SimWars
This post is part of a series developed in preparation for participation in ACEP SimWars. It contains a review of several prominent emergency medicine topics which may be relevant for board preparation. Unless otherwise cited, content is based on HippoEM videos.
- Pediatric Emergencies
- Altitude and Dysbarism
- Bites
- Electrical Injuries
- Heat Emergencies
- Hypothermia
- Radiation Exposure
- Submersion Injury
- Hematologic Emergencies
- Bleeding Disorders
- Oncologic Emergencies
- Adrenal/Pituitary Emergencies
- Thyroid Emergencies
- Acid-Base Disturbances
- Dermatologic Emergencies
- Toxicology
Diseases by Age
- 1 week – 1 month: Ductal dependent cardiac lesions
- 1st month: Malrotation with volvulus
- 1 – 2 months: Pyloric Stenosis
- 2 – 6 months: CHF
- 3 months – 2 years: Intussusception
- 6 months – 2 years: Croup
- <2 years: Bronchiolitis
- 2 years: Meckel’s
- 2 years – 6 years: Epiglottitis
Table of contents
Cardiology
Ductal Dependent Lesions
- Present 1st week to 1st month
- Normal duct seals by 3 weeks
- If dependent on shunt for pulmonary flow cyanosis
- If dependent on shunt for systemic flow cold shock (may be worse w/ fluids)
- Prostaglandin E1
- 1 mg/kg/min
- Side effects include apnea, bradycardia, hypotension, seizure
- Consider intubating prior to administration
- IVF, cover for sepsis
Congestive Heart Failure
- Present 2nd to 6th month
- Presents with respiratory symptoms (wheezing, retractions, tachypnea)
- Difficulty with feeding (the infant stress test)
- Treatment: Supportive
Tetrology of Fallot
- Calm the child, knee to chest
- O2 = reduction in PVR
- Analgesia: morphine 0.1mg/kg, fentanyl 1.5 mcg/kg, ketamine 0.25 mg/kg
- Establish Access: 10-20cc/kg bolus
- Phenylephrine 0.2 mg/kg IV (to increase SVR)
- +/- HCO3 1mmol/kg (if acidosis)
- +/- beta blocker (with cardiology consultation)
- PGE1 0.05mcg/kg/min titrating to 0.1mcg/kg/min
Dermatology
Slapped Cheek/5th Disease
- Parvo B19
- Slapped cheeks, lacy reticular pattern of rash on body
- Complications:
- Pregnancy hydrops
- Sickle Cell Disease aplastic crisis
Measles
- Koplik spots, conjunctivitis, fever
- Can cause blindness
VZV
- Different stages of development
- Treat with acyclovir if > 12 years old
- Give VZIG in neonates and immunocompromised
Scarlet Fever
- Erythematous rash, palatal petechiae, pastia’s lines
- Strawberry tongue
- Trunk to periphery
- Treat with Pen VK: 50mg/kg BID x10d or Amox 20mg/kg BID x10d
- Pen allergic: Azithro 10mg/kg day 1 then 5mg/kg 2-5
Staphylococcal Scalded Skin Syndrome
- Toxin mediated, negative Nikolsky, good prognosis
- Treatment: Anti-staphylococcal antibiotics
- Nafcillin 25mg/kg/d IV
- Augmentin 45mg/kg/d PO in 2 divdied doses 7-10d
- Keflex 10mg/kg/d QID x7-10d
Henoch-Schonlein Purpura
- Palpable purpura in dependent areas
- Arthralgia/Arthritis (50-84%)
- Abdominal pain (50%): vascular lesions in bowel, may be intussusception lead point
- Renal Disease (20-50%) may develop within 2 months
- Treatment: Supportive, NSAIDs
Kawasaki Disease
- 5 days of fever + 4/5 of criteria
- Diffuse polymorphous diffuse rash
- Conjunctivitis
- Mucous membrane change (strawberry tongue)
- Cervical LAD (usually unilateral)
- Extremity changes
- Incomplete and atypical forms more common in infants
- Treatment (drop complications from 25% to 4-5%)
- Aspirin 20mg/kg/dose Q6H
- IVIG 2gm/kg over 12H
Gastroenterology
Bilious Vomiting
- Bilious vomiting malrotation with volvulus until proven otherwise surgical emergency
- 1st month of life “pre-verbal child’s disease”
- Dx: Upper GI Series (10-15%) false positive rate
Necrotizing Enterocolitis
- 10% of cases full term
- XR w/ pneumatosis intestinalis
Hirschsprung’s
- No meconium, slightly distended abdomen
- Less severe later presentation, p/w constipation
Pyloric Stenosis
- Presents around 6 wks: vomiting but very hungry
- Diagnosis
- US pylorus > 4mm thick, >15mm long
- NGT aspiration 5cc is abnormal
- Treatment
- Resuscitate
- Correct metabolic abnormalities
- Consult surgery
Intussusception
- Most common infant emergency
- 3 months – 2 years
- Abdominal pain, currant jelly, palpable mass (30% only)
- Typical presentation
- Lethargy (may be only sign)
- Vomiting
- Paroxysms of pain
- SBO
- PO intolerance
- Diagnosis: US
- Treatment: Enema (80-95% successful), 10% recurrence
Meckel’s Diverticulum
- Around 2 years of age, boys > girls
- Obstruction, intussusception
- Diagnose with technetium scan
Appendicitis
- 1/3rd with vomiting and diarrhea (AGE-type syndrome)
Hemolytic Uremic Syndrome
- Watery/bloody diarrhea
- Three components
- Acute renal failure
- Thrombocytopenia
- Microangiopathic hemolytic anemia (MAHA)
- Signs
- Pallor
- Abdominal Pain
- Decreased urine output
- Low energy/AMS
- Hypertension
- Edema
- Petechiae
- Icterus
- Treatment: Supportive vs. Dialysis (50%)
GI Bleed by Age
Age | Well-Appearing | Ill-Appearing |
---|---|---|
Neonate | Allergic Proctocolitis | Malrotation with Volvulus |
Anal Fissure | Necrotizing Enterocolitis | |
Swallowed Maternal Blood | Coagulopathy | |
Infant/Young Child | Allergic Proctocolitis | Meckel’s |
Gastritis | Intussusception | |
Infectious Colitis | Vascular Malformation | |
Older Child/Adolescent | Gastritis | IBD |
Esophageal Bleeding | Cryptic Liver Disease | |
Juvenile Polyps | Intestinal Ulceration |
Congenital Disorders
Congenital Adrenal Hyperplasia
- Presents in first two weeks of life
- Chief complaint may be vomiting
- Lyte: HyperK, HypoNa, Hypoglycemia dysrhythmias, seizures
- Treatment
- IVF (usual dose)
- Glucose (usual dose)
- Hydrocortisone: 25mg (neonate/infant), 50mg child, adolescent/adult 100mg
Inborn Errors of Metabolism
- Possible CC: Vomiting, Lethargy, Seizures, Hepatomegaly, Metab Acidosis, Odor
- May have normal labs and imaging
- Life-threatening: Metabolic acidosis, Hypoglycemia, Hyperammonemia, Sepsis
- Labs
- VBG (acidosis),
- CMP (liver, kidney, anion gap)
- Ammonia, lactate, urine (ketones, reducing substance)
- Bunch of extra tubes for labs later
- Treatment
- NPO
- IVF bolus
- D10 at 1.5x maintenance
- Treat Sepsis
- Control seizures PRN, correct hyperammonemia/acid/lyte (may need dialysis)
Pulmonary
Croup
- Toddlers (6-24 months), 5% of all children, boys > girls
- PIV #1
- Rhinovirus, Metapneumovirus, PIV II-IV, RSV, Flu A/B
- Frequent co-infections with one or more viruses
- Sx: 1-3 days of URI Sx Abrupt cough/stridor worse for one day, then better
- Signs: Nontoxic, if wheezing likely RSV
- Studies: XR to r/o FB (steeple sign if positive)
- Treatment: Racemic Epi: 0.25-0.75 cc in 3 cc Q 20 minutes, lasts < 2 hours
- Disposition: If stridor at rest then treat if no improvement, then admit
Stridor | Steroids | Racemic Epi | Dispo |
---|---|---|---|
Mild | 0.15 mg/kg | No | Home |
At rest with WOB | 0.30 mg/kg | Yes | Admit |
Severe at rest | 0.60 mg/kg | Yes | ICU |
Bronchiolitis
- Children < 2 years old, November through April (peak Jan/Feb)
- Apnea in neonates and ex-premies < 2 months
- Bacterial superinfection is very rare
- Presentation: Desat, tachypnea, nasal flaring, intercostal retractions, secretions
- Exam: Fine rales, diffuse/fine wheezing
- Treatment: Suction, O2 (if < 90%), NPPV
- Maybe albuterol, but no steroids/epi/abx
Epiglottitis
- Bimodal (2-6, 20-40y), < 1% URI with stridor, boys = girls, al year
- Non-typable H.flu, staph/strep, Moraxella
- Candida, HSV, VZV, crack cocaine
- Symptoms: Muffled voice, drooling rapid progression in hours
- Signs: No pharyngeal findings with severely tender anterior neck
- Studies: XR w/ thumb sign
- Treatment: Laryngoscopy, airway management
Bacterial Tracheitis
- Preschool (1-10y), boys = girls, Downs
- Symptoms: Several days’ URI toxic in hours, rapid progression
- Signs: Subglottic diffuse inflammation, edema with exudates and pseudomembranes
- Studies: CXR demonstrates narrow trachea
- Treatment: Emergent intubation, 3rd generation cephalosporin