Carolinas Core Concepts Core Concepts in EM; a repository for Carolinas lecture summaries.


Pediatric Textbook Review – Lower Extremity Fractures and Upper Airway Management

Lee Garvey, MD

  • Toddler’s fractures may be missed on the normal two views. Consider getting an oblique view.
  • Pediatrics upper airway management requires significant forethought. Have your second and third backups ready.
  • For suspected epiglottitis, do NOT agitate the child until ENT/anesthesia available. NO IVs, NO meds, just transfer.
  • Proper documentation for likely viral URI
    • Position of uvula
    • Erythema of tonsillar pillars
    • Symmetry of tonsils
    • No pain on external manipulation of larynx
    • No trismus

Pediatrics M&M

Maneesha Agrawal, MD

  • For new diagnosis of leukemia, watch for:
    • Neutropenic fever
    • Disseminated Intravascular Coagulopathy (DIC)
    • Hyperviscosity syndrome
    • High output cardiac failure
  • Life threatening diagnoses on new born screen at 1 week of life
    • Congenital adrenal hyperplasia
    • Galactosemia
    • Maple Syrup Urine Disease
  • Henoch-Schonlein Purpura
    • Risk for ileo-ileo intussusceptions as opposed to the more common ileo-cecal intussusceptions because of intramural hematoma

Pediatric Abdominal Pain

Michael Preis, DO

  • FAST scan in trauma for children is controversial.
    • Sensitivity of 66-83%
  • In appendicitis, the positive likelihood ratio of WBC and CRP combined is 7.75 but only between 4-5 individually.
  • Time is testicle – Salvage rate related to time.
    • 4 hours – 96%
    • 12 hours – 20%
    • 24 hours – 10%
  • Intussusception
    • Imaging modality depends on clinical suspicion
      • High likelihood: Air contrast or barium enema
      • Moderate or low likelihood: ultrasound
        • Have to be aware that ultrasound may miss diagnosis especially if the child doesn’t have pain during exam

PEM: Moderate Sedation

Randolph Cordle, MD

  • Selection of appropriate patients to sedate in the ED is as important as knowing how to give drugs. Remember your ASA classifications and assure you have both the capacity and equipment to recover the patient if there is an issue.
  • Give Ketamine slowly or they will become apneic (first 3-4 minutes is riskiest part).
  • Preoxygenate during your sedations and use ETCO2 as your early indicator and remember that a Flat line on ETCO2 is apnea or airway occlusion until proven otherwise. Don’t assume it is equipment failure.

Neutropenic Fever & Sickle Cell

  • Defined with a temp of >38C and an ANC of <500.  Shotgun cultures and cover with broad-spectrum antibiotics + vancomycin.
  • Peak ages for acute chest syndrome are between 2-4 years of age.  Often not present on initial ED evaluation; develops days later in hospital.  Have a high suspicion for any fever in sicklers.

Pediatric Master Class

  • Rule of 50's for glucose replacement:
    • 1mL/kg of D50 (only in adults... some would argue it's too caustic even then)
    • 2mL/kg of D25 (in kids and adults)
    • 5mL/kg of D10 (in neonates)
  • Absence of the cremasteric reflex is the most sensitive sign for early testicular torsion.

Pericarditis / Myocarditis

  • Pediatric systolic blood pressure should be 70+ (age x 2)
    • Consider 90 + (age x 2) if you want to be more conservative
  • Change your initial fluid bolus to 10mL/kg if you are considering restrictive cardiac disease; watch carefully for signs of fluid overload!

Pediatric Procedures

Sean Fox, M.D.
  • Remember that the pediatric larynx is anterior and cephalad, which makes the airway easy to occlude. Often a simple jaw thrust or shoulder roll is enough to open up the airway.
  • Basic Bag Valve Mask ventilation is a skill that must be mastered and done correctly: be aware, pushing too hard on the eyes can make your patient reflexively bradycardic and, hence, make your job more difficult.
  • There is no good data supporting or refuting lidocaine or atropine pretreatment in pediatric RSI. Much of the data is actually due to hypoxia as a cause for bradycardia, not vagal stimulation.
  • Studies showing increased ICP with ketamine were done on patients with malfunctioning VP shunts - and therefore obstructive hydrocephalus. Raising blood pressure in this case will cause increased ICP's.
  • Cuffed tubes are ok to use (recent American Heart Association publications support this) and may have a mechanical advantage when ventilating patients with pulmonary processes (ex. pneumonia, asthma).
  • Never forget to place an OG immediately after intubating. "Intubate the stomach!"
  • McGyver jet ventilator: 18ga angiocath, connector from a 3.0 ETT, 3mL syringe, and a 7.5 ETT

Pediatric Master Class

  • The workup of the crying child is veterinary medicine: a thorough physical exam includes checking for hair tourniquets to the fingers, toes, and penis.  Consider fluorescein staining of the eyes and a urinalysis for occult UTI.
  • Many ALTE presentations can be clarified with careful history.  Consider 24 hour observation in the child whose story is still unclear.
  • Cyclosporine metabolism changes with several medications we commonly give.  Pay attention before you prescribe transplant patients methylprednisolone, trimethoprim, NSAIDS, sulfonamides, or aminoglycosides.