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

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

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

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
  • 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
  • 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

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
  • 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
  • Antihypertensives in pregnancy
    • Safe medications- labetalol, hydralazine, nifedipine
      • Can be dosed every 10-20 minutes
  • 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