8:00 am Joint EM/Trauma conference

Patients with traumatic head and chest injuries generally require CTA neck.

For pediatric trauma:
GCS 12 or less: Head CT needs to be done prior to transferring a child, regardless of estimated transfer time

PECARN head trauma rule:

PECARN Head Trauma Rule - Source: Lancet (https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)61558-0/fulltext)
 

9:00 am Case conference by Dr. Kevin Kammel

Intern in a hot seat: Dr. Alex Mercado
Life-line: Dr. Mike Torre

CC: Acting strange

Intracerebral hemorrhage

Spontaneous ICH 8-11% of all strokes
7-day mortality is 30%
2x more common in black males

Risk
HTN
AVM
Aneurysm
Tumors
Anticoagulant use

Axial illustration of the brain showing the subtypes of intracranial haemorrhage - Source: (https://www.bmj.com/content/339/bmj.b2586)
 

Clinical:
HA, N/V, truncal instability/ataxia, gaze palsies, depressed LOC

Dx:
CT
CTA
MRI

Treatment:
ABC
Hyperthermia – treat with antipyretics
Seizure prophylaxis
BP management
Reverse coagulopathy – Vit K, K-Centra, PCC, etc.
ICP management: HOB elevation 30 degrees, sedation, anesthesia
Osmotic agents: mannitol
Avoid succinylcholine for RSI due to BP elevation/fasciculations

10:00 am "Stroke" by Dr. Eric Stander

CVA is the 5th leading cause of death in USA

Risk factors:
HTN
Drug use
DM
HLD
Smoking
Older age
African American race
Males
Obesity

Types of strokes:
Hemorrhagic
Ischemic – embolic vs thrombotic

Factors affecting stroke size:
Time
Type of vessel
BP
Presence of anticoagulation
Body temp
Glucose level

Cerebral blood flow:
Ischemic core and penumbra
15% of resting CO goes to brain
Microthrombi
Conversion of ischemic to hemorrhagic stroke

SBP of 185 or higher needs to start treating it

Prehospital care:
Glucose, BP, onset of sxs
BEFAST

BEFAST - Source: http://www.charlestonphysicians.com/cardiology/what-everyone-needs-know-about-strokes.php

Source: https://www.cathlabdigest.com/article/Newly-Demonstrated-Safe-Approach-Rationale-Intravenous-rtPA-Used-Acute-Stroke-Patients-NIHSS

In ED:
NIHSS

4-25 – consider tPA

Posterior circulation:
Ataxia, truncal instability, wide gait, inability to tandem walk, etc.
Dizziness
HA
N/V

Brainstem:
Autonomic functions
Thermoregulation
Balance and coordination
Rapid Alternating movements - dysdidakokinesia
Weakness/paralysis
CN palsies (III, IV, VI)
Coma
HINTS:

• Head impulse, nystagmus, skew
• Any 2 of 3 suggest central
• Only 51% had positive HINTS

Stroke mimics:
Hypoglycemia
Psychogenic
Seizures
Migraine with aura (complex migraines)
HTN encephalopathy
Wernicke’s
CNS abscess
CNS tumor
Drug toxicity (lithium, Dilantin, etc)
Bell’s palsy

Dx:
CT dry
CTA head/neck
MRI/MRA

Contraindications to tPA:

Acute Hypertension Management: Optimizing Door-to-Needle Time in Ischemic Stroke - Source: https://www.medscape.org/viewarticle/849726_transcript

tPA is a standard of care at this point.

BP control:
Labetalol – 1st line drug, 10-20 mg IV load, repeat Q 10 min. Hard to titrate
Nicardipine – easy to titrate, rapid onset
Nitroprusside – works well, but is falling out of favor due to narrow therapeutic window, cumulative, cyanide toxicity

Anticoagulation – no
Antiplatelet Agents Acutely – ASA?, no others.
Thrombectomy – within 24 hours of onset of sxs

11:00 am "Pediatric Fever 2019" by Dr. Al Sacchetti

Fever without a source
Only 20% of ED patients
Respiratory sxs
GI sxs

Febrile neonates:
Historic fever is 35% accurate, take mom’s word for it, 8.4% had bacterial infection
Palpable fever: 67& sensitive, 84% specific – so take mom’s word for it as well
Full septic workup: CXR, LP, blood cx, urine cx
Admission for obs
Usually UTI organisms (E.coli, GBS)

29-60 days:
Hx: term infant, no recent Abx
PE: normal
CBC: 5-15K
UA <10/HPF, neg G stain
CXR: no infilrates

PECARN: prediction rule

Children >60 days
Hx: parental concern (+LR 14), duration of fever – the longer, the more likely SBI (UTI)
If recently immunized, 7%
If not recently immunized, 2.9%
Height of fever does not matter
PE:
Retractions/tachypnea – the only thing that matters
MD’s clinical instinct - yes
Cyanosis - yes
Petechial rash – no, unless it’s diffuse
Poor peripheral perfusion - yes
Hypoxia <94% - yes

Labs:
CBC – sensitivity 70%
CRP, PCT – similar to CBC, not very sensitive
UA

In the future:
Will use RNA PCR to predict viral vs bacterial infection
Maharan: JAMA 2015

Fever in unvaccinated kids:

Worry about fever on day 1
Height of fever – if >102, you worry
PE: matters
CBC >15K
Blood cx

The information on these pages is provided for general information only and should not be used for diagnosis or treatment, or as a substitute for consultation with a physician or health care professional. If you have specific questions or concerns about your health, you should consult your health care professional.

The images being used are for illustrative purposes only; any person depicted is a model.

 
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