conference pearls 7-5-2011
- 7-05
- cool heat stroke as fast as possible. mist and fan technique probably easiest to get together quickly, also can use cool guard
- if nurse asks if there is anything else you want to do on oral boards, there is.
- be agressive on oral board cases, do everything now
- disciplined exam is critical on oral board cases
- pres syndrome tx= calcium channel blockers
- preecclampsia can test with urine protein/ urine cr ratio, serum uric acid
- air in ventricles from epidural anesthesia can cause headache. tx with 100%oxygen
- blood patch very effective for post lp or post epidural headache
- Systematic cxr eval A=air and airway, B=breathing aka lungs and bones, C=cardiac and mediastinum, D=devices, diaphragms, and data, E=external to rib cage
- mediastinal hematoma caused by rupture of smaller vessels like azygos
- wide mediastinum is >8cm on PA chest
- Overall incidence of SBI in kids is @10%, meningitis is 1%.
- Incidence in well appearing kids is @7%.
- SBI includes pneumonia, uti, bone/joint infection, meningitis, cellulitis, bacterial enteritis
- Cautious simple approach to fever in kids: up to 8 weeks of age do a full septic workup, give ceftriaxone and decide dispo with pediatrician
- 3-36 months get urine in girls up to 24 months, uncircumcised boys up to 12 months, circumcised boys up to 6 months
- RSV in kids less than 60 days old the risk of SBI is 7% and risk of meningitis is close to 0. Consider getting urine and blood cultures in these kids.
- Vaccination up to date in the 3-36 month kid lowers risk of SBI
7/5/11
Pneumocephalus is rare complication of epidural anesthesia. Usually characterized by acute onset of headache after procedure. +/- neuro deficits. Giving O2 speeds absorption of air. Can also be seen after trauma, cancer, otogenic infection. Prognosis based on cause, but generally good. Remember peripartum headache can be bad.
Joint Pediatric/EM conference 6.14.2011
Topic: Infectious Disease (panelists Dr. Maryanne Collins, Dr. Bill Schroeder, Dr. Omar Sawlani, Dr. Surasek P.)
1. Consensus of panel-avoid alternating acetaminophen and ibuprofen. Using both increases medication errors, doesn't significantly improve fever control, and adds to fever phobia. To mitigate concerns of "brain damage" from fever, explain that fever is the body's internal response to illness and will not cause harm. This is in contrast to the potential dangers of external/environmental heat such as heat stroke.
2. The pediatricians in the audience encourage the continued culturing of SSTI (skin and soft tissue infections/abscesses). When a child shows up in the office with a worsening SSTI, it help the PMD to know the resistance pattern. FYI, at ACMC, approximately 50% of SSTI are MRSA.
3. When to admit pediatric SSTI? Per Dr. Collins, consider age of patient, site, size of infection, prior infections, followup, and toxicity of patient.
4. Periorbital vs. Orbital cellulitis. We rely on globe pain, restricted eye movements/pain with eye movements, high fever, proptosis, spread/amount of erythema/swelling, overall toxicity when distinguishing the two clinically. Orbit CT is indicated if concerned about orbital cellulitis, but for the gray zone cases, no need to CT in the ED. Initial management is IV antibiotics, and if poor response, the CT can happen the next day. Treatment difference for the two conditions is twofold: potential for surgery and longer duration of antibiotic treatment for orbital cellulitis.
5. Fever 3-36 months in well appearing child: There is a variety of acceptable work-ups, ranging from nothing to partial septic work-up. Much depends on followup/where you see the patient: more tests usually performed in ED, when doctor doesn't know family and there may not be great followup. Remember, children need the first two sets of vaccines (2 and 4 months) to be considered "immunized"; after this, no testing usually necessary except for the consideration of a UA and urine culture (always send both in diaper wearing kiddos). Urine may be deferred for happy kids with one day of fever, but need to warn parents that if fever continues for more than 2 days, UA/culture may be needed.