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Pediatric Emergency Playbook

Tim Horeczko, MD, MSCR, FACEP, FAAP

15
Followers
10
Plays
Pediatric Emergency Playbook

Pediatric Emergency Playbook

Tim Horeczko, MD, MSCR, FACEP, FAAP

15
Followers
10
Plays
OVERVIEWEPISODESYOU MAY ALSO LIKE

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About Us

You make tough calls when caring for acutely ill and injured children. Join us for strategy and support -- through clinical cases, research and reviews, and best-practice guidance in our ever-changing acute care landscape. Please visit our site at http://PEMplaybook.org/ for show notes and to get involved with the show -- see you there!

Latest Episodes

Heat-Related Illness

A spectrum — but will you recognize the blurry signposts? Temperature (core) Presentation Management Miliaria Crystallina Normal Salt-colored tiny papules, easily burst; not pruritic Modify environment; light clothing; hydration Miliaria Rubra Normal Discrimiate, red papules, not assocaited with follicles; pruritic Above plus cool compresses; calamine lotion; symptomatic tx for pruritis Miliaria Profunda Normal Confluent flesh-colored, “lumpy-bumpy”; burning Same as rubra Miliaria Pustulosa Normal May resemble rubra and/or crustallina, but pustular; h/o previous dermatitis Same as above, but may may need antibiotic if no improvement over time Heat edema Normal Swelling of feet, ankles, and/or lower legs Modify environment; elevate legs Heat syncope Normal Dizziness, orthostatic hypotension, and syncope after exertion with rapid return to normal mental status when supine Modify environment; rehydration; monitoring Heat cramps May be elevated to 40°C (104°F) Exercise-induced cramping in large muscle groups, especially legs Hydration; consider labs (Cr, total CK); may counsel to stretch muscles passively, gently Heat tetany May be elevated to 40°C (104°F) Hyperventilation with paresthesia, carpopedal spasm Modify environment; hydration; may place non-rebreather mask on low (or off) for rebreathing CO2 Heat exhaustion Elevated up to 40°C (104°F) Normal mental status, fatigue, that rapidly improves with treatment; tachycardia; GI symptoms; electrolyte abnormalities Cool environment; hydration; consider labs with severe symptoms, or if not improved Heat Stroke >40 to 40.5°C (104 to 105°F) Altered mental status; tachypneic; tachycardic with hypotension; electrolyte abnormalities; GI symptoms; often with renal failure, rhabdomyloysis, renal failure; possibly with cardiogenic shock or ARDS or DIC Rapid cooling with all modalities available (radiation, conduction, convection, evaporation); IV rehydration; labs; monitoring; ICU admission Miliaria Crystallina Miliaria Crystallina — Infant Miliaria Crystallina — Older Child Miliaria Rubra — Infant Miliaria Rubra — Infant Miliaria Rubra — Toddler Miliaria Rubra — Adolescent Miliaria Profunda Selected References Bergeron MF, Devore C, et al. Council on Sports Medicine and Fitness and Council on School Health, Policy statement—Climatic heat stress and exercising children and adolescents. Pediatrics 2011; 128:e741. Casa DJ et al. The Inter-Association Task Force for Preventing Sudden Death in Secondary School Athletics Programs: Best-Practices Recommendations. J Athl Train. 2013 Jul-Aug; 48(4): 546–553. DeFranco MJ et al. Environmental issues for team physicians. Am J Sports Med. 2008 Nov;36(11):2226-37. Ishimine P. Hyperthermia. In: Pediatric Emergency Medicine, Baren JM, Rothrock SG, Brennan JA, Brown L (Eds), Saunders Elsevier, Philadelphia 2008. p.992. Jardine DS. Heat illness and heat stroke. Pediatr Rev 2007; 28:249.

44 MIN1 w ago
Comments
Heat-Related Illness

Diarrhea

Traditional Approach: Secretory-- poisoned mucosal villi -- "the sieve" Cytotoxic-- destroyed mucosal villi -- "the shred" Osmotic-- malabsorption -- "the pull" Inflammatory-- edema, motility -- "the push" Lots of overlap, difficult to apply to clinical signs and symptoms. Bedside Approach: Fever/No Fever, Bloody/No Blood Non-bloody, febrile-- most likely viral Non-bloody, afebrile--maybe viral Bloody, febrile-- likely bacterial Non-bloody, afebrile-- full stop.Eval for Hemolytic Uremic Syndrome Workup Ask yourself -- again -- why is this not... appendicitis-torsion-intussusception-etc. Admit sick children, but most go home, so... Non-bloody, febrile-- no workup necessary; precautionary advice Non-bloody, afebrile-- be more skeptical, but generally same as above Bloody, febrile-- stool culture, follow up; do not treat empirically unless septic and admitted. Culture will dictate treat/no treat/how. Bloody, afebrile-- evaluate for hemolytic uremic syndrome, especially if under 5 years old: CBC, chemistries, UA, stool culture Evaluate Hydration Status Selected References Khan WA et al. Central Nervous System Manifestations of Childhood Shigellosis: Prevalence, Risk Factors, and Outcome. Pediatrics. 1999 Feb;103(2):E18 Lee JY et al. Diagnostic yield of stool culture and predictive factors for positive culture in patients with diarrheal illness. Medicine (Baltimore). 2017 Jul; 96(30): e7641. Nelson JD et al. Treatment of Salmonella gastroenteritis with ampicillin, amoxicillin, or placebo. Pediatrics 1980; 65:1125.

50 MINJUL 1
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Diarrhea

DKA Like A Boss

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DKA Like A Boss

Zen and the Art of Pediatric Readiness

Pediatric Readinessis not just an ideal -- it's a tangible plan, a toolkit, and even better,an attitude How to improve your institution, and your own personal pediatric readiness. National Pediatric Readiness Project (NPRP) Los Angeles County Pediatric Readiness Project

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Zen and the Art of Pediatric Readiness

Pediatric Dysrhythmias

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44 MINAPR 1
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Pediatric Dysrhythmias

Otitis Media

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50 MINMAR 1
Comments
Otitis Media

Major Burns in Children

Lund and Browder Chart to Estimate Burn Size in Children Parkland Formula for Burns Amount neededin addition tomaintenance fluids: 4 mL/kg x BSA% = X Add 1/2 ofXto maintenance over the 1st 8 hours Add the other 1/2 ofXto maintenance over the next 16 hours Escharotomy Guide and the "Roman Breastplate" Yin et al.Bedside Escharotomies for Burns Classic Paragraph Selected References Mahar PD et al. Clinical differences between major burns patients deemed survivable and non-survivable on admisssion. Injury. 2015; 46:870-873. Mathis E et al. Pediatric Thermal Burns and Treatment: A Review of Progress and Future Prospects. Medicines. 2017; 4:91. Osuka A et al. Glycocalyx shedding is anhanced by age and correlates with increased fluid requirement in patients with major burns. Shock. 2017; 50(1):60-65. Sebastian R et al. Percutaneous pigtail catheter in the treatment of pneumothorax in major burns: The best alternative? Burns. 2015; e24-227 Sherren PB et al. Lethal triad in severe burns. Bur...

43 MINFEB 1
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Major Burns in Children

Anemia. Now What?

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43 MINJAN 1
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Anemia. Now What?

Pediatric Sports Injuries

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39 MIN2019 DEC 1
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45 MIN2019 NOV 1
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Latest Episodes

Heat-Related Illness

A spectrum — but will you recognize the blurry signposts? Temperature (core) Presentation Management Miliaria Crystallina Normal Salt-colored tiny papules, easily burst; not pruritic Modify environment; light clothing; hydration Miliaria Rubra Normal Discrimiate, red papules, not assocaited with follicles; pruritic Above plus cool compresses; calamine lotion; symptomatic tx for pruritis Miliaria Profunda Normal Confluent flesh-colored, “lumpy-bumpy”; burning Same as rubra Miliaria Pustulosa Normal May resemble rubra and/or crustallina, but pustular; h/o previous dermatitis Same as above, but may may need antibiotic if no improvement over time Heat edema Normal Swelling of feet, ankles, and/or lower legs Modify environment; elevate legs Heat syncope Normal Dizziness, orthostatic hypotension, and syncope after exertion with rapid return to normal mental status when supine Modify environment; rehydration; monitoring Heat cramps May be elevated to 40°C (104°F) Exercise-induced cramping in large muscle groups, especially legs Hydration; consider labs (Cr, total CK); may counsel to stretch muscles passively, gently Heat tetany May be elevated to 40°C (104°F) Hyperventilation with paresthesia, carpopedal spasm Modify environment; hydration; may place non-rebreather mask on low (or off) for rebreathing CO2 Heat exhaustion Elevated up to 40°C (104°F) Normal mental status, fatigue, that rapidly improves with treatment; tachycardia; GI symptoms; electrolyte abnormalities Cool environment; hydration; consider labs with severe symptoms, or if not improved Heat Stroke >40 to 40.5°C (104 to 105°F) Altered mental status; tachypneic; tachycardic with hypotension; electrolyte abnormalities; GI symptoms; often with renal failure, rhabdomyloysis, renal failure; possibly with cardiogenic shock or ARDS or DIC Rapid cooling with all modalities available (radiation, conduction, convection, evaporation); IV rehydration; labs; monitoring; ICU admission Miliaria Crystallina Miliaria Crystallina — Infant Miliaria Crystallina — Older Child Miliaria Rubra — Infant Miliaria Rubra — Infant Miliaria Rubra — Toddler Miliaria Rubra — Adolescent Miliaria Profunda Selected References Bergeron MF, Devore C, et al. Council on Sports Medicine and Fitness and Council on School Health, Policy statement—Climatic heat stress and exercising children and adolescents. Pediatrics 2011; 128:e741. Casa DJ et al. The Inter-Association Task Force for Preventing Sudden Death in Secondary School Athletics Programs: Best-Practices Recommendations. J Athl Train. 2013 Jul-Aug; 48(4): 546–553. DeFranco MJ et al. Environmental issues for team physicians. Am J Sports Med. 2008 Nov;36(11):2226-37. Ishimine P. Hyperthermia. In: Pediatric Emergency Medicine, Baren JM, Rothrock SG, Brennan JA, Brown L (Eds), Saunders Elsevier, Philadelphia 2008. p.992. Jardine DS. Heat illness and heat stroke. Pediatr Rev 2007; 28:249.

44 MIN1 w ago
Comments
Heat-Related Illness

Diarrhea

Traditional Approach: Secretory-- poisoned mucosal villi -- "the sieve" Cytotoxic-- destroyed mucosal villi -- "the shred" Osmotic-- malabsorption -- "the pull" Inflammatory-- edema, motility -- "the push" Lots of overlap, difficult to apply to clinical signs and symptoms. Bedside Approach: Fever/No Fever, Bloody/No Blood Non-bloody, febrile-- most likely viral Non-bloody, afebrile--maybe viral Bloody, febrile-- likely bacterial Non-bloody, afebrile-- full stop.Eval for Hemolytic Uremic Syndrome Workup Ask yourself -- again -- why is this not... appendicitis-torsion-intussusception-etc. Admit sick children, but most go home, so... Non-bloody, febrile-- no workup necessary; precautionary advice Non-bloody, afebrile-- be more skeptical, but generally same as above Bloody, febrile-- stool culture, follow up; do not treat empirically unless septic and admitted. Culture will dictate treat/no treat/how. Bloody, afebrile-- evaluate for hemolytic uremic syndrome, especially if under 5 years old: CBC, chemistries, UA, stool culture Evaluate Hydration Status Selected References Khan WA et al. Central Nervous System Manifestations of Childhood Shigellosis: Prevalence, Risk Factors, and Outcome. Pediatrics. 1999 Feb;103(2):E18 Lee JY et al. Diagnostic yield of stool culture and predictive factors for positive culture in patients with diarrheal illness. Medicine (Baltimore). 2017 Jul; 96(30): e7641. Nelson JD et al. Treatment of Salmonella gastroenteritis with ampicillin, amoxicillin, or placebo. Pediatrics 1980; 65:1125.

50 MINJUL 1
Comments
Diarrhea

DKA Like A Boss

PEMplaybook.org

45 MINJUN 1
Comments
DKA Like A Boss

Zen and the Art of Pediatric Readiness

Pediatric Readinessis not just an ideal -- it's a tangible plan, a toolkit, and even better,an attitude How to improve your institution, and your own personal pediatric readiness. National Pediatric Readiness Project (NPRP) Los Angeles County Pediatric Readiness Project

30 MINMAY 1
Comments
Zen and the Art of Pediatric Readiness

Pediatric Dysrhythmias

PEMplaybook.org

44 MINAPR 1
Comments
Pediatric Dysrhythmias

Otitis Media

PEMplaybook.org

50 MINMAR 1
Comments
Otitis Media

Major Burns in Children

Lund and Browder Chart to Estimate Burn Size in Children Parkland Formula for Burns Amount neededin addition tomaintenance fluids: 4 mL/kg x BSA% = X Add 1/2 ofXto maintenance over the 1st 8 hours Add the other 1/2 ofXto maintenance over the next 16 hours Escharotomy Guide and the "Roman Breastplate" Yin et al.Bedside Escharotomies for Burns Classic Paragraph Selected References Mahar PD et al. Clinical differences between major burns patients deemed survivable and non-survivable on admisssion. Injury. 2015; 46:870-873. Mathis E et al. Pediatric Thermal Burns and Treatment: A Review of Progress and Future Prospects. Medicines. 2017; 4:91. Osuka A et al. Glycocalyx shedding is anhanced by age and correlates with increased fluid requirement in patients with major burns. Shock. 2017; 50(1):60-65. Sebastian R et al. Percutaneous pigtail catheter in the treatment of pneumothorax in major burns: The best alternative? Burns. 2015; e24-227 Sherren PB et al. Lethal triad in severe burns. Bur...

43 MINFEB 1
Comments
Major Burns in Children

Anemia. Now What?

PEMplaybook.org

43 MINJAN 1
Comments
Anemia. Now What?

Pediatric Sports Injuries

PEMplaybook.org

39 MIN2019 DEC 1
Comments
Pediatric Sports Injuries

EtCO2 Masterclass

45 MIN2019 NOV 1
Comments
EtCO2 Masterclass
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