Caution in Pediatrics

Important medico-legal issues

-Recognize high risk cases (i.e. close contact with Neisseria meningitis)
-Be wary of unexplained tachycardia!
-Avoid discharge diagnoses of “viral syndrome” or “gastroenteritis.” Use “fever” or “vomiting” instead.
-Considering discharge? Double check, vitals, document.

Progression of Meningitis
-Bacteremia -> Spread to meninges -> Cerebral Edema
-Neisseria meningitis can have very rapid progression (death within hours of arrival to ED)

Blood in Stool
-Less than < 2 years, almost always pathologic
-Consider: Meckel’s, intussusception,  bacterial enteritis/HUS

Abnormal syncope?
-Patient on chemotherapy, post-ictal type confusion for 20 minutes
-Diagnosis: Cavernous sinus thrombosis (complication from therapy)
-Get consultants on board if you are suspicious

 

Trauma Hirsch Rounds

Case: Multiple GSW (anterior chest, upper back, arm)
-Setup: P1 activation, call for blood, US in room, airway equipment available, chest tube set up
-Cavitary Triage: Chest, Abdomen, Retroperitoneum, Long Bone, Scene
Repeat vitals (after volume resus): Responder, Non-responder, Transient Responder (most dangerous)
-X-ray extremity: Need to know about fractures prior to blood vessel repairTelemedicine: Can we get a picture/video from the field? Added info to case
-Stop the bleeder: Direct pressure, elevate, tourniquets, reduce dislocations, correct coagulopathy, Foley, (no clamping)

Vascular Injury
WEST Guidelines: www.westerntrauma.org/algorithms/algorithms.html
Hard signs: Loss of pulses, bruit, expanding hematoma, active hemorrhage, ischemia
-YES? Go to OR
Soft signs: single nerve deficit, non-expanding hematoma, reduced pulses, proximity to vascular structures, hypotension
-YES? Measure API’s. <0.9? CT Angiogram

 

Pedi Cases

Hemolytic Uremia Syndrome (HUS)
-Microangiopathic hemolytic anemia (Hgb <10, +Schistocytes, neg coombs) + Thrombocytopenia (<140) + AKI (elevated BUN/Cr, micro/macro hematuria)
-Progression: Ingestion (chipotle/jack in the box) -> 3d +N/V/D/abd pain -> Bloody diarrhea (90%)
-Shiga toxin producing E. Coli (0157:H7)
-Occurs in 6-9% STEC infections, 2.9% mortality in hospitalized patients
-Tx: Hydrate, Dialysis

Meckel’s Diverticulum
-Incomplete obliteration of the vitelline duct
-Painless bright red lower GI bleeding
-Rule of 2’s: 2% pop, M:F 2:1, 2 ft from ileocecal valve, 2 inch long, Complications < 2
-Complications: ulceration of the intestinal wall (from gastric acid), bleeding/perforation

Intussusception
-Painful abdominal pain with periods of lethargy
-“Currant jelly” stool, blood in stool
-Lead point typically ileocecal
-Tx: Air enema -> surgery

Henoch-Schonlein Purpura (HSP)
-Rash in 75% in 1-2 days: Appears in gravity dependent areas
-Abdomen pain: severe/diffuse , intussusception possible (typically small bowel)
-Renal complications: hematuria, proteinuria, rare renal failure (<1%)
-Diarrhea: 50% will have positive guaiac
https://lifeinthefastlane.com/horrible-spots-and-pain/

Splenic Sequestration Crisis
-Occurs in 30% patients with sickle SS, greatest risk < 5 years
-Second leading cause of death in sickle cell
-Sudden enlargement of the spleen
http://pedemmorsels.com/splenic-sequestration-be-a-spleen-detective/

 

ICU: Hemoptysis 

Case: cough with hemoptysis, no PMHx
-DDx: Hemoptysis (tracheobronchial tree), Pseudo-hemoptysis (nose/oropharynx), Hematemesis
-UA with casts? Consider pulmonary renal syndrome. May need steroids.
-CXR with hyperinflation, no gross masses or cavitary lesion
-May consider CT scan
-Likely bronchitis, d/c with follow up

Massive Hemoptysis
-Multiple definitions, >100cc/hr, 100-200 to fill anatomic dead space
-Bronchial (systemic)  circulation (95% cases) = higher pressures
-Chronic infectious/inflammatory lung disease -> bronchial aa hypertrophy -> abnormal vascular anastomoses -> neovascularization with weak vessels
-Tx: AIRWAY, aggressive early control, intubate GOOD lung with 8.0 ETT, position bleeding side down
-Find the cause (and fix): CT angiogram, Bronchoscopy, IR for BAE (broncheoalveolar embolization)
-Definitive therapy: surgical resection of the lung (done electively for massive hemoptysis, mortality 18%)
EMCRit Podcast: https://emcrit.org/racc/massive-hemoptysis/

 


ED-ECMO
-ECMO/ECPR: Bypass in select cardiac failure patients with potential reversible cause

-Why consider this? Our outcomes even with the best CPR candidates (witnessed VF arrest, healthy, bystander CPR) have low rates of discharge with favorable neurologic outcomes.

Indications: Bridge to definitive therapy (PCI, organ transplant, LVAD), Refractory shock, Cardiac arrest, Overdose, ARDS, Hypothermia arrhythmias

3 Stage Process
1) Cannulation unilateral femoral vein and artery
2) Wire/Dilator, Insert large trocars.
3) Confirm complete bypass with good flow. Stop CPR.

Better prognostic factors (Debaty et al. Resus ’17)
-Initial shockable rhythm
-Lower serum lactate
-Higher serum pH
-Shorter low flow duration

ED ECMO: Possible, happening at multiple centers. Requires trained staff, equipment, and 2 physicians.

Outcomes: Much Optimism, but unclear without RTCs (University of Michigan has one ongoing – EROCA)

Who should get ED ECMO? http://edecmo.org/edecmo-39-put-ecmo-new-data-prognostics/
EM Docs, Basics of ED ECMO: http://www.emdocs.net/extracorporeal-membrane-oxygenation-ecmo-in-the-ed/

 

Resident Author: Jeffrey Rixe, MD