Pediatric EM Morsels

AUGUST 9, 2024

Worldwide, congenital syphilis complicates about 1 million pregnancies / year. Usually in 1st week of lif e Copious, white-ish drainage Teeming with spirochetes! gross ) Rash Occurs 1-2 weeks after rhinitis. 2024 Jan 16;17(1):e257694. 2024 Jan;24(1):e24-e35. Is this scalp swelling normal? May be on soles of feet !

E-9-1-1 152

E-9-1-1 Plasma Emergency Department OR 152

Core EM

JANUARY 25, 2024

REFERENCES: Castleberg E, Jenson N, Dinh VA. 2014;15(1):111-113. 2020;12(1). Accessed March 9, 2022. EVALUATION: Scan the affected and contralateral body part for comparison with a sterile cover (or Tegaderm) overlying a high frequency linear probe. Western Journal of Emergency Medicine. Clark ML, Fisher KL.

E-9-1-1 246

E-9-1-1 Emergency Department OR 246

Pediatric EM Morsels

MAY 10, 2024

Chest Pain in Children: Hysteria vs Vigilance Diverse pathology can present as chest pain in children Cardiac 1-9% GI 2-10% Musculoskeletal – 2-20% No Identifiable cause – 21-45% of the time! Chest Pain in Children is a great example of one of these complaints. Have you ever had chest pain or shortness of breath in exercise?

E-9-1-1 268

E-9-1-1 OR EMS 268

Pediatric EM Morsels

JULY 19, 2024

Since tonsillectomy is one of the most common pediatric surgeries in the US (~500,000 per year) and the rate of post-tonsillectomy hemorrhage is about 1-5% , it is a good idea that we all are familiar with how to manage this issue! Get a hold of ENT early as OR management and/or admission are common. Set up suction x2 in the room!

E-9-1-1 286

E-9-1-1 Epinephrine Emergency Department OR 286

Core EM

JANUARY 25, 2024

7 86% of burn injuries are thermal burns (as opposed to chemical or electric), with 43% resulting from a direct exposure to fire, 34% from scalding liquid, and 9% from a hot object. 4 Survival rate for all burn injuries is around 97%, which is a notable increase from 75% in the 1960’s.

ED 246

ED E-9-1-1 First Aid OR 246

Pediatric EM Morsels

JULY 28, 2023

Rates of type 1 diabetes have increased since the COVID-19 pandemic. Kendra Jackson and Rebecca Raffler While we’ve gotten to snack on a Morsel on this subject before , new guidelines and research surrounding DKA and cerebral edema have come to light since the first go ‘round! Neuroimaging is NOT required. GCS score is not sensitive enough.

E-9-1-1 246

E-9-1-1 ALS OR Critical Care 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. Pre-warmed ultrasound gel is helpful when available.

E-9-1-1 177

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

Pediatric EM Morsels

OCTOBER 27, 2023

Initially tested in Johannesburg, South Africa: 1 month old to 12 years old Broselow predicted within 10% of weight in 63.6% Reduces dosing errors during resus, up to 33.88%. Recommended by ATLS and PALS. Broselow-Luten System: Supportive Data Physician estimates of weight can underdose children by 49% or overdose by up to 116%. x exp[0.02

E-9-1-1 269

E-9-1-1 Emergency Medical Services Life Support ALS 269

ALiEM

OCTOBER 11, 2023

Most pufferfish contain tetrodotoxin , a dangerous marine toxin up to 1200 times more toxic to humans than cyanide [1]. 4, 9-12] Consider activated charcoal for patients presenting within 60 minutes of ingestion if the patient’s airway is not an imminent threat or has been secured. 2022;20(1):47. 2007;48(9):830-833.

E-9-1-1 204

E-9-1-1 ALS OR 204

Pediatric EM Morsels

JUNE 30, 2023

References Dessole F, Virdis G, Andrisani A, Vitagliano A, Cappadona R, Dessole S, Cosmi E, Capobianco G. Leblanc C, Baron M, Desselas, E, Phan, MH, Rybak A, Thouvenin G, Lauby C, Irtan S. Dec: 9 (12): 1830. Fetal Congenital Cystic Adenomatoid Malformation (CCAM): Pathogenesis, Diagnosis, and Clinical Management: A Case Report.

E-9-1-1 281

E-9-1-1 ED EMS OR 281

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. This was sent to me from Sam Ghali ( @EM_Resus ) with no other information. I assumed it was a patient with acute chest pain. Real or just fake?"

E-9-1-1 110

E-9-1-1 Coronary ALS ED 110

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. 2024 Jul 4;391(1):9-20. doi: 10.1016/S0140-6736(24)00700-1.

E-9-1-1 109

E-9-1-1 Emergency Department ICU ALS 109

Pediatric EM Morsels

FEBRUARY 2, 2024

While there is no “right” work up for these patients, hopefully this morsel will help illuminate your evaluation of Travel-Related Illness in Children: Travel-related Illness: Basics International travel has been significantly increasing since commercial airlines made travel much easier. A study of swiss tourists found they compromised 53.4%

E-9-1-1 161

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

EMDocs

OCTOBER 29, 2024

General: Intubated sedated CV: Tachycardic, regular rhythm, systolic murmur Pulm: Clear to auscultation bilaterally Skin: Mottled and cool Neuro: GCS 3T What is the underlying this patient’s vasopressor and inotrope refractory shock? m/s)—problematic and elevated > 50 mm Hg (2.5 m/s)—problematic and elevated > 50 mm Hg (2.5

E-9-1-1 87

E-9-1-1 ICU Epinephrine EMS 87

EMDocs

NOVEMBER 13, 2024

Commonly a monomicrobial infection with gram-negative bacteria like E. Paracentesis is a safe procedure with a low complication rate (< 1%). For the remaining fluid inject 1 mL into a purple top EDTA blood tube for cell count; send 2-3 mL for Gram stain in a red-top tube or sterile urine container. coli (50-90% of cases).

E-9-1-1 72

E-9-1-1 ALS OR ED 72

Dr. Smith's ECG Blog

AUGUST 14, 2024

R waves 6 through 9 have no preceding P waves and are suspiciously regularly spaced. Impulses E, F, G, H, and I were blocked. Progress in Biophysics and Molecular Biology , 120 (1–3), 164–178. Science Translational Medicine , 9 (400). Janssen, P. & Fedorov, V. link] Li, N., Hansen, B. Ignozzi, A. Zakharkin, S.

E-9-1-1 93

E-9-1-1 OR ALS 93

ALiEM

MAY 19, 2023

The SB tube was created in 1950 in order to help tamponade variceal bleeds [1]. Apply traction to the tube by tying a roller bandage to the end of it and then the other end to a 1 L bag of IV fluids. Pearl 1: Check the units of pressure being used. The conversion rate is: 1 cmH2O = 0.74 1950 May;131(5):781-9.

E-9-1-1 245

E-9-1-1 Emergency Department ICU OR 245

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-9-1-1 118

E-9-1-1 Coronary ACS BLS 118

Dr. Smith's ECG Blog

SEPTEMBER 2, 2024

ECG #1 Interpretation: ECG #1 shows sinus rhythm at a heart rate of 77 bpm. Following more detailed questioning — it turned out the patient had started taking 9 different herbal remedies to ease lethargy and unspecific neurological symptoms. For clarity in Figure-1 — I've reproduced the initial ECG in today's case.

E-9-1-1 104

E-9-1-1 ALS Defibrillator OR 104

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).

E-9-1-1 246

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

REBEL EM

FEBRUARY 29, 2024

1, 2 Its occurrence often portends worse outcomes in intubated patients, whose projected hospital course was already tenuous. 1, 4, 6 The overall incidence of VAP is somewhere around 5%-40% of all intubated patients, depending on the study and country from which it is reported. 4, 8 Paper: Dahyot-Fizelier, C.,

E-9-1-1 126

E-9-1-1 ICU OR ALS 126

Dr. Smith's ECG Blog

OCTOBER 1, 2024

== MY Comment , by K EN G RAUER, MD ( 8/30 /2024 ): == I was sent the ECG shown in Figure-1 — knowing only that the patient was being seen in the ED ( E mergency D epartment ). Figure-1: The initial ECG in today's case. After seeing ECG #2 — Can you explain: i ) Why no negative P wave was seen in lead V1 of ECG #1? —

E-9-1-1 99

E-9-1-1 STEMI ED OR 99

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. What are the symptoms of Methemoglobinemia? doi:10.1053/j.jvca.2013.02.005.

E-9-1-1 130

E-9-1-1 ALS OR 130

EMDocs

OCTOBER 19, 2024

to 1 case per 100,000 children. to 1 case per 100,000 children. Question: What’s the next step in your evaluation and treatment, and what is the potentially life-threatening diagnosis? 2] Bacterial infection usually preceded by viral infection. Typically in children less than 6 years of age. [3] The epiglottis will appear normal. [2][3]

EMS 87

EMS E-9-1-1 Epinephrine OR 87

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. Refers to the Spinal Cord Function and Reflexes, not specifically hemodynamic issues. Basics are the Best!

E-9-1-1 300

E-9-1-1 Epinephrine ALS EMS 300

EMDocs

NOVEMBER 6, 2024

Exam is notable for tremulous extremities. Shortly after labs are obtained, he yells and arches his back. He becomes rigid in all extremities and his abdomen. There is no convulsive activity or eye deviation, and the patient is yelling in pain. Questions: What is the differential diagnosis for toxicologic causes of severe muscle spasm and tetany?

E-9-1-1 78

E-9-1-1 ALS EMS OR 78

Dr. Smith's ECG Blog

NOVEMBER 3, 2024

Below in Figure-1 is a tracing obtained from the in-house telemetry. The rhythm strip in Figure-1 shows four ECG leads. Figure-1: The initial rhythm strip in today’s case. Figure-1: The initial rhythm strip in today’s case. Beat #9 is wide, and manifests a different QRS morphology than the other wide beats.

E-9-1-1 65

E-9-1-1 ALS OR 65

Dr. Smith's ECG Blog

DECEMBER 11, 2023

Moreover , the patient has ongoing symptoms and has an unexplained elevated troponin, so she is having an MI and the only question is whether it is type 1 or type 2 due to hypertension. Case continued She was loaded with aspirin 325 mg, and repeat troponin drawn around the time of EKG 1 resulted at 267 ng/L. At midnight. At midnight.

E-9-1-1 121

E-9-1-1 ACS Coronary STEMI 121

REBEL EM

MAY 25, 2023

mental status, urine output, capillary refill) is more important than an actual goal PERMISSIVE HYPOTENSTION IN PTS WITH TBI Brotfain E et al. mental status, urine output, capillary refill) is more important than an actual goal PERMISSIVE HYPOTENSTION IN PTS WITH TBI Brotfain E et al.

E-9-1-1 145

E-9-1-1 Plasma ALS OR 145

REBEL EM

NOVEMBER 6, 2024

Elbow Dislocation Definition: Disarticulation of the proximal radius & ulna bones from the humerus Epidemiology: Incidence Second most common joint dislocation (after shoulder) in adults Most commonly dislocated joint in children Accounts for 10-25% of all injuries to the elbow ( Cohen 1998 ) Posterolateral is the most common type of dislocation (..)

E-9-1-1 59

E-9-1-1 ACS OR Emergency Department 59

Pediatric EM Morsels

APRIL 5, 2024

Time from tick bite to onset of symptoms generally ranges from 1 week to 4 weeks but can start within 2 days (CDC 2022) Tick-Borne Encephalitis can also be transmitted in unpasturized dairy. These resolve within 1 week. 2004 Nov 15;39(10):1493-9. 2018 Mar; 3(1): 8. 2024 Jan 25;78(1):80-89. Clin Infect Dis.

E-9-1-1 161

E-9-1-1 ALS OR EMS 161

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 ). Answer : Bedside ultrasound!

E-9-1-1 109

E-9-1-1 Coronary STEMI ALS 109

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 114

EMS E-9-1-1 OR ED 114

EMDocs

FEBRUARY 15, 2024

1 These plants contain tropane alkaloids such as atropine (mixture of d-hyoscyamine and l-hyoscyamine) and scopolamine which are muscarinic receptor antagonists. 2 Jimson weed ( Datura stramonium, Figure 1) is one of several anticholinergic plants that if ingested can cause anticholinergic toxicity. 3 Figure 1. 3 Figure 1.

E-9-1-1 89

E-9-1-1 Overdose ED OR 89

ALiEM

OCTOBER 30, 2023

It should be no surprise that academic clinical educators are at high risk for burnout, stalled career advancement, and abandonment of academic medicine altogether [1, 2]. After spending her first year acclimating to the new department and achieving board certification, Dr. Garcia finds herself at a bit of a crossroad. In short, no.

E-9-1-1 161

E-9-1-1 ALS OR 161

Broome Docs

MAY 31, 2024

Freund Y, Viglino D, Cachanado M, Cassard C, Montassier E, Douay B, Guenezan J, Le Borgne P, Yordanov Y, Severin A, Roussel M, Daniel M, Marteau A, Peschanski N, Teissandier D, Macrez R, Morere J, Chouihed T, Roux D, Adnet F, Bloom B, Chauvin A, Simon T. PMID: 37019501 Pulmonary primatology is harder than you may think Drew T, Võ ML, Wolfe JM.

E-9-1-1 97

E-9-1-1 ED Critical Care ICU 97