12 Days of Pediatrics
Dr. Nelson
1. Two approaches to Nursemaid’s reduction: supinate and flex or hyperpronate
2. Hair tourniquet on digits: digital block and lateral incision to the bone.
3. Six surgical pediatric emergencies:
Procedural sedation and analgesia
Dr. Zhao
1. Don’t delay procedural sedation based on fasting (Level B)
2. Risk stratify your patient-check their airway
3. Capnography may be used as an adjunct to pulse ox (Level B)
4. Propofol: deep sedation and short procedures.
5. Etomidate: Minimal cardiovascular effects and short acting
6. Ketamine: preserves respiratory drive, longer lasting, does NOT increase ICP
Dr. Nelson
1. Two approaches to Nursemaid’s reduction: supinate and flex or hyperpronate
2. Hair tourniquet on digits: digital block and lateral incision to the bone.
3. Six surgical pediatric emergencies:
- 6min: TE Fistula
- 6hr: duodenal atresia
- 6 days: Malrotation
- 6 weeks: pyloric stenosis (pi)
- 6mo: intussusception
- 6yrs: appendicitis
Procedural sedation and analgesia
Dr. Zhao
1. Don’t delay procedural sedation based on fasting (Level B)
2. Risk stratify your patient-check their airway
3. Capnography may be used as an adjunct to pulse ox (Level B)
4. Propofol: deep sedation and short procedures.
5. Etomidate: Minimal cardiovascular effects and short acting
6. Ketamine: preserves respiratory drive, longer lasting, does NOT increase ICP
Critical Care Conference
Dr. Leon Eydelman, Dr. Fraser, Dr. Souchon
1. Cardiac arrest in trauma: usually it’s a good heart with obstructive pathology, hypovolemia or hypoxia. CPR in trauma tends to be ineffective and may actually worsen the traumatic injury and/or obstruct other life-saving interventions.
2. ED Thoracotomy (EAST guidelines):
· Strongly recommend for EDT: Pulseless with signs of life after penetrating thoracic injury.
· Conditionally recommend for EDT: Pulseless with signs of life after blunt thoracic injury or pulseless with absent signs of life after penetrating thoracic injury.
· Conditionally recommend against EDT: Pulseless with absent signs of life after blunt thoracic.
· Recommend against: Pulseless with absent signs of life with CPR >5minutes in blunt thoracic injury or pulseless with no signs of life with CPR > 15min in penetrating thoracic injury
3. FAST as predictor of outcomes in trauma cardiac arrest: If no pericardial fluid, and no cardiac motion, probability of survival almost zero and EDT not indicated.
4. REBOA (resuscitative endovascular balloon occlusion of aorta) may replace the EDT
Head Injury in Blood-Thinned Patients
Dr. Cleveland
1. Who needs head CT
· Anticoagulants: 100% of patients with head injury on anticoagulant get a head CT, even if INR is subtherapeutic.
· Antiplatelet: 100% of patients with head injury on antiplatelet get head CT, although data isn’t as good.
2. Who to repeat head CT and/or Obs: Antiplatelet and not a scary history and normal physical examàhome. Everyone else stays and gets a repeat CT.
3. Treatment:
· Anticoagulants: Options include Vitamin K, FFP, 4 factor PCC, Feiba, Kcentra ($8K) 1 dose= 8U FFP, Praxbind (Pradaxa), Andexanet (Rivaroxaban).
· Antiplatelet: DDAVP in head injured antiplatelet patients with radiographic evidence of ICH.
4. When to treat during ED course: no data about reversal prior to imaging studies.
Gastric Decontamination: Dispelling the Myths
Dr. Roberts
1. Activated Charcoal: May be used up to 24hrs in ingestions such as Tylenol, but is most effective in first four hours. Consider in patients with serious ingestion who is protecting airway.
2. Whole Bowel Irrigation: May be an adjunct/alternative to AC
3. Gastric Lavage: Not useful and may actually increase rate of absorption, and is associated with adverse outcomes. Use of ipecac, cathartics and GL have been discouraged and do not change clinical outcomes and have significant side effects.
Dr. Leon Eydelman, Dr. Fraser, Dr. Souchon
1. Cardiac arrest in trauma: usually it’s a good heart with obstructive pathology, hypovolemia or hypoxia. CPR in trauma tends to be ineffective and may actually worsen the traumatic injury and/or obstruct other life-saving interventions.
2. ED Thoracotomy (EAST guidelines):
· Strongly recommend for EDT: Pulseless with signs of life after penetrating thoracic injury.
· Conditionally recommend for EDT: Pulseless with signs of life after blunt thoracic injury or pulseless with absent signs of life after penetrating thoracic injury.
· Conditionally recommend against EDT: Pulseless with absent signs of life after blunt thoracic.
· Recommend against: Pulseless with absent signs of life with CPR >5minutes in blunt thoracic injury or pulseless with no signs of life with CPR > 15min in penetrating thoracic injury
3. FAST as predictor of outcomes in trauma cardiac arrest: If no pericardial fluid, and no cardiac motion, probability of survival almost zero and EDT not indicated.
4. REBOA (resuscitative endovascular balloon occlusion of aorta) may replace the EDT
Head Injury in Blood-Thinned Patients
Dr. Cleveland
1. Who needs head CT
· Anticoagulants: 100% of patients with head injury on anticoagulant get a head CT, even if INR is subtherapeutic.
· Antiplatelet: 100% of patients with head injury on antiplatelet get head CT, although data isn’t as good.
2. Who to repeat head CT and/or Obs: Antiplatelet and not a scary history and normal physical examàhome. Everyone else stays and gets a repeat CT.
3. Treatment:
· Anticoagulants: Options include Vitamin K, FFP, 4 factor PCC, Feiba, Kcentra ($8K) 1 dose= 8U FFP, Praxbind (Pradaxa), Andexanet (Rivaroxaban).
· Antiplatelet: DDAVP in head injured antiplatelet patients with radiographic evidence of ICH.
4. When to treat during ED course: no data about reversal prior to imaging studies.
Gastric Decontamination: Dispelling the Myths
Dr. Roberts
1. Activated Charcoal: May be used up to 24hrs in ingestions such as Tylenol, but is most effective in first four hours. Consider in patients with serious ingestion who is protecting airway.
2. Whole Bowel Irrigation: May be an adjunct/alternative to AC
3. Gastric Lavage: Not useful and may actually increase rate of absorption, and is associated with adverse outcomes. Use of ipecac, cathartics and GL have been discouraged and do not change clinical outcomes and have significant side effects.
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