearney R, Edwards T, Braford M, Klein E. 2019;35(9):624-629. 2017;186:87-94.e16. e2 Hoskins B, Marek S. J Hosp Med.

E-9-1-1 133

E-9-1-1 Emergency Department ALS ED 133

REBEL EM

MAY 27, 2024

No significant differences in heart rate 1 minute after cardioversion were observed between the three groups. References: Appelboam A, Reuben A, Mann C, Gagg J, Ewings P, Barton A, et al. 2010;17(1):44-49. Duration of Antiarrhythmic Effect: MVM group: 35.44 seconds (SD = 7.73) Adenosine group: 24.24 seconds (range: 22.5,

OR 137

OR E-9-1-1 ED ALS 137

EMDocs

MARCH 2, 2024

Answer : Pneumocephalus 1-21 Background: Pneumocephalus is defined by the presence of air within the cranial cavity. 1-3] The most common location is the frontal region, followed by the occipital and temporal regions. [4] 1-3] The most common location is the frontal region, followed by the occipital and temporal regions. [4]

EMS 120

EMS E-9-1-1 OR ED 120

REBEL EM

JANUARY 25, 2024

Article: Arvig MD, Lassen AT, Gæde PH, et al. What They Did: Design: Randomized, controlled, blinded-outcome trial Sites: Three emergency departments in Denmark Duration: October 9, 2019 to May 26, 2021. The first evaluation of the patient was to be done within 1 hour of arrival to ED (Including the first POCUS). Emerg Med J.

ED 128

ED E-9-1-1 Emergency Department ALS 128

EMDocs

NOVEMBER 21, 2023

Epidemiology: Prevalence of hypoPP is approximately 1 per 100,000. References: Statland JM, Fontaine B, Hanna MG, et al. 2022;26(1):123-125. 2013 Jan;47(1):41-5. Venance SL, Cannon SC, Fialho D, et al; CINCH investigators. 2006 Jan;129(Pt 1):8-17. Miller TM, Dias da Silva MR, Miller HA, et al.

E-9-1-1 95

E-9-1-1 ALS ED OR 95

FOAMfrat

MAY 19, 2024

While transporting to the emergency department, the patient’s mother informed me that PDCD affects less than 1 in 50,000 individuals and is more common in males than females. The patient will thank you for it; we are only human. References 1. Ostergaard E, Moller LB, Kalkanoglu-Sivri HS, et al. 2009 Jun 11.

E-9-1-1 98

E-9-1-1 ALS Emergency Department EMT 98

Broome Docs

DECEMBER 22, 2024

2024 Oct 9. There were no differences in survival (12% with IO vs 10% with IV) or neurologically intact survival (9% vs 8%). 2024 Nov 1. Restrictive vs Liberal Transfusion Strategy in Patients With Acute Brain Injury: The TRAIN Randomized Clinical Trial. doi: 10.1001/jama.2024.20424. 2024.20424. Shorter courses of antibiotics.

E-9-1-1 52

E-9-1-1 ACS Paramedic Emergency Department 52

REBEL EM

SEPTEMBER 13, 2023

Features Urticaria and pruritis Rapid onset (1-2 hours) IgE Dependent (Type I Hypersensitivity) Reactions An allergen cross-links two or more IgE molecules on mast cells or basophils and initiates a signal cascade leading to degranulation. PMID 25629740 Hassen GW et al. PMID 23062323 Kostis JB et al. Zuraw et al.

Frozen Plasma 104

Frozen Plasma Allergic Reaction FFP Plasma 104

EMDocs

APRIL 10, 2024

1-5] Since then, many more medications have been developed and deployed. 1-5] This post focuses on the identification and management of Local Anesthetic Systemic Toxicity (LAST). 3-5,7] Symptom onset is usually within 1 minute of intravascular injection but can be delayed if multiple injections or continuous infusion. [5]

E-9-1-1 111

E-9-1-1 Plasma Epinephrine Life Support 111

EMDocs

MAY 25, 2024

Massaging the gland causes expression of purulent material. What is the diagnosis?

EMS 98

EMS E-9-1-1 OR ED 98

Don't Forget the Bubbles

NOVEMBER 22, 2023

Of these signs, mortality in children is associated with hepatomegaly and fever; meanwhile, mortality in adults is associated with hyperkalaemia, traumatic brain injury, propofol infusion rates >5mg kg -1 h -1 and ECG changes. 1998;8(6):491-9. Vanlander AV, Okun JG, de Jaeger A, Smet J, De Latter E, De Paepe B, et al.

E-9-1-1 126

E-9-1-1 Critical Care Operating Room ALS 126

EMDocs

OCTOBER 30, 2023

1 The shortage in supply posed difficulties for hospitals that significantly depend on GE Healthcare as their supplier, which encompassed approximately 50% of hospitals in the United States (US). 11 Table 1. Preparation 9 Hospitals had to prepare for the impending contrast shortage as soon as potential shortage news occurred.

E-9-1-1 101

E-9-1-1 Emergency Department ALS CCT 101

EMDocs

AUGUST 7, 2023

1 A D-dimer level can, therefore, be used as a non-specific and indirect biomarker for the presence of intravascular clotting, which may be useful in the diagnosis of VTE. 1-3 In this patient population, the NPV of a negative D-dimer level is high, such that a negative test makes further evaluation for VTE unnecessary.

E-9-1-1 96

E-9-1-1 ALS Plasma OR 96

Don't Forget the Bubbles

JUNE 17, 2024

Here are ten things to think about: 1. Churruca K, Pavithra A, McMullan R, Urwin R, Tippett S, Cunningham N, Loh E, Westbrook J. 2014 Jun 26;23(12):653-9. Frich JC, Brewster AL, Cherlin EJ, Bradley EH. 2020 Jan 1;35(1):70-6. 2023 Oct 31;21(1):403. Roche E, Jones A, Plunkett A. Organizational dynamics.

E-9-1-1 105

E-9-1-1 Critical Care CPR ICU 105

Don't Forget the Bubbles

SEPTEMBER 13, 2023

When considering tumours, 37 observation studies involving 2661 children found that 3% (95% CI 1-7%) had tumours. doi:10.1093/tropej/fmz071 Expert Panel on Pediatric Imaging, Trofimova A, Milla SS, et al. 2019-0134 Hirtz D, Ashwal S, Berg A, et al. Reaffirmed October 17, 2020 Jaffe M, Bar-Joseph G, Tirosh E. Pediatr Rev.

E-9-1-1 131

E-9-1-1 Emergency Department ALS OR 131

Dr. Smith's ECG Blog

NOVEMBER 15, 2023

Post cath ECG: Now there are hyperacute T-waves again, and recurrent ST depression in V2 This ECG would normally diagnostic of OMI until proven otherwise No further troponins were measured, but it looks like there is recurrent OMI Next day: A CT Coronary Angiogram was done (CTCA) CARDIAC MORPHOLOGY AND FUNCTION: 1. IMPRESSION: 1.

Coronary 109

Coronary E-9-1-1 STEMI ACS 109

REBEL EM

FEBRUARY 5, 2024

Article: Marx T, Joly LM, Parmentier AL, et al. Sites: Investigators recruited patients at 31 French emergency departments at university and nonuniversity hospitals Duration : June 1, 2009 to March 31, 2015. Recurrence of pneumothorax within 1 year. Panacek, E. Cochrane Database of Systematic Reviews 2017, Issue 9.

E-9-1-1 103

E-9-1-1 ALS Emergency Department OR 103