Explorez tous les épisodes du podcast Pediatric Emergency Playbook
| Titre | Date | Durée | |
|---|---|---|---|
| From the Ashes of SIRS: The Phoenix Sepsis Score | 01 Jun 2024 | 00:23:49 | |
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| Torticollis | 01 Mar 2024 | 00:25:06 | |
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| Hemolytic Uremic Syndrome | 01 Feb 2023 | 00:31:29 | |
| Push-Dose Epi | 01 Jan 2023 | 00:27:42 | |
| Environmental Injuries in Children | 01 Dec 2022 | 00:39:08 | |
| PEM Myths | 01 Nov 2022 | 00:38:38 | |
| Palms and Soles | 01 Oct 2022 | 00:28:26 | |
| The Febrile Infant | 01 Sep 2022 | 00:48:43 | |
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| Animal Bites in Children | 01 Aug 2022 | 00:44:47 | |
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| Focus On: Maneuvers for Murmurs | 01 Jul 2022 | 00:19:44 | |
| Pathologic Murmurs in Children | 01 Jun 2022 | 00:30:01 | |
| Benign Murmurs in Children | 01 May 2022 | 00:23:12 | |
| Resuscitative Umbilical Vein Catheterization | 01 Dec 2023 | 00:16:41 | |
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| The Newborn and Infant Neuro Exam | 01 Apr 2022 | 00:25:49 | |
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| Eczema | 01 Mar 2022 | 00:30:52 | |
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| Sickle Cell Complications | 01 Feb 2022 | 00:27:11 | |
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| Focus On: Pyloric Stenosis | 01 Jan 2022 | 00:16:10 | |
Myth: “No olive, no problem”
Reality: Rare finding, since we diagnose earlier Pyloric stenosis occurs in young infants because the pyloric sphincter hypertrophies, causing near-complete obstruction of the gastric outlet. More common in boys, preterm babies, first-born. Less common in older mothers. Association with macrolide use.
Presentation Young infant arrives with forceful vomiting, but can’t quite get enough to eat “the hungry, hungry, not-so-hippo”. Early presentation from 3 to 5 weeks of age: projectile vomiting Later presentation up to 12 weeks: dehydration, failure to thrive, possibly the elusive olive Labs may show hypOchloremic, hypOkalemic metabOlic acidosis: “all the Os” Watch out for hyperbilirubinemia, the “icteropyloric syndrome”: unconjugated hyperbilirubinemia from dehydration. Ultrasound shows a pylorus of greater than 3 mm wide and 14 mm long. Memory aid: 3.14 is “pi”. In pyloric stenosis, π-lorus > 3 x 14
Treatment Various options, may be deferred depending on age, availability, severity of illness, including: Pyloromyotomy — definitive. The Ramstedt pyloromyotomy is an open procedure and involves a involves a longitudinal incision along the pylorus, and blunt dissection just to level of the submucosa. The laparoscopic approach (umbilicus) is less invasive but may convey an increased risk of incomplete relief of the obstruction or perforation through the mucosa. Also, this approach involves longer OR and anesthesia time. Endoscopic balloon dilation – not as effective as pyloromyotomy; reserved for poor surgical candidates. Conservative management — an NG tube is passed by IR, and the infant slowly feeds and “grows out of it”. Atropine is sometimes used to relax the pyloric sphincter. Also usually reserved for poor surgical candidates. Selected references Aboagye J, Goldstein SD, Salazar JH, Papandria D, Okoye MT, Al-Omar K, Stewart D, Lukish J, Abdullah F. Age at presentation of common pediatric surgical conditions: Reexamining dogma. J Pediatr Surg. 2014 Jun;49(6):995-9. Bakal U, Sarac M, Aydin M, Tartar T, Kazez A. Recent changes in the features of hypertrophic pyloric stenosis. Pediatr Int. 2016 May;58(5):369-71. Sharp WW, Chan W. Images in emergency medicine. Infant with projectile vomiting. Peristaltic abdominal waves associated with infantile hypertrophic pyloric stenosis. Ann Emerg Med. 2014 Mar;63(3):289,308. Staerkle RF, Lunger F, Fink L, Sasse T, Lacher M, von Elm E, Marwan AI, Holland-Cunz S, Vuille-Dit-Bille RN. Open versus laparoscopic pyloromyotomy for pyloric stenosis. Cochrane Database Syst Rev. 2021 Mar 9;3(3):CD012827. | |||
| Pediatric Vital Signs: What Are We Missing? | 01 Dec 2021 | 00:31:22 | |
| Focus On: Gun Shot Wounds in Children | 01 Nov 2021 | 00:17:21 | |
| Syndromes You Should Know | 01 Oct 2021 | 00:34:59 | |
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| Focus On: Inguinal Hernias in Children | 01 Sep 2021 | 00:13:10 | |
Hernia Myth: “If it’s not strangulated, it’s elective” Reality: Unlike in adults, all hernias in children are repaired at the time of diagnosis because:
Most groin hernias in children are indirect inguinal hernias (incomplete closure of processus vaginalis). Most indirect hernias are in boys (10-fold risk), and on the right (60%). Premature babies are at higher risk as well. 15% are bilateral. Hernias often bulge further with crying. For infants, in supine position, gently restrain their feet on the gurney. They hate it and will cry. For older children, have them laugh, cough, or blow through a syringe. The “silk glove sign” is not reliable, but if found is highly suggestive of an inguinal hernia. Roll the cord structures across the pubic tubercle. If you feel catching, like two sheets of silk rubbed together, this suggests edema from the patent processus vaginalis. Most (80%) incarcerated hernias can be reduced initially and admitted for surgery 24-48 hours after edema has improved. Use age- and patient-appropriate sedation and reduce if no peritonitis or concern for strangulation. Hydroceles usually are: non-communicating (with the abdomen); worse with crying or during the day; improve by morning; and self-resolve by age 2 without intervention. Communicating hydroceles are: usually present at birth; are associated with a patent processus vaginalis; and are often repaired later, if not resolved by 1 or 2 years of age. Girls may have an ovary incarcerated in hernial sac. Open repair or laparoscopic techniques are used. The laparoscope offers visualization of the contralateral side without significant risk of injury to vas deferens. A metachronous hernia develops later on the other side. Some surgeons opt to explore both sides at the time of diagnosis, others take conservative approach (small risk of fertility issues if both are open-explored) My take: regardless of presentation, needs admission
Selected References Abdulhai S, Glenn IC, Ponsky TA. Inguinal Hernia. Clin Perinatol. 2017 Dec;44(4):865-877 Brandt ML. Pediatric hernias. Surg Clin North Am. 2008 Feb;88(1):27-43, vii-viii. doi: 10.1016/j.suc.2007.11.006. Esposito C, Escolino M, Cortese G, Aprea G, Turrà F, Farina A, Roberti A, Cerulo M, Settimi A. Twenty-year experience with laparoscopic inguinal hernia repair in infants and children: considerations and results on 1833 hernia repairs. Surg Endosc. 2017 Mar;31(3):1461-1468. Olesen CS, Mortensen LQ, Öberg S, Rosenberg J. Risk of incarceration in children with inguinal hernia: a systematic review. Hernia. 2019 Apr;23(2):245-254 | |||
| Focus On: Pediatric Emergency Eye Exam | 01 Aug 2021 | 00:20:10 | |
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| Focus On: Breath Holding Spells | 01 Jul 2021 | 00:14:55 | |
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| Update 2023 | 01 Sep 2023 | 00:08:57 | |
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| Overdose: Just Right (?) | 01 Jun 2021 | 00:32:20 | |
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| Overdose: Too Cold! | 01 May 2021 | 00:42:02 | |
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| Overdose: Too Hot! | 01 Apr 2021 | 00:37:26 | |
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| Constipation and the way out | 01 Mar 2021 | 00:48:40 | |
Constipation as a diagnosis can be dangerous, mainly because it is a powerful anchor in our medical decision-making. Chances are, you’d be right to chalk up the pain to functional constipation — 90% of pediatric constipation is functional, multifactorial, and mostly benign — as long as it is addressed. We’re not here for “chances are“; we’re here for “why isn’t it?“ Ask yourself, could it be: Anatomic malformations: anal stenosis, anterior displaced anus, sacral hematoma Metabolic: hypothyroidism, hypercalcemia, hypokalemia, cystic fibrosis, diabetes mellitus, gluten enteropathy Neuropathic: spinal cord abnormalities, trauma, tethered cord Neuromuscular: Hirschprung disease, intestinal neuronal dysplasia, myopathies, Down syndrome, prune belly syndrome Connective tissue disorders: scleroderma, SLE, Ehlers-Danlos syndrome Drugs: opioids, antacids, antihypertensives, anticholinergics, antidepressants, sympathomimetics Ingestions: heavy metals, vitamin D overload, botulism, cow’s milk protein intolerance Red Flags Failure to thrive Abdominal distention Lack of lumbosacral curve Midline pigmentation abnormalities of the lower spine Tight, empty rectum in presence of a palpable fecal mass Gush of fluid or air from rectum on withdrawal of finger Absent anal wink
You gotta push the boat out of the mud before you pray for rain. — Coach
Medications for disimpaction (do this first!) Polyethylene Glycol (PEG) 3350 (Miralax): 1 to 1.5 g/kg PO daily for 3 to 6 consecutive days. Maximum daily dose: 100 g/day PO. Follow-up with maintenance dose (below) for at least 2 months (usually 6 months) Lactulose: 1.33 g/kg/dose (2 mL/kg) PO twice daily for 7 days Mineral Oil (school-aged children): 3 mL/kg PO twice daily for 7 days Medications for Maintenance (do this after disimpaction!) Polyethylene Glycol (PEG) 3350 (Miralax): 0.2 to 0.8 g/kg/day PO. Maximum daily dose: 17 g/day. Maintenance dosing for Miralax may need to be tailored; up to 1 g/day maintenance. Lactulose: 1 to 2 g/kg/day (1.5 to 3 mL/kg/day)PO divided once or twice daily. Maximum daily dose: 60 mL/day in adults. Mineral Oil: 1 to 3 mL/kg/day PO divided in 1 to 2 doses; maximum daily dose: 90 mL/day Docusate (Colace): 5 mg/kg/day PO divided QD, BID, or TID (typical adult dose 100 mg BID) Senna, Bisocodyl — complicated regimens; use your local reference Enemas
Selected References Freedman SB et al. Pediatric Constipation in the Emergency Department: Evaluation, Treatment, and Outcomes. JPGN 2014;59: 327–333.
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| Pediatric IV Tips and Tricks | 01 Feb 2021 | 00:26:46 | |
Top 10 [details in audio]
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| Vagal Maneuvers In Children | 01 Jan 2021 | 00:28:30 | |
| Conjunctivitis | 01 Dec 2020 | 00:44:02 | |
| Go or No Go: Pediatric Presedation Assessment | 01 Nov 2020 | 00:43:06 | |
| Caustic Ingestions | 01 Oct 2020 | 00:32:12 | |
| Pediatric Hand Fractures | 01 Sep 2020 | 00:43:20 | |
Tuft Fracture https://i2.wp.com/pemplaybook.org/wp-content/uploads/2020/08/Tuft-fracture.jpg Yeh PC et al. Pediatric Hand Fractures. Techniques in Orthopaedics. 2009. Seymour Fracture https://i2.wp.com/pemplaybook.org/wp-content/uploads/2020/08/Seymour-Fracture.jpgNellans et al. Pediatric Hand Injuires. Hand Clin. 2013 November ; 29(4): 569–578 https://i1.wp.com/pemplaybook.org/wp-content/uploads/2020/08/Seymour-2.jpgYeh PC et al. Pediatric Hand Fractures. Techniques in Orthopaedics. 2009. Mallet Fracture https://i0.wp.com/pemplaybook.org/wp-content/uploads/2020/09/mallet-2.jpgAdolescent with mallet finger and Kirschner wire fixation. Nellans et al. Pediatric Hand Injuires. Hand Clin. 2013 November ; 29(4): 569–578 https://i0.wp.com/pemplaybook.org/wp-content/uploads/2020/09/mallet-1.jpgMallet finger in splint. Yeh PC et al. Pediatric Hand Fractures. Techniques in Orthopaedics. 2009. Volar Plate Injury https://i2.wp.com/pemplaybook.org/wp-content/uploads/2020/08/Volar-plate.jpgYeh PC et al. Pediatric Hand Fractures. Techniques in Orthopaedics. 2009. Central Slip InjuryLee SA et al. Ultrasonography of the finger. Ultrasonography 2016; 35(2): 110-123. https://i2.wp.com/pemplaybook.org/wp-content/uploads/2020/08/Central-slip.jpgYeh PC et al. Pediatric Hand Fractures. Techniques in Orthopaedics. 2009. Rotational Deformity https://i2.wp.com/pemplaybook.org/wp-content/uploads/2020/09/rotation.jpgA, B: Relatively normal appearance; C: in flexion, rotational abnormality evident. Liao CY et al. Pediatric Hand and Wrist Fractures. Clin Plastic Surg 46 (2019) 425–436 https://i1.wp.com/pemplaybook.org/wp-content/uploads/2020/08/rotational-abnormality.jpgYeh PC et al. Pediatric Hand Fractures. Techniques in Orthopaedics. 2009. Extra-Octave Fracture https://i2.wp.com/pemplaybook.org/wp-content/uploads/2020/08/extra-octave-1.jpgMims L et al. Extra-Octave Fracture in a 14-Year-Old Basketball Player. Journal of Pediatrics. 2017; 186: P206-206 https://i2.wp.com/pemplaybook.org/wp-content/uploads/2020/08/extra-octave-2.jpgSame boy, after reduction and ulnar splint https://i2.wp.com/pemplaybook.org/wp-content/uploads/2020/08/extr-octave-3-1.jpgSame boy, on follow-up at 17 days Ulnar Collateral Ligament Injury https://i0.wp.com/pemplaybook.org/wp-content/uploads/2020/08/ucl.jpgYeh PC et al. Pediatric Hand Fractures. Techniques in Orthopaedics. 2009. Bennett Fracture https://i0.wp.com/pemplaybook.org/wp-content/uploads/2020/08/bennett.jpegradiopaedia.org Rolando Fracture https://i1.wp.com/pemplaybook.org/wp-content/uploads/2020/08/Rolando_fracture.jpgwikipedia.org Selected ReferencesKiely AL et al. The optimal management of Seymour fractures in children and adolescents: a systematic review protocol. Systematic Reviews. 2020; 9 (150). Liao CY et al. Pediatric Hand and Wrist Fractures. Clin Plastic Surg 46 (2019) 425–436 Lin JS et al. Treatment of Acute Seymour Fractures. J Pediatr Orthop. 2009; 39(1):e23-e27. Mims L et al. Extra-Octave Fracture in a 14-Year-Old Basketball Player. Journal of Pediatrics. 2017; 186: P206-206 Mohseni M et al. Ulnar Collateral Ligament Injury. Stat Pearls. 2020 Nellans et al. Pediatric Hand Injuires. Hand Clin. 2013 November ; 29(4): 569–578 Pattni A et al. Volar Plate Avulsion Injury. Eplasty. 2016; 16: ic22. Stevenson J et al. The use of prophylactic flucloxacillin in treatment of open fractures of the distal phalanx within an accident and emergency department: a double-blind randomized placebo-controlled trial. The Journal of Hand Surgery: British & European. 2003; 28(5): 388-394 Yeh PC et al. Pediatric Hand Fractures. Techniques in Orthopaedics. 2009 | |||
| Neonatal Resuscitation | 01 Aug 2023 | 00:34:46 | |
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| Heat-Related Illness | 01 Aug 2020 | 00:44:05 | |
A spectrum — but will you recognize the blurry signposts? Temperature (core) Presentation Management Miliaria Crystallina Normal Salt-colored tiny papules, easily burst; not pruritic Modify environment; light clothing; hydration Miliaria Rubra Normal Discrimiate, red papules, not assocaited with follicles; pruritic Above plus cool compresses; calamine lotion; symptomatic tx for pruritis Miliaria Profunda Normal Confluent flesh-colored, “lumpy-bumpy”; burning Same as rubra Miliaria Pustulosa Normal May resemble rubra and/or crustallina, but pustular; h/o previous dermatitis Same as above, but may may need antibiotic if no improvement over time Heat edema Normal Swelling of feet, ankles, and/or lower legs Modify environment; elevate legs Heat syncope Normal Dizziness, orthostatic hypotension, and syncope after exertion with rapid return to normal mental status when supine Modify environment; rehydration; monitoring Heat cramps May be elevated to 40°C (104°F) Exercise-induced cramping in large muscle groups, especially legs Hydration; consider labs (Cr, total CK); may counsel to stretch muscles passively, gently Heat tetany May be elevated to 40°C (104°F) Hyperventilation with paresthesia, carpopedal spasm Modify environment; hydration; may place non-rebreather mask on low (or off) for rebreathing CO2 Heat exhaustion Elevated up to 40°C (104°F) Normal mental status, fatigue, that rapidly improves with treatment; tachycardia; GI symptoms; electrolyte abnormalities Cool environment; hydration; consider labs with severe symptoms, or if not improved Heat Stroke >40 to 40.5°C (104 to 105°F) Altered mental status; tachypneic; tachycardic with hypotension; electrolyte abnormalities; GI symptoms; often with renal failure, rhabdomyloysis, renal failure; possibly with cardiogenic shock or ARDS or DIC Rapid cooling with all modalities available (radiation, conduction, convection, evaporation); IV rehydration; labs; monitoring; ICU admission Miliaria Crystallina Miliaria Crystallina — Infant Miliaria Crystallina — Older Child Miliaria Rubra — Infant Miliaria Rubra — Infant Miliaria Rubra — Toddler Miliaria Rubra — Adolescent Miliaria Profunda Selected References Bergeron MF, Devore C, et al. Council on Sports Medicine and Fitness and Council on School Health, Policy statement—Climatic heat stress and exercising children and adolescents. Pediatrics 2011; 128:e741. Casa DJ et al. The Inter-Association Task Force for Preventing Sudden Death in Secondary School Athletics Programs: Best-Practices Recommendations. J Athl Train. 2013 Jul-Aug; 48(4): 546–553. DeFranco MJ et al. Environmental issues for team physicians. Am J Sports Med. 2008 Nov;36(11):2226-37. Ishimine P. Hyperthermia. In: Pediatric Emergency Medicine, Baren JM, Rothrock SG, Brennan JA, Brown L (Eds), Saunders Elsevier, Philadelphia 2008. p.992. Jardine DS. Heat illness and heat stroke. Pediatr Rev 2007; 28:249. | |||
| Diarrhea | 01 Jul 2020 | 00:50:30 | |
Traditional Approach: Secretory -- poisoned mucosal villi -- "the sieve" Cytotoxic -- destroyed mucosal villi -- "the shred" Osmotic -- malabsorption -- "the pull" Inflammatory -- edema, motility -- "the push" Lots of overlap, difficult to apply to clinical signs and symptoms. Bedside Approach: Fever/No Fever, Bloody/No Blood Non-bloody, febrile -- most likely viral Non-bloody, afebrile -- may be viral Bloody, febrile -- likely bacterial Non-bloody, afebrile -- full stop. Eval for Hemolytic Uremic Syndrome Workup
Ask yourself -- again -- why is this not... appendicitis-torsion-intussusception-etc. Admit sick children, but most go home, so... Non-bloody, febrile -- no workup necessary; precautionary advice Non-bloody, afebrile -- be more skeptical, but generally same as above Bloody, febrile -- stool culture, follow up; do not treat empirically unless septic and admitted. Culture will dictate treat/no treat/how. Bloody, afebrile -- evaluate for hemolytic uremic syndrome, especially if under 5 years old: CBC, chemistries, UA, stool culture Evaluate Hydration Status Selected References Khan WA et al. Central Nervous System Manifestations of Childhood Shigellosis: Prevalence, Risk Factors, and Outcome. Pediatrics. 1999 Feb;103(2):E18
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| DKA Like A Boss | 01 Jun 2020 | 00:45:39 | |
PEMplaybook.org | |||
| Zen and the Art of Pediatric Readiness | 01 May 2020 | 00:30:32 | |
Pediatric Readiness is not just an ideal -- it's a tangible plan, a toolkit, and even better, an attitude How to improve your institution, and your own personal pediatric readiness. National Pediatric Readiness Project (NPRP) Los Angeles County Pediatric Readiness Project | |||
| Pediatric Dysrhythmias | 01 Apr 2020 | 00:44:02 | |
PEMplaybook.org | |||
| Otitis Media | 01 Mar 2020 | 00:50:51 | |
PEMplaybook.org | |||
| Major Burns in Children | 01 Feb 2020 | 00:43:37 | |
Lund and Browder Chart to Estimate Burn Size in Children Parkland Formula for Burns Amount needed in addition to maintenance fluids: 4 mL/kg x BSA% = XAdd 1/2 of X to maintenance over the 1st 8 hours Add the other 1/2 of X to maintenance over the next 16 hours Escharotomy Guide and the "Roman Breastplate" Yin et al. Bedside Escharotomies for Burns Classic ParagraphSelected References Mahar PD et al. Clinical differences between major burns patients deemed survivable and non-survivable on admisssion. Injury. 2015; 46:870-873. Mathis E et al. Pediatric Thermal Burns and Treatment: A Review of Progress and Future Prospects. Medicines. 2017; 4:91. Osuka A et al. Glycocalyx shedding is anhanced by age and correlates with increased fluid requirement in patients with major burns. Shock. 2017; 50(1):60-65. Sebastian R et al. Percutaneous pigtail catheter in the treatment of pneumothorax in major burns: The best alternative? Burns. 2015; e24-227 Sherren PB et al. Lethal triad in severe burns. Burns. 2014; 1492-1496. Strobel AM et al. Emergency Care of Pediatric Burns. Emerg Med Clin N AM. 2018; 441-458. | |||
| Anemia. Now What? | 01 Jan 2020 | 00:43:39 | |
PEMplaybook.org | |||
| Pediatric Sports Injuries | 01 Dec 2019 | 00:39:11 | |
PEMplaybook.org | |||
| EtCO2 Masterclass | 01 Nov 2019 | 00:45:22 | |
| Stridor, Stertor, and Noisy Breathing | 01 Jul 2023 | 00:31:07 | |
PEMplaybook.org | |||
| Neck Masses in Children | 01 Oct 2019 | 00:39:48 | |
The differential diagnosis is long... You need an approach. The Rule of 3s: 3 minutes -- Traumatic 3 days -- Inflammatory 3 months -- Neoplastic 3 years -- Congenital 3 Minutes? Traumatic 3 Days? Inflammatory [caption id="attachment_1777" align="alignnone" width="262"] Cervical Node Chain; Lymphadenopathy[/caption] [caption id="attachment_1773" align="alignnone" width="298"] Bacterial Lymphadenitis[/caption] [caption id="attachment_1772" align="alignnone" width="300"] Bacterial lymphadenitis with small abscess[/caption] [caption id="attachment_1771" align="alignnone" width="300"] Large Abscess[/caption] 3 Months? Neoplastic3 Years? Congenital [caption id="attachment_1784" align="alignnone" width="300"] Thyroglossal Duct Cyst[/caption] [caption id="attachment_1783" align="alignnone" width="300"] Thyroglossal Duct Cyst[/caption] [caption id="attachment_1776" align="alignnone" width="278"] Branchial Cleft Cyst[/caption] [caption id="attachment_1775" align="alignnone" width="263"] Branchial Cleft Cyst[/caption] [caption id="attachment_1774" align="alignnone" width="233"] Branchial Cleft Cyst[/caption] [caption id="attachment_1779" align="alignnone" width="300"] Cystic Hygroma[/caption]
[caption id="attachment_1778" align="alignnone" width="235"] Cystic Hygroma[/caption] Selected ReferencesEnepekides DJ. Management of congenital anomalies of the neck. Facial Plast Surg Clin North Am 2001; 9:131. Lin ST, Tseng FY, Hsu CJ, et al. Thyroglossal duct cyst: a comparison between children and adults. Am J Otolaryngol 2008; 29:83. Mandell DL. Head and neck anomalies related to the branchial apparatus. Otolaryngol Clin North Am 2000; 33:1309. Marler JJ, Mulliken JB. Current management of hemangiomas and vascular malformations. Clin Plast Surg 2005; 32:99. Silverman, J. F., Gurley, A. M., Holbrook, C. T., Joshi, V. V. (1991) Pediatric fine needle aspiration biopsy. American Journal of Clinical Pathology 95: 653–659 Sonnino RE, Spigland N, Laberge JM, Desjardins J, Guttman FM. Unusual patterns of congenital neck masses in children. J Pediatr Surg. 1989 Oct;24(10):966-9. | |||
| Intraosseous Devices | 01 Sep 2019 | 00:46:27 | |
https://www.youtube.com/watch?v=cQVKIpLc8bk
Selected References
Jousi M, Saikko S, Nurmi J. Intraosseous blood samples for point-of-care analysis: agreement between intraosseous and arterial analyses. Scand J Trauma Resusc Emerg Med. 2017;25(1):92. Published 2017 Sep 11. doi:10.1186/s13049-017-0435-4
Knuth, et al. Intraosseous Injection of Iodinated Computed Tomography Contrast Agent in an Adult Blunt Trauma Patient. Annals of Emergency Medicine. 2011; 57 (4) 382-386
Miller LJ. et al A new study of intraosseous blood for laboratory analysis.Arch Pathol Lab Med. 2010 Sep;134(9):1253-60. | |||
| Cyanosis | 01 Aug 2019 | 00:36:48 | |
Your eyes may fool you... Keep your differential diagnosis open.
Selected References Aravindhan N, Chisholm DG. Sulfhemoglobinemia presenting as pulse oximetry desaturations. Anesthesiology. 2000;93:883–884. Ginimuge PR et al. Methylene Blue: Revisited. J Anaesthesiol Clin Pharmacol. 2010 Oct-Dec; 26(4): 517–520. Mack E. Focus on diagnosis: co-oximetry. Pediatr Rev. 2007;28:73–4. So T-Y et al. Topical Benzocaine-induced Methemoglobinemia in the Pediatric Population. J Pediatr Health Care. 22(6):335–339. | |||
| Failure to Thrive | 01 Jul 2019 | 00:36:24 | |
Failure to Thrive (FTT) is not just for the clinics. We need to be on the lookout, because if we find it, there is already a big problem.
Definitions of Failure to Thrive may quibble on the details, but for us in the ED:
We can get around the longitudinal requirement by looking at weight as a "spot check" -- if grossly below weight without any other chronic condition, be alarmed.
Failure to thrive results from inadequate calories. This may be due to:
Any concern should trigger a more complete H&P (in audio).
Classic instructional video on the mother-infant dyad (scan through for various types).
After a focused H&P, you may need to admit the child for further workup, or to show that he can/cannot gain weight with routine care.
Remember, if you are the first one to bring this up, there is a real problem. By definition, an outpatient plan has failed. We will not be able to distinguish among the various possibilities of organic and non-organic causes (or mix thereof); our job is to be ready to catch it and act on it. The child's development, future intelligence, and welfare are at risk.
References
Birth to 24 months: Boys Weight-for-length percentiles and Head circumference-for-age percentiles
Jaffe AC. Failure to Thrive. Pediatrics in Review. 2011; 32(3)
Prutsky GJ et al. When Developmental Delay and Failure to Thrive Are Not Psychosocial. Hospital Pediatrics. 2016; (1):6 | |||