Conference 7-19-2011

7-19-2011  Conference Highlights
STUDY GUIDE Tetanus shot  (td) safe in pregnancy.   Avoid Tdap in pregnancy.  Rapid sequence drugs are ok. Propofol and narcotics are ok if not near delivery.   Avoid NSAID's because it reduces uterine blood flow.
Highest radiation risk to fetus neuro development is 8-15 weeks post conception  Highest teratogenicity is 2-8 weeks as this is period of organogenesis.
Mastitis: staph most common organism, have mom continue breast feeding unless there is an abscess
Hydatidifrom mole:  presents with 1st or 2nd trimester bleed, hyperemesis, very high beta hcg.  Treatment with d and c.   Associated with choriocarcinoma.
Kleihauer Betke test is basically only for identifying large fetomaternal hemorrhage that would require extra rhogam. 
Mondor's Disease:sperficial phelbitis nar breast, benign and disappears spontanously
JOELLEN'S LECTURE  
Arachnoid Cyst:  Can present with headache or seizure.   Cysts can also occur in spine.   JoEllen's pt had cervical cord compression from the cyst.
In the fussy child always consider shaken baby or other types of abuse.   Look for incarcerated hernia, hair tourniquet, corneal abraision, torsion, cardiac disease etc.
Intussusception:  usually ileocolic junction.  6-36 month old child.  male:female ratio 4:1.   70% will be heme positive.  Atypical presentations include lethargy in 20%.   Child will progressively worsen.  
Diagnosis with ultrasound or barium enema. Recurrence rate of 30% usually in the first 48 hours. 
MICHELLE'S LECTURE
EKG Basics:  Systematic Approach is Rate,  rhythm, axis, conduction, s-t segments
wandering pacemaker=slowed down version of MAT 
Heart Block analogy of your significant other "stepping out on you" .  The relationship gets worse untile in third degree block,  the p and the QRS never see each other. 
Tachyarrythmias:  Break it down to Wide/Narrow and Regular/Irregular
V-tach has fusion and capture beats
Can't miss issues:brugada, wellen's,  long qt, wpw
EKG case presented with tachycardia and posterior ami findings
ORAL BOARDS
Vijay and Elise
Case #1=Lemierre's Syndrome (septic thrommbophlebitis of IJ) with septic emboli to lungs.  Lungs are most common secondary site.  Broad spectrum abx and consider anticoagulation.  Affects young patients.
Case#2=Multiple Trauma with flail chest/ pulmonary contusion and hemoperitoneum.    Hypoxia is max at 48 hours after pulmonary contusion.
Case#3=Ulnar Collateral ligament rupture of thumb.  Thumb spica Splint with outpt ortho follow up.
RICARRDI LECTURE
KILLER BABIES, HTN in pregnancy
Treatment of pre-existing htn: don't treat for less than 150/100.  po labetalol or methyl dopa
Gestational htn: no proteinuria
Pre-ecclampsia: BP=/>140/90, proteinuria, edema no longer in definition.  risk fractors: first kid, obesity,htn, dm.   Severe pre-ecclampsia is defined by signs of organ failure.  Definitive treatment is delivery. Treat BP with labetalol or hydralazine.  Get BP down to 130/80
Ecclampsia: seizures are self limited.  It can be ecclampsia even if BP is ok and there is no proteinuria.  Also consider other structural or metabolic causes of seizure in the patient without elevated BP or proteinuria.
Magnesium 6 grams bolus then 2gram/hour.  Can give IM magnesum 5gm in each buttock.   Calcium gluconate is antidote for magnesium toxicity.  
Preecclampsia/ecclampsia can occur up to 6 weeks after delivery.
THink HELLP Syndrome in pregnant patients with epigastric or ruq pain.
JIM JENSEN LECTURE
Intra-nasal administration of drugs: need low volume and high concentration of drug to use this route.   Can use this route for fentanyl, versed, narcan, flumazenil.     
Fentanyl dosing this route is 2micrograms/kg.  Morphine is 0.1mg/kg.  Versed is 0.2mg/kg.  Narcan is 1mg in each nostril.  Ref.  intransal.net

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.