Conference Notes 10-11-2011
ELISE STUDY GUIDE PEDS
Fifth’s disease: parvovirus B19, slapped cheeks, lacey rash, risk of complications in diabetics and sickle cell disease
Hemophilia A is factor 8 deficiency. For head injuries gotta give 50u/kg to get 100% activity. For joints give 25u/kg for joint or other bleeds to get to 50% activity. Give factor replacement prior to CT head. Hemophilia causes an abnormal PTT. Remember WEPT=warfarin/extrinsic/PT. HIPTT=Heparin/Hemophilia/Intrinsic/PTT
Hydroxyurea used in SCD to increase the amount of fetal hgb production.
Tx for VonWillibrands (most common congenital bleeding disorder) is DDAVP which increases the release of VWF from endothelial cells . vWF;Factor 8 concentrate if not responsive to DDAVP
Impetigo (honey colored crusting is buzword)is strep or staph. If bullous impetigo it is staph or MRSA.
Kerion= scalp mass from tinea. Don’t I and D this! Treat with griseofulvin or terbinafine po. Topicals do not work.
Eczema Herpeticum: Diffuse herpes overlying eczema. Cover staph and strep and add acyclovir.
In SCD although staph is most common cause of bone/joint infection, these patients are also at risk for Salmonella bone infection. Dactylitis (swelling and painful fingers in little kids) may be presenting complaint for SCD.
Treatment for acute chest syndrome in a sickle cell patient is abx and transfusion if PAO2 is less than 70.
Scabies in infants has different presentation. They will have scaly lesions on palms/soles and possibly wide spread rash. Other family members may or may not be affected.
Typhlitis=neutropenic enterocolitis. Think about in patient getting chemo with right lower abdominal pain. Treat with broad spectrum, big gun abx. May need surgery. Cecum usually involved.
Tumor lysis syndrome causes release of potassium, uric acid and phosphate. Think sick puppy (Potasium-Uric acid-Phosphate-py). Treat with iv fluids, bicarb, allopurinol or rasburicase.
Bone/joint pain due to Leukemia may not have way out of wack CBC. CBC may show only nonspecific multiple mild abnormalities (anemia/low wbc count).
Roseola infantum= infant with high fever that breaks and rash develops.
ALISSA GOTTESMAN TRAUMATIC BRAIN INJURIES TBI
Definition: impairment of brain function due to mechanical force
1/3 of trauma deaths due to TBI.
TBI: severe is 3-8, moderate 9-13, mild 13 and up.
GCS </=8 intubate. Induce with etomidate. Use C-spine precautions. SZ prophylaxis with phenytoin for 7 days. Only hyperventilate when pt’s have signs of herniation.
High pressure bleeding with epidural hematoma from meningeal artery can cause herniation in 4 hours. Underlying brain injury is small so surgery can be life and disability saving. On CT bleeds appear with football shape appearance. Convex on medial surface. Occurs in space between skull and dura.
Subdural hematomas usually due to injury to bridging veins in elderly or alcoholics. Usually underlying brain injury is more severe than epidural. On CT bleeds appear with concave surface medially. Occurs in space between dura and pia mater.
SAH on CT shows blood in CSF.
Probably scan all Elderly patients with head trauma.
High risk criteria for scan: 8B’s Brain dysfunction (seizure, amnesia, altered mental status, etc), Boney fx/step off, Banger (bad headache), Blow chow (vomiting), Bombed (intoxicated), Babies, Boomers (over 60yo), Bleeders (coumadin or plavix use).
Cspine injury as high as 34% prevalence in the unconscious pt.
Jefferson burst fx oc C1 is unstable.
Hangman’s fx is due hyperextension injury of C2. Unstable
Teardrop Fracture due to severe flexion injury. Unstable.Can get anterior cord injury.
Clay Shoveler’s is fx of spinous process of C7. Stable.
When to scan Cspine? Use Nexus or Canadian Rules. If you can’t CT neck or want further eval, MRI of cervical spine is indicated.
If C-collar is to be on patient for more than 6 hours switch them to an Aspen Collar which is more comfortable and causes less skin breakdown.
ERIK KULSTAD VARIATION IN MEDICAL PRACTICE
Research on Practice variation started about 40 years ago. First study showed striking variation in tonsillectomies/hysterectomies/cholecystectomies in two Vermont towns.
The factor most important driving this variation is physician behavior and resource availability.
This type of finding has been replicated numerous times.
Dartmouth Health Atlas evaluates outcomes across the country in relation to intensity of care.
Health Care can be categorized as effective/necessary (15% of medicare spending), preference-sensitive care (influence by physician opinion and accounts for 25% of medicare spending), supply-sensitive care (includes referrals/consults/imaging/admission to ICU. Accounts for 60% of medicare spending)
Article in Science suggested that Variance is due to physician practice and there is risk of too much medical care vs. to too little care.
Medical Market Is in disequilibrium because excess supply pushes demand. The assumption that more care is better, supplies are used up to exhaustion.
Unintended consequences of medical care make it possible that increased medical intensity leads to worse outcomes.
Informed patient choice has been shown to decrease utilization of healthcare usage.
PIKUL PATEL LBBB AND AMI
7% of MI’s had LBB in National Registry of AMI. Many did not get thrombolysis.
Most useful criteria: serial ekg changes, st elevation, abnormal q waves,
Cabrera’s sign is prominent notching in ascending limb of s wave in V3 or V4. 27% sensitive and 48% specific for AMI in LBB
Sgarbossa Criteria are concordant st elevation 1mm, concordant depression 1mm, discordant st elevation of 5mm.
Smith Modified Sgarbossa Criteria: concordant ste 1mm or concordant std 1mm, or discordant ste with ratio of discordance of at least 0.2 ste/s wave depth
SHANNON LOVETT PEDIATRIC PROCEDURES
Peds airway differences: bigger head, bigger tongue, narrowest point is subglottic region -cricoid ring, epiglottis is bigger and more floppy and u shaped, larynx is more anterior and cephalad.
ETT tube size in kids: Use cuffed ET tube (age/4)+3. Depth is ETT size x 3. Use uncuffed tube in newborns (3.5 size ETT)
Needle cric for kids under 8yo. Inspiratory/expiratory ration is ¼. More time for passive expiration. You will likely be stacking breaths somewhat.
Peds secretary has key to EZIO cabinet in PED.
Place IO in prox tibia just below tuberosity or medial maleolus.
Peds LP: keep bevel parallel to fibers of dura. Neck flexion is unnecessary.
Putting in a chest tube: between ribs 4,5, anterior to mid axillary line, use finger and be cautious with hemostat. Teens:28-32 french tube. Child:18french tube. Little kid: 8 French tube.