Pediatric Cases– Dr Alina Khurgel
- Case 1- 3 month old girl who had a pause in breathing with quick return to baseline
- BRUE– infant less than 1 year old with a sudden episode of central cyanosis, irregular/absent breathing, changes in tone, and altered level of consciousness
- Low risk features- older than 60 days, not premature, first time event, no CPR, no concerning physical exam findings, no concerning history
- If not low risk then patient is high risk
- In these situations always have a concern for NAT
- Management
- Consider ECG and brief observation in the ED and educate patients/recommend CPR training
- Need close outpatient follow up
- DO NOT send indiscriminate testing or admit for tele monitoring
- No evidence for increased risk for SIDS but should educate patients about risk actors
- Safe sleeping environment (sleep on back, no co-sleeping or things in the crib, cigarette smoking)
- Case 2- otherwise healthy 3 month old boy born at 40 weeks without complications here for persistent crying
- Colic– unexplained inconsolable baby
- Need very thorough history and head to toe examination for potential explanation
- If there is improvement of symptoms and have a reassuring exam no further workup is necessary
- Strategies for parents- swaddling, changing position, shushing sounds, swinging, sucking
- Resources
- CHOP Clinical Pathways
- Google Drive Boston Children’s Pathways
Trauma Activations– Dr Nicholas Huyn
- The policies for trauma activation have been revised and updated as of July 2023
- We are responsible for activating traumas based on the various guidelines
- Trauma activations
- There are some discrepancies between the updated policy and the cards that we currently have that will be updated soon
- There is a preference from the trauma service for us over triage traumas when they arrive
- Morel Lavalee lesions
- Closed degloving due to shearing forces leading to hematoma formation and separation of tissue layers
- Diagnosed via CT or US but often times is a delayed diagnosis
- Resources
- Look for the trauma cards in your resident mailbox in the resident room if you do not already have them
Pediatric Thoracic Trauma– Dr Sabina Khan
- In the setting of trauma, pediatric patients are more susceptible to internal organ injury
- Hypotension is a late finding in shock due to ability to compensate
- Pneumo and hemothorax in pediatric patients
- Tension pneumo is the most common complicated injury in children
- In patients with an open pneumo you should place an occlusive dressing to prevent accumulation of air in the thorax
- Pediatric thoracotomy indications
- Please reference the trauma guidelines below in the resources section
- Pulmonary contusion can be a common finding in patients with new/persistent hypoxia in the setting of thoracic trauma even in the absence of rib fractures
- Blunt cardiac injury
- Blunt trauma leading to ECG abnormalities, myocardial injury, and sometimes arrhythmia/changes in cardiac function
- Have high suspicion for cardiac tamponade
- Need a formal ECHO as part of their workup
- Aortic injuries are less common in pediatric trauma but are associated with high decelerating injuries
- Have a high suspicion and need for definitive diagnosis with CT imaging
- Chest wall injuries
- Look for paradoxical breathing in the setting of flail chest with high mechanism trauma
- Clavicular fractures are the most common injury in pediatrics
- Diaphragmatic injuries
- No definitive management in the ED, treated surgically
- Resources
- Pediatric thoracotomy guidelines from EAST and WEST trauma
- Please reference the “LIFE THREATENING INJURIES” portion on the R for a detailed explanation of management of various thoracic injuries
- PEM Guides
Spooky Deliveries– Dr Kerry McCabe
- Health disparities affecting pregnancy
- Black patients have substantially higher rates of premature birth, deaths due to pregnancy
- Pre-eclampsia and hypertension occur at significantly higher rates in patients of color
- Normal vaginal delivery
- Apply downward pressure to move the shoulder under the pubic symphysis
- Check for presence of a nuchal cord
- Post delivery care- APGAR scoring, warming, suctioning, stimulating, clamp and cut cord
- Maternal care- deliver placenta, apply fundal/suprapubic pressure, oxytocin to promote increased uterine tone
- Shoulder dystocia
- Impaction of the anterior shoulder on the pubic symphysis
- Maneuvers for reduction
- McRoberts- hyperflexion of the hips
- Suprapubic pressure between contractions
- Woods corkscrew- hands placed anteriorly and posteriorly at the shoulders and twisting with contraction
- Posterior arm and shoulder delivery- reaching under to grab posterior arm at the elbow bend the arm up and pull at the elbow to deliver the shoulder
- Breech delivery
- Head is the largest part of the baby and has not molded ot the birth canal
- Highest risk for hypoxia due to obstruction of umbilical cord
- Footling- feet first with minimal dilation
- Surgical emergency
- Frank- legs folded in half (butt first)
- Complete- butt first with compaction of the legs against the abdomen
- Incomplete is when one leg is fully folded up
- Attempt to deliver the legs, apply downward traction, deliver one arm and rotate the baby to deliver the other arm, then bring the baby toward the floor and then superiorly
- Try to keep the sacrum anterior and flex the head, apply suprapubic pressure
- Mauriceau- reach posteriorly to feel the face/mouth to flex the head
- Resuscitative hysterotomy
- This is meant to aid in the resuscitation of the mother
- If there is a uterus above the umbilicus in a patient who has arrested this procedure needs to be initiated within 4 minutes
- Vertical midline incision through the skin down to the level of the uterus, open the uterus with scissors and remove the baby and the placenta
- Necessary equipment- 10 blade scalpel, scissors, kelly clamps
- Afterwards need to give uterotonics and pack the abdomen to provide compression
- Resources
- Breech delivery
- Shoulder dystocia delivery
- Resuscitative hysterotomy
Pass the Pointer US Edition– Dr Meera Muruganandan
- LOG YOUR SCANS
- Qpath website: bmc.qpath.cloud
- EFAST tips
- In the LUQ look for fluid between the spleen and the diaphragm
- Can sometimes identify stomach on the LUQ view and would need to move more posteriorly for the correct view
- The liver tip is the most sensitive spot for abdominal free fluid (200-650cc)
- To get an appropriate exam patients need to be lying flat
- In the LUQ look for fluid between the spleen and the diaphragm
- RUQUS
- >3mm of anterior wall thickness is concerning for cholecystitis
- Aorta- cutoff for normal diameter in the abdomen is 3cm and 1.5cm at the bifurcation
- Cardiac US
- Can use the SALPI acronym to help identify WMA in the short axis
- Tamponade basics- plethoric IVC with effusion is concerning
- M mode in PLAX to evaluation for RA/RV diastolic collapse
- Mitral inflow velocity variation with respiration >25%
- Signs of PE- dilated RV >1:1, septal flattening
- Lower extremity US
- The vein will always be more medial to the artery
- Start the DVT scan at the junction of the FV and saphenous vein
- Proximal saphenous clots are treated as DVTs
- Lung US
- B lines can be causes by edema, consolidation, ARDS, viral PNA, contusion
- Ocular US
- When measuring ONSD need to be 3mm back from the insertion of the nerve into the eye
- Normal is <5mm
- When measuring ONSD need to be 3mm back from the insertion of the nerve into the eye
- Pelvic US
- IUP can be confirmed by identification of a gestational sac and a yolk sac within the uterus
- When measuring the myometrium want to have the thinnest part be greater than 8mm (concern for interstitial ectopic)
- Resources
- Quick tutorial videos on 5 minute sono
Medication in Pregnancy– Temi Sofeso, PharmD
- Due to physiologic changes of pregnancy there needs to be changes in dosing and administration for various medications
- There are various ways in which medications can cross the placenta and into breast milk depending on the drugs themselves
- Teratogenicity of medication is highest risk during weeks 3-8 of gestation
- The PLLR is the new rating system that provides information about risk in pregnancy
- Listed on the package insert in section 8
- Antibiotics in pregnancy
- Aminoglycosides, beta lactams, metronidazole, and vancomycin are safe in all trimesters
- Azithromycin also safe but other macrolides have adverse effects
- Nitrofurantoin and bactrim are both relatively safe in all trimesters
- Avoid FQ and tetracycline type agents
- Be aware that STI therapies may vary if the patient is pregnant
- There is overlap between safe antibiotics in lactation but be aware that certain medications may need to be avoided
- Aminoglycosides, beta lactams, metronidazole, and vancomycin are safe in all trimesters
- Antiemetics in pregnancy
- B6, antihistamines, and dopaminergic agents are all safe in all trimesters
- Zofran safe in 2nd and 3rd (conflicting evidence regarding 1st trimester safety)
- First line- B6 and doxylamine
- Second line- reglan, zofran, promethazine
- B6, antihistamines, and dopaminergic agents are all safe in all trimesters
- Antihypertensives in pregnancy
- Safe medications- labetalol, hydralazine, nifedipine
- Can be dosed every 10-20 minutes
- Safe medications- labetalol, hydralazine, nifedipine
- AEDs in pregnancy
- Always remember 4g of Mg for eclampsia
- Otherwise benzos are first line
- Second line keppra and lamictal are safest
- Phenytoin and phenobarb are preferred over valproate
- May need increased dosing of medications with pregnancy
- Resources
- Daily Med- easy way to find the PLLR
- LactMed- NIH website for drug safety in lactation
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