Author: Zack (Page 6 of 9)

Peds H- Heart Failure and Congenital Heart Disorders

February 4, 2018 /

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Common Chief Complaints

  • Cyanosis
  • Difficulty feeding
  • Failure to thrive

Cyanotic Heart Lesions

  1. Truncus arteriosus
    • Aorta and pulmonary artery are fused
    • Single vessel comes from both ventricles
  2. Transposition of great vessels
    • Aorta comes off RIGHT ventricle
    • Pulmonary artery comes off LEFT ventricle
  3. Tricuspid atresia
    • Blood unable to get from right atrium to right ventricle
  4. Tetrology of fallot
    • Overriding aorta
    • Ventricular septal defect
    • Right ventricular outflow tract obstruction
    • Hypertrophy of right ventricle
  5. Total anomalous pulmonary venous return
    • Pulmonary vein empties into the right ventricle

Ductal Dependent Lesions

  • Classically presents in first 30 days of life
  • Treatment = Prostaglandins
  • Common lesions
    • Hypoplastic left heart
    • Aortic stenosis
    • Coarctation of the aorta

Congestive Heart Failure

  • Common Presentation
    • Difficulty feeding
    • Organomegaly
    • Cardiomegaly on CXR
  • Treatment
    • Furosemide
    • Vasopressors
  • Admit

Additional Reading

Peds S- Sepsis and Serious Bacterial Infections

January 28, 2018 /

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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
      • Require admission and antibiotics
    • Age 30-60 days
      • ILL appearing
        • Treat same as fever in <30 day patient
      • WELL appearing
        • Testing and treatment differ by institution
        • Multiple criteria established to help in this age range
          • Rochester criteria
          • Philadelphia criteria
          • PECARN criteria
        • Choose one and use consistently
    • Age >60 days
      • (Assumes immunizations are up to date)
      • Workup is more targeted
        • Blood cultures, Urine cultures, Chest X-Rays still common

Additional Reading

  • Rochester Criteria Febrile Infants (MDCalc)
  • PECARN Rule for Low Risk Febrile Infants (MDCalc)

Peds H- Hyperglycemia and Hypoglycemia

January 21, 2018 /

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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 breathing
    • Treatment = mannitol

Hypoglycemia

  • Multiple causes
    • Sepsis
    • Inborn errors of metabolism
    • Endocrine disorders
  • Replace glucose using “Rule of 50s”
    • Dextrose % x Volume = 50
      • Neonates: 5ml/kg of D10
      • Pediatrics: 2ml/kg of D25
      • Teens/Adults: 1ml/kg of D50
    • 1 “amp” of D50 = 25g of sugar = 50ml

Additional Reading

Peds O- Oxygen, Airway, and Respiratory Disorders

January 14, 2018 /

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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 abscess
    • HIDDEN BEHIND behind the airway
  • Common presentations of airway emergencies
    • Voice changes
    • Drooling
    • Stiff neck
  • Testing
    • Most are seen on neck X-Ray
    • Peritonsillar abscess is clinical diagnosis
  • Treatment
    • Manage the airway
    • IV Antibiotics
    • Peritonsillar abscess needs drainage

Breathing Emergencies

  • Bronchiolitis = Badly breathing booger babies
    • Upper respiratory infection caused by virus
    • Signs of severe illness requiring admission
      • Grunting
      • Nasal flaring
      • Retractions
      • Hypoxemia
      • Unable to tolerate PO
    • Treatment
      • Deep suctioning
      • Can consider albuterol trial
      • Oxygen supplementation as needed
    • Generally avoid
      • Chest X-rays
      • Steroids
      • Antibiotics
  • Asthma
    • Treatment
      • First line
        • Albuterol/ipratropium
        • Steroids
      • Additional options as needed
        • Magnesium
        • Ketamine
        • IV epinepherine
  • Croup
    • Presentation
      • Barky cough
      • Stridor
    • Treatment
      • Steroids
      • Consider racemic epinephrine
  • Pneumonia
    • Diagnosed by x-ray
    • Treat with antibiotics
  • Cystic fibrosis
    • Albuterol/ipratropium
    • Nebulized saline
    • Antibiotics

Additional Reading

How to Save a Dying Baby

January 7, 2018 /

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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 days of age
  • Fever >60 days of age

Heart- Consider Congenital Heart Abnormalities

  • Truncus arteriosis
  • Transposition of great vessels
  • Tricuspid atresia
  • Tetrology of fallot
  • Total anomalous pulmonary venous return
  • Ductal dependent lesions
  • Congestive heart failure

Inborn Errors of Metabolism/Endocrinology

  • Congenital adrenal hyperplasia

Tummy/Trauma- Consider Abdominal Processes and Non Accidental Trauma

  • Non-accidental trauma
  • Necrotizing enterocolitis
  • Volvulus
  • Toxic megacolon
  • Intussusception
  • Pyloric stenosis

And never forget… If you feel flustered… GRAB THE BROSLOW!!!

Additional Reading

Bleeding Disorders

December 31, 2017 /

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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 (factor VIII binds vWF)
        • Transfuse cryoprecipitate

The Hemophilias

  • Symptoms of DEEP bleeding
    • Hemarthrosis
    • Hematomas
    • Intracranial Bleeding
  • Factor IX deficiency (Christmas disease)
    • Treat by replacing factor IX
      • Rate the “severity” of the bleeding on a scale of 1-100
        • Dosing equals the severity score in milligrams
          • For example
          • 25 = 25mg/kg factor = mild bleeding (mild hematuria with stable hemoglobin, painful but contained hemarthrosis)
          • 50 = 50mg/kg factor = moderate bleeding = (rapid nose bleeds, rapid bleeding that won’t resolve)
          • 75 = 75mg/kg factor = severe bleeding = (GI bleeds with dropping hemoglobin, retroperitoneal hematoma)
          • 100 = 100mg/kg factor = deadly bleeding = (intracranial hemorrhage)
  • Factor VIII deficiency (Hemophilia A)
    • Treat by replacing factor VIII
      • Dosing similar to factor IX but you take severity score and divide by 2
        • For example
        • 25 = 12mg/kg factor = mild bleeding (mild hematuria with stable hemoglobin, painful but contained hemarthrosis)
        • 50 = 25mg/kg factor = moderate bleeding = (rapid nose bleeds, rapid bleeding that won’t resolve)
        • 75 = 37mg/kg factor = severe bleeding = (GI bleeds with dropping hemoglobin, retroperitoneal hematoma)
        • 100 = 50mg/kg factor = deadly bleeding = (intracranial hemorrhage)

Additional Reading

How to Read an EKG

December 3, 2017 /

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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 waves
  • Check for ST segment elevation or depression
    • Compare the J point with baseline (TP segment)
  • Check for peaked T waves and T wave inversions
    • T wave inversions in V1 and aVR are normal

Step 3: Look at Intervals

  • PR interval
    • Wolf-Parkinson White Syndrome
    • 1st degree heart block
  • QRS interval
    • Left bundle branch block
    • Right bundle branch block
    • Sodium channel blockade
  • QT interval
    • Long QT syndrome
    • Hypokalemia
    • Risk of torsades de pointes

Step 4: Get an Old EKG

  • If you find anything abnormal looking, compare to an old EKG

Bonus: Scarbossa Criteria

  • Identifies ischemia in patients with a left bundle branch block
    • 1 lead with concordant ST elevation
    • 1 lead with concordant ST depression (V1-V3)
    • Severely discordant ST elevation (>25% preceding S wave)

Additional Reading

Pediatrics Exam

November 26, 2017 /

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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
    • Easiest ways to keep kids distracted
      • Let parents hold/play with them
      • Toys
      • Stethoscope
      • Funny sounds/noises

ENT

  • Many times the kids don’t localize the symptoms
  • May present with vomiting, fever, irritability, etc
  • If difficulty examining pharynx, consider triggering a gag reflex

Fully Undress

  • Look for bruising, rash, blisters
  • Signs of non-accidental trauma
  • GU exam (especially in boys, check the testes!)

Additional Reading

Pediatrics History

November 19, 2017 /

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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 the patient have prenatal care?
    • Any issues with the pregnancy?
    • Was mom GBS positive?
  • Peribirth
    • What gestational age was patient born at?
    • Vaginal delivery or c-section?
    • How long did baby have to stay in hospital after delivery?
  • Postbirth
    • Diagnosed medical/surgical problems
    • Immunization status

Additional Reading

Fever in a Returning Traveler

November 12, 2017 /

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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 before leaving?
  • Did they take any immunizations or medicines prior to departure?
  • Did they continue prophylaxis as instructed?

Step 4: Go to the CDC website

  • Look up the country of concern
  • Will help establish your differential

Step 5: Test for malaria

  • If you are concerned that patient has malaria…
  • Order thick and thin blood smear

Additional Reading

Diarrhea

November 5, 2017 /

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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 gastroenteritis may cause gas cramping but shouldn’t be tender or severely painful)
    • Bonus red flag!!!
      • POST-PRANDIAL pain
      • Consider mesenteric ischemia
  • Recent antibiotics or hospitalization?
    • Consider C. difficile
      • Treat with PO vancomycin
  • Recent travel?
    • ~80% travelers diarrhea is bacterial
      • Treat with ciprofloxacin
        • Note: See FDA black box for fluoroquinolones prior to prescribing
  • Do you have history of atrial fibrillation?
    • Increases risk for mesenteric ischemia and ischemic colitis

Consider Testing if Patient is Ill or has Red Flags

  • CBC
  • Electrolytes
  • Stool studies
    • Stool WBCs
    • Stool culture
    • C-diff
    • Ova/Parasite
  • CT abdomen/pelvis with IV contrast

Common Antidiarrheals

  • Loperamide (Imodium)
  • Bismuth (Pepto-Bismol)
  • Dphenoxylate (Lomotile)

Additional Reading

  • Fluoroquinolone Black Box Update (FDA)

Appendicitis

October 22, 2017 /

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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 WBC count has both low sensitivity and low specificity for acute appendicitis
  • Step 2: Get a detailed history
    • When did the pain start?
      • How many HOURS into their syndrome are they (remember stages of appendicitis)
      • Is the pain migrating?
    • Objective fever?
    • Did the pain start before the vomiting started?
    • Does the patient have decreased appetite?
  • Step 3: Perform a physical exam
    • Pain over McBurney’s point
      • Right lower quadrant
      • 1/3 the distance from the ASIS to the umbilicus
    • Peritoneal signs (Rigidity, Rebound, Guarding)
    • Psoas sign
      • Lie patient on left side with legs extended
      • Extend their hip behind them
      • Pain = Suspected retroperitoneal inflammation
    • Obturator sign
      • Have patient lie on back with hip/knee flexed at 90 degrees
      • Internally rotate hip (move ankle away from body)
      • Pain = Suspected obturator internus inflammation
  • Step 4: Imaging
    • Most adults
      • CT scan +/- IV contrast
    • Pregnant women
      • MRI abdomen
    • Pediatric patients
      • RLQ ultrasound
  • Step 5: Disposition
    • Perform a repeat abdominal exam
    • Even if CT is negative, consider followup in ED in 12-24 hours

Additional Reading

Eye Complaints

October 15, 2017 /

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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 fluorescein strip with eye drops and apply to pocket
      • Have the patient blink to distribute the dye
    • Look under woods lamp for bright “uptake” areas that don’t move with blinking
      • These represent abrasions, ulcers, etc
    • This step is also a good opportunity to evert the eyelids and examine for foreign bodies if appropriate
  • Step 3: Examine the anterior chamber with slit lamp
    • “Cell and flare” (example HERE)
    • Representative of iritis, uveitis
    • This is also a good opportunity to examine any other abnormal areas of the eye under magnification!!!
  • Step 4: Check intraocular pressure
    • Pressure >20mmHg (especially when unequal) is concerning for acute angle closure glaucoma
    • Multiple tools to measure pressure on market, ask somebody to show you how to use
  • Step 5: If appropriate, use ultrasound to evaluate posterior eye
    • Multiple things can be diagnosed with ultrasound of the eye
      • Retinal detachment
      • Optic neuritis
      • Papilledema
      • Foreign bodies

Additional Reading

Bradycardia

October 8, 2017 /

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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 type 2 = Intermittent dropped beats
      • 3rd degree = None of the atrial beats result in a ventricular beat
    • Evidence of hyperkalemia?
  • Step 2: Determine if patient is SYMPTOMATIC
    • Hypotension
    • Chest Pain
    • Syncope
    • Lightheadedness
    • Note: Many patients have benign and asymptomatic resting bradycardia (I’ve seen as low as 30s!) and this does not necessarily require aggressive treatments/IV medications
  • Step 3: If patient is having symptoms… Give atropine!
    • Typical dose is 0.5mg IV atropine
  • Step 4: If patient still having symptoms… Give epinephrine!
  • Step 5: If patient still having symptoms… Cardiac pacing!
    • If symptoms are minimal or resolved, patient can sometimes wait for permanent pacemaker with cardiology
    • Transcutaneous pacing
      • Sometimes difficult to get mechanical capture
    • Transvenous pacing
      • Place through the right internal jugular vein

Additional Reading

Anaphylaxis

October 1, 2017 /

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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
    • Cardiovascular symptoms
      • Hypotension
      • Lightheadedness
    • Gastrointestinal symptoms
      • Nausea/Vomiting
      • Diarrhea
  • Step 2: Give epinepherine
    • A major pitfall in the treatment of anaphylaxis is delay of epinephrine!!!
    • Normal adult “EpiPen” contains 0.3mg epinephrine
    • Normal dosing of IM epinephrine is 0.01mg/kg
  • Step 3: Consider intubation
    • The second biggest pitfall in the treatment of anaphylaxis is delaying intubation until it’s extremely difficult to intubate!!!
  • Step 4: Give adjunct medications
    • H1 blocker
      • Diphenhydramine
    • H2 blocker
      • Ranitidine
    • Steroids
      • Prednisone, dexamethasone, etc
  • Step 5: Send the patient home with an EpiPen prescription
    • Education them on this
    • Articulate this part of the plan to your attending
  • Bonus
    • Refractory anaphylaxis
    • Beta-blockers?
      • Treat with glucagon

Additional Reading

Tachycardia

September 10, 2017 /

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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
      • Treat with AV blockers (diltiazem)
    • Other (less common) diagnoses
      • Atrial flutter with variable block
      • Multifocal atrial tachycardia
  • Step 4: Is this a WIDE and REGULAR tachycardia?
    • Assume ventricular tachycardia until proven otherwise
      • Treatment is immediate cardioversion if unstable
      • May try chemical cardioversion if stable
        • Procainamide
        • Amiodarone
        • Lidocaine
    • Other diagnoses
      • ANTIdromic Wolf Parkinson White
      • Narrow complex tachycardias PLUS aberrancy
  • Step 5: Is this a WIDE and IRREGULAR tachycardia?
    • Atrial fibrillation with bundle branch block
      • Extremely fast and bizarre in appearance?
        • Consider atrial fibrillation with Wolf Parkinson White

Additional Reading

  • Calcium Channel Blockers for Stable SVT (ALiEM)
  • Atrial Fibrillation in WPW – Pearls and Pitfalls (County EM)

Status Epilepticus

September 3, 2017 /

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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 agents for 30 minutes
    • If seizure continues, you must move onto step 4…
  • Step 4: Sedate and intubate the patient
    • Propofol
    • Phenobarbital
  • Step 5: Start patient on continuous EEG
    • Detects non-convulsive status epilepticus
    • Usually started once patient is in ICU

Additional Reading

Seizure

August 27, 2017 /

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Basic Approach

  • Step 1: Describe the seizure
    • Did patient have an aura?
    • Was there loss of consciousness?
    • What did the movements look like?
    • Did they have postictal phase?
    • Did they have a trauma as well?
  • Step 2: Ask about TIME (mnemonic)
    • Tongue biting
      • Usually occurs on the lateral sides of tongue
    • Incontinence
    • Medication changes/adjustments
    • Ethanol use
  • Step 3: Do a FULL neurologic examination
    • Mental Status
    • Cranial nerves
    • Visual fields
    • Speech
    • Cerebellar (finger-nose)
    • Motor
    • Sensation
    • Reflexes
    • Gait
  • Step 4: Testing plan
    • Glucose
    • Pregnancy Test
    • CBC
    • Electrolyte panel
    • Urine drug screen
    • Drug levels of anti-epileptic agents
  • Step 5: Simple seizures (<5 minutes) do not require immediate treatment
    • Roll them on side
    • Suction

Additional Reading

Cardiac Arrest (ACLS)

August 20, 2017 /

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Hard, fast, unrelenting chest compressions are the core of ACLS!!!

Step 1: Check the Patient’s Pulse

  • If the patient does not have a pulse, start CPR
    • Hard, fast, unrelenting compressions
      • Intubated patients
        • Continuous Compressions
      • Non-intubated adults
        • 30 compressions then 2 breaths… Repeat
      • Non-intubated pediatrics
        • 15 compressions then 2 breaths… Repeat

Step 2: Determine if the Rhythm is Shockable or Non-shockable

  • Shockable rhythms
    • Ventricular Fibrillation (VF)
    • Ventricular Tachycardia (VT)
  • Non-shockable rhythms
    • Pulseless electrical activity (PEA)
    • Asystole

Step 3: Start a Timer For 2 Minutes

  • Do a rhythm/pulse check every 2 minutes

Step 4: Is the Patient in a Shockable Rhythm?

  • Repeat/coordinate shocks with every 2-minute pulse check
  • Give 1mg IV/IO epinephrine every 3-5 minutes
  • Give amiodarone
    • 300mg with first dose
    • 150mg with a repeat dose

Step 5: Is the Patient in a Non-Shockable Rhythm?

  • Give epinephrine every 4 minutes (every other cycle)

Quick Facts

  • Shockable rhythms (VT/VF) have best prognosis
    • Frequently related to myocardial infarction
  • Asystole has the worst prognosis
  • PEA has mixed prognosis (depends on diagnosis)
    • Two types (wide and narrow)
      • “Wide” PEA frequently caused by metabolic abnormalities
        • Consider bicarb and calcium chloride
      • “Narrow” PEA frequently caused by shock state
        • Perform bedside ultrasound in attempt to determine cause
    • “The H’s and T’s”
      • Hypoxemia
      • Hypovolemia
      • Hydrogen Ions
      • Hyper/hypokalemia
      • Tension pneumothorax
      • Tamponade
      • Toxins
      • Thrombosis (MI/PE)

Additional Reading

RUQ Abdominal Pain

August 13, 2017 /

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There are 5 key diagnoses classically associated with right upper quadrant (RUQ) abdominal pain.

Cholelithiasis and Biliary Colic

  • Cholelithiasis = Gallstones in the gallbladder
    • Frequently seen on CT scan or RUQ ultrasound
    • Present in 15% of the population
  • Biliary colic = Intermittent episodes of pain if stone passes
    • Classically colicky/crampy/spasmy pain in RUQ
      • Frequently radiates to right shoulder/flank
      • Pain is intermittent and resolves after a few hours
    • Patients need pain control and outpatient follow up with general surgery

Cholecystitis (Inflammation of the Gallbladder)

  • Caused by obstruction of the cystic duct
    • Increased pressure in the gallbladder results in ischemia/inflammation
  • Diagnosis
    • RUQ Ultrasound
      • Gallbladder wall thickening
      • Pericholecystic fluid
      • Cholelithiasis
    • CT of the abdomen and pelvis also has decent sensitivity/specificity
  • Admit for cholecystectomy

Choledocolithiasis (Common Bile Duct Obstruction)

  • Terminology
    • Cholecystitis = Stone in CYSTIC DUCT
    • Choledocolithiasis = Stone in COMMON BILE DUCT
  • Symptoms similar to cholecystitis
  • Testing
    • LFTs will be elevated
      • Results from blockage of bile outflow from liver
    • RUQ Ultrasound
      • Shows dilation of the common bile duct
  • Treatment
    • GI Consult
    • Endoscopic Retrograde Cholangiopancreatography (ERCP)

Cholangitis (Infection of Bile Duct/Liver)

  • Common complication of choledocolithiasis
  • Charcots triad
    • RUQ pain
    • Fever
    • Jaundice
  • Reynolds pentad
    • RUQ pain
    • Fever
    • Jaundice
    • Altered mental status
    • Shock/hypotension
  • Treatment
    • Fluids
    • IV antibiotics
    • ERCP

Gallstone Pancreatitis

  • Gallstone obstructs PANCREATIC DUCT
  • Testing
    • Lipase will be elevated
    • LFTs will be elevated
    • RUQ will show dilation of the CBD
  • Treatment
    • Fluids
    • Pain medicine
    • ERCP

Additional Reading

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