Conference Notes 1-17-2012
JOINT EM-PEDIATRIC CONFERENCE SEIZING CHILD
Simple Febrile Seizure: 6mo to 6 years, generalized tonic clonic sz lasting less than 15 min, no focality, pt has temp >38. Consider blood glucose level. LP is not mandatory. Approach child as having no seizure at all and look for source of infection with history and physical exam. Don’t get a CT brain on these kids. Admit if child has more than 1 sz in 24 hours or any sign of complex febrile seizure. If seizure does not occur in first day of illness this could be a red flag and consider admission. Similarly, if first febrile seizure occurs after the age of 5 the pt should have a neuro eval inpatient or outpatient.
First Non-Febrile Seizure: Careful clinical exam for any focal neuro deficit. Labs should be ordered based on individual clinical circumstances. UTox should also be considered. EKG should be done only with a history of syncope. No EKG needed if seizure is focal. LP only with concern about meningitis. EEG is a recommended outpt option in all these kids. EEG within 24 hours is best if possible but don’t go nuts trying to get this arranged from the ER. Focal seizures, Todd’s paralysis, not returning to baseline within a few hours all require an ED CT. If you can get the radiologist to do the MRI do that instead of CT. Kids with first time generalized seizure with no focality, no Todd’s paralysis, and no failure to return to baseline do not need ED imaging. Seizures in kids who are on seizure meds don’t need imaging even if seizures have some change in character from usual or child has trivial head injury. If child returns to normal after seizure they can go home and get outpt work up. Admit kids with first time seizure who are under 6mo.
Status Epilepticus: First line is Benzos, Second line: Fosphenytoin. Can give phenobarb 5-10mg/kg prior to getting level if patient is on phenobarb at home. Third line: IV Keppra, IV Depacon. Fourth line: Propofol. If kids get to the ED per EMS or family still seizing that in effect is status. Loading levels for all seizure meds Is 20 mg/kg.
Sudden Unexplained Death in Epilepsy: More likely in patients whose seizures are poorly controlled. Adults more common than kids. Adults:1:650, Kids 0.2:1000
HAYWARD HEME-ONC STUDY GUIDE
RDW changes prior to MCV in deficiency anemias.
Platelet deficiency usually shows up as petechiae, epistaxis, mucosal bleeding, but not deep tissue bleeding.
D-Dimer can be normal in liver disease but should be very abnormal in DIC. Thus it can differentiate between the two.
Low platelets is the most common lab abnormality in DIC.
Most common cause of DIC is sepsis
In hemophilia give factor 8 prior to getting imaging study done. 50 international uinits for possible head bleeds (100% of factor activity), and 25 IU for joint bleeds (50% of factor activity).
DDAVP is mainstay of treatment for kids with type 1 von Willebrand Disease.
Hemolysis due to transfusion reaction will result in decreased serum haptoglobin, increase ldh, increased serum hemoglobin and hemoglobinuria. Increased LDH and low haptoglobin are 90% specific for hemolysis.
TTP= thrombocytopenia, MAHA, fever, renal impairment, and neurologic impairment.
Treatment of TTP is plasma exchange.
GROMIS-RADAWI CURBSIDE CONSULT GI BLEED
Black stool means digested stool. It passed through small bowel. 90% Started above the ligament of treitz. 10% can come from right colon. Melanotic is an incorrect term. Melenic is the correct term. Hematochezia is 90% colonic bleed but 10% have upper gi source. That 10% is at high risk of shock from an arterial bleed in an ulcer.
Medications in GI bleed are secondary to identification of major bleeder and circulatory support. Use of PPI’s in GI bleed started from data showing that blood clotted better in stomach when ph was higher. Most GI bleeders don’t need continuous PPI drip. Major league bleeders should probably be on continuous drip.
NG tube can be helpful to assess the pace of bleeding. There are false negatives however. Helps to better visualize GI tract with endoscopy. Varicies do not contra-indicate NG tube placement.
IV Erythro can be used to induce gastric motility and improve the endoscopic visualization of the stomach and small bowel.
ANDREA CARLSON POISONING WITH CV DRUGS
Class 1a: Quinidine is prototype. Procainamide is more common. Infusions can result in hypotension and QRS widening. Disopyramide is a strong negative inotrope. Blocks pancreatic islet cells resulting in hypoglycemia. QRS widening/QTC prolongation due to sodium channel blockade. Tx with Bicarb for QRS widening. Avoid acidosis. Prolonged resuscitation is indicated. You can try lidocaine (1b).
Class 1C: Flecainide and Propafenone. Strong NA channel blockers. Effects are hypotension, bradycardia, QRS/QT prolongation. Flecainide can cause Brugada Pattern. Tx with Bicarb. For propafenone follow up with hypertonic saline. Amiodarone (Class 3), lipid rescue, and pacing may help.
Class 1A/1C Mimics: TCA’s, cocaine, phenothiazines, Benadryl, tegretol, choloral hydrate, propoxyphene.
Class 1b: Lidocaine and Mexiletine. Also NA channel blockers but selective for rapidly depolarizing or ischemic cells. At times used as a cutting agent for cocaine. Can cause methemoglobinemia. Fasiculaitons and seizures can result from bigger OD’s. Treat seizures with benzos or phenobarb. Don’t use phenytoin because it is a 1b also.
Class 3: Amiodarone acts at the potassium channel. Sotalol is a potassium channel blocker and beta blocker. Tx is supportive for these. Glucagon may benefit sotalol OD. Multaq (Dronedarone) is a new Class 3 drug but has a lot other properties (dirty drug).
Adenosine is unclassified drug. Increases AV nodal refractoriness. No reports of overdose. Use lower dose in cardiac transplant patients and those using persantine. Increase dose in patients on methylxanthines. Caution in asthmatic patients theoretically could induce bronchospasm.
BILL SCHROEDER CONCUSSION/HEAD INJURY EVALUATION
SCAT2 : Ask the head-injured player questions about this game and the last game. Do the standing tandem gait balance test for 20 seconds. More than 5 adjustments in that 20 seconds requires pulling the kid from the game.
After head injury, kids need rest with no physical activity or school until symptoms resolved without Tylenol/ibuprofen. Limit video games and texts. 80-90% of concussions will resolve in 7-10 days.
Post-traumatic headaches can be treated with amitriptyline. Topomax if there is a history of migraines.
Sertraline helps with cognitive effects following head injury. Other medications possible are Ritalin and Concerta.
Step wise progression for return to play. Don’t even start until symptom free. As the patient increases activity, if symptoms recur they need to rest for 24 hours and restart at lower level.
Children should not return to play the same day as concussion because they are more prone to cerebral edema in “second impact syndrome”. Only 2 cases in adults. Seen basically only in teenagers. Rapid death 2-5 minutes after second impact. Peak incidence of second impact syndrome in the mouse model is 3 days out from first injury.
Concussion is due to stretching of neuronal and axonal membranes. Ion influx then other bad oxidative and metabolic stuff in the nerve cell.
RESIDENT SELECTION COMMITTEE MEETING