Grand Rounds Summary 8.10.2022
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Acute Valvular Insufficiency WITH Dr. Vaishnav
Acute Aortic Regurgitation
Etiologies
Infective Endocarditis
Aortic Dissection
Rupture of congenital fenestrated cusp
Trauma
Iatrogenic
Aortic balloon valvotomy
TAVR
Cardiac catheterization
Presentation
Acute LV failure
Shortness of breath, palpitations, dizziness, syncope, chest/back pain
Physical Exam
Hypotension/shock
Rales/pulmonary edema
Early diastolic low-pitched murmur
Narrow pulse pressure
EKG
Non-specific ST segment and T wave changes
Signs of ischemia if coronary ostia are involved in an aortic dissection
CXR
Pulmonary congestion
Typically, normal cardiac silhouette
May see cardiac silhouette enlargement if pericardial effusion with dissection
May see mediastinal widening with aortic dissection
TTE
Color doppler echocardiography demonstrates the backflow of blood across the aortic valve in diastole
TTE also permits evaluation of rapid equilibration of the aortic and LV diastolic pressures, aortic root, and LV size and systolic function
May see valvular vegetations or perivalvular abscesses
May see hemopericardium or dissection flap with TTE
TEE is more sensitive than TTE (98% vs 60-80%) and may be considered in hemodynamically unstable patients with suspected ascending aortic dissection, though CTA is more commonly used
Treatment
Emergent aortic valve replacement
Decrease LV afterload
Inotropes as needed
For aortic dissection, HR and blood pressure control
Antibiotics if concern for IE
Tricuspid Regurgitation
Etiologies
Primary causes
Infective endocarditis
Trauma/deceleration injury
Pacemaker/ICD lead
Rheumatic valve disease
Carcinoid syndrome
Connective tissue diseases
Secondary causes
Left sided heart failure
Mitral stenosis/regurgitation
Pulmonary disease
Cor pulmonale, pulmonary embolism
Stenosis of the pulmonary valve or PA
Presentation
Shortness of breath
Exercise intolerance
JVD
Atrial fibrillation
Ascites
Hepatomegaly
Peripheral edema
Diagnosis and echocardiography
Tricuspid valve motion abnormalities
Dilation of right atrium, right ventricle, tricuspid annulus
Paradoxical interventricular septal movement
Other abnormalities may be seen when the tricuspid regurgitation are due to pulmonary hypertension secondary to a left-sided cardiac abnormality.
Peak regurgitant flow velocity measurement across the tricuspid valve helps estimate right ventricular and pulmonary arterial systolic pressures.
Treatment
Cardiac surgery if suspicion for IE
Medical management for right sided heart failure
Diuretics, blood pressure control
Coronary CT Angiogram WITH Dr. Hughes
Test characteristics
96% sensitive for coronary plaque
92% sensitivity for significant coronary stenosis
Stress MPI 55%
87% specificity for coronary stenosis
Stress MPI 78%
CT-Based Fractional Flow Reserve (FFR-CT)
Can obtain functional test parameters from CT, uses computational fluid dynamics
Values < 0.8 may correlate with inducible ischemia
CATCH Trial 2013
Prospective RCT comparing functional stress testing vs. CCTA
Examined rates of ICA referral and PPV for detecting significant stenosis with subsequent revascularization
Outcome: CCTA led to an increase in invasive coronary angiography, but found more intervenable disease
PROSPECT TRIAL 2015
Prospective RCT in low to intermediate risk ED patients with acute chest without known CAD who had no ECG changes and negative initial conventional troponin
Compared CCTA vs. nuclear stress test on impact of cardiac catheterization that did not lead to intervention
Outcome: CCTA noninferior when compared to NST, no change in resource utilization
PROMISE TRIAL 2017
Prospective multicenter trial at 193 North American sites that looked at intermediate pre-test probability
This is key because the majority of trials looking at CCTA had a very low risk patient population – the same population that we now discharge from the ED using the HEART pathway. In this study however, the Framingham risk was >10% for all patients and a quarter of patients had a CAD equivalent diagnosis (stroke, DM, and PVD)
Primary end point was death, MI, unstable angina hospitalizations over a median follow up of 26 months
The rate of normal testing was lower for CCTA
But if the testing was normal, CCTA outperformed functional testing with a lower MACE i.e. NPV
Additionally, CCTA outperformed functional testing in terms of PPV for moderately abnormal test results,
CCTA was able to detect an at-risk group of patients with non-obstructive CAD who then had a 3 fold increase in MACE risk over 2 year follow up
In summary, CCTA provided better prognostic data compared to functional testing
NICE Guidelines 2017
NICE recommend cardiac CT as the first-line test for the evaluation of stable coronary artery disease in chest pain pathways
Levsy JACC: Cardiovascular Imaging 2018
In low to intermediate risk ED acute chest pain patients without known CAD who had no ECG changes and negative initial conventional troponin
Comparing CCTA to stress echo
Showed that CCTA led to more hospitalizations, and that it increased LOS
Utilized patients with TIMI 0-1, which is very low risk and probably not an applicable study for such low risk patients (enrolled in 2011-2016 before HEART pathway)
CONSERVE Trial 2019
Randomized, prospective, open-label trial at 22 multinational sites
Intermediate risk patients with symptoms suggestive of CAD OR abnormal stress test
Investigated whether or not performing CCTA first, as a way to perform less heart caths, led to non-inferior MACE at 1 year follow up
MACE rates were similar at 4.6%
CCTA arm had lower costs because there were less LHC and less PCI – 23% v 100%, 11 v 15%
Additionally CCTA group had better diagnostic yield – normal caths were only found in one quarter of patients compared to >60% in the direct referral arm
2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain
1A - no known CAD after negative or inconclusive evaluation of ACS, CCTA is useful for exclusion of atherosclerotic plaque and obstructive CAD
2A - known nonobstructive CAD, CCTA can be useful to determine progression of atherosclerotic plaque and obstructive CAD
2A - with evidence of previously mildly abnormal stress test results (≤1 year), CCTA is reasonable for diagnosing obstructive CAD
2A - no known CAD, as well as inconclusive prior stress test, CCTA can be useful for excluding the presence of atherosclerotic plaque and obstructive CAD
CCTA Exclusion Criteria
Risk or contraindications
≥ 65 years old
Iodine allergy
Pregnancy
GFR < 30
BMI > 39
Irregular heart rhythm
Inability to follow instructions to hold breath for 10 seconds
Unable to lower HR to < 65 bpm with beta blockade
Contraindication to receiving nitroglycerin
Prior chest CT with at least moderate coronary calcifications
Warranty Intervals (for intermediate risk populations) - if otherwise reassuring workup
Any stress test < 1 year (if adequate & negative)
CCTA < 2 years (if no stenosis or plaque)
Left heart catheterization (negative or non-obstructive CAD)
Interpretation of CCTA results
CAD-RADS score depends on percent stenosis, plaque features
CAD-RADS 0, 1, 2 = ACS low risk, discharge
CAD-RADS 3 = ACS possible, cardiology consultation, admit
CAD-RADS 4, 5 = ACS likely, should obtain LHC
HALO (High Acuity Low Opportunity) and LALO (Low Acuity Low Opportunity) Procedures Lab WITH Drs. Zalesky, Mullen, Broadstock, Kimmel, Comiskey, Goff, Winslow, Crawford, Gillespie
Cranial Burr Hole
Indications:
CT confirmed epidural hematoma w/ depressed mental status (GCS < 9) AND known prolonged transport to neurosurgeon/trauma surgeon
CT confirmed large subdural hematoma w/ depressed mental status (GCS < 9) AND known prolonged transport to neurosurgeon/trauma surgeon
Landmarks:
Use CT for guidance:
Some sources recommend placing a landmark (i.e., electrode sticker) on scalp prior to CT and measuring the distance to the center of the hematoma radiographically from this landmark, while others recommend providers count down the number of slices from the top (and multiple by slice thickness) to the center of the hematoma to calculate how many centimeters below the vertex the burr hole should be
If no CT is available: 2 cm superior, 2 cm anterior to tragus, ipsilateral to blown pupil (temporal site)
Steps: Adapted from EM: Reviews and Perspectives
Shave the hair, prep and drape.
Inject lidocaine with epinephrine. Palpate the superficial temporal artery (STA) and remain anterior to it.
Skin incision - Make a vertical incision down to bone.
Insert the retractor to expose periosteum.
Use the periosteal elevator to expose the skull.
Trephination technique varies with equipment. Have an assistant stabilize the head.
Epidural hematoma - Epidural blood will evacuate once through the skull. Irrigate and suction the clotted blood.
Subdural hemorrhage - For a subdural bleed, make a 3-sided window incision in the dura. You may irrigate using sterile fluid but do not suction.
Apply a sterile dressing over the wound
Administer antibiotics (ceftriaxone)
Note: In dire circumstances, exploratory burr holes without CT images can be done in the following sequence: Ipsilateral temporal, contralateral temporal, ipsilateral frontal, ipsilateral parietal.
Transvenous Pacing
A comprehensive review can be found on Taming the SRU at the following links:
Minnesota Tube
There are several balloon tamponade devices available for management of life-threatening upper GI bleed
Sengstaken-Blakemore tube
250 cc gastric balloon AND esophageal balloon
Single gastric aspiration port
Minnesota tube
500 cc gastric balloon AND esophageal balloon
Gastric aspiration port AND esophageal aspiration port
Linton-Nachlas tube
600 cc gastric balloon
Single gastric aspiration port
UCMC and ACMC carry the Minnesota Tube
Placement:
Insert the Minnesota tube like an orogastric tube (use of laryngoscope and Magill forceps can aid in placement), and advance to 50cm
Inflate the gastric balloon to 50cc
Confirm position of gastric balloon below the diaphragm on X-ray
Inflate gastric balloon to 500cc and clamp the gastric balloon port
Gently retract the tube until resistance is met-this will help to further tamponade varices along the gastric fundus
Secure tube with traction – suggest a hanging bag of saline once tube is affixed to ETT holder
If ongoing bleeding noted from esophageal aspiration port, inflate the esophageal balloon to 30 mmHg using a cufflator. Aspirate again, and if bleeding persists, the esophageal balloon can be inflated to 45 mmHg. Clamp the esophageal balloon port.
Anatomy to know:
Eponychium
Nail fold
Sterile matrix
Germinal matrix
Greater than 50% of patients who present to the ED with nailbed injuries will also have an underlying distal phalanx fracture.
A subungual hematoma is an accumulation of blood under an intact nail plate, often the result of a direct crush injury to the fingertip. Trephination is indicated if 25-50% of the nail is involved, with accompanying pain. This is often performed within 24 hours of the initial injury. If >24 hours, the blood is likely clotted and cannot be removed through trephination. Traditional teaching suggests that for subungual hematomas involving more than 50% of the nail bed, the nail should be removed given the risk of concomitant nail bed laceration. There is little data to support this practice, and newer convention is to leave the nail in place if it is laying flat on the nail matrix and is intact.
Methods of trephination
Electrocautery
Incision w/ 18 gauge, scalpel
After trephination, pain relief is generally immediate, and patients should be instructed to soak the affected finger in warm, soapy water 2-3 times daily for one week. There is no data to suggest the need for antibiotics without accompanying fracture.
When using an electrocautery pen, choose a location in the center of the hematoma. Apply very gentle pressure to the nail until you are through the nail. When you have penetrated the nail, you will see blood. At that time, you can stop using electrocautery and manually express the hematoma. The patient should feel immediate relief of their pain.
Ring Removal
Perform digital block, palmar approach may be best to reduce added edema
Methods:
Destructive
Dremel
Tungsten rings - cannot be cut, requires vice grip
Lubrication
Water based lubricant
Windex
Surfactants reduce the surface tension between the ring and the patient’s skin, likely generated from sweat and trace edema
Elastic band technique (non-rebreather)
Wrap distal to proximal
Slip proximal end of elastic band underneath the right and then unwrap proximal to distal
Dental Trauma
Relevant Anatomy:
Enamel = white
Dentin = yellow
Pulp = red
Fracture Classification and Management:
Ellis 1: enamel only
Dental follow-up prn
Ellis 2: enamel + dentin
Smooth edge with file, apply sealant, consider abx, dental f/u in 24 hours
Ellis 3: enamel + dentin + pulp
Apply sealant, prescribe abx, dental consult or f/u in 24 hours
Bonus Tip:
When mixing dental sealant (calcium hydroxide) , add catalyst to base, mix and place into 3 cc syringe by smearing onto the plunger. Reassemble and attach 18g angiocath for easy application.
Storage of avulsed tooth:
Best is Hank’s solution or Pedialyte (12-24 hours)
Milk (3-8 hours)
Dry (1 hour)
Try to reimplant the tooth immediately. Touch only the crown to avoid damaging the periodontal ligament.
Periodontal ligament = a fibrous joint that anchors the root of the tooth to the alveolar bone socket.
Primary teeth should not be reimplanted
If it is not immediately reimplanted, soak it in normal saline for 30 minutes and then in doxycycline solution for 5 minutes, then attempt reimplantation. Doxycycline helps rid root of bacteria that inhibits reimplantation
If reimplanted, give tetanus toxoid and doxycycline (clinda or PCN if allergic)
Splint tooth and arrange for dentistry follow up in 24-48 hours
If history of trauma, consider CT or XR to assess for alveolar fractures = requires OMFS consultation and likely operative repair
For subluxations, lateral luxations, need splinting and close dentistry follow up
For tooth intrusions, seek OMFS consultation
A temporary dental bridge can be made using dermabond and the metal nasal bridge found on a non-rebreather. See ALiEM’s write up for more details.
Anterior Epistaxis:
Direct Nasal Pressure
Blow nose, apply afrin, and hold pressure for 15 to 20 minutes before checking
Cautery
Again, apply afrin and attempt to visualize Kesselbach’s plexus
Apply silver nitrate sticks to this area to cauterize active bleed
Never cauterize both sides of the septum due to risk of septal perforation
Rapid Rhino/Rhino rocket
Rapid Rhino contains a balloon whereas the Rhino Rocket does not and only contains an absorbent foam packing
Soak balloon with water and insert along the floor of the nasal cavity
Inflate slowly with air until the bleeding stops
There is evidence to suggest that antibiotics are not needed for isolated anterior packing, but local practice patterns and ENT recommendations may differ
Traditional Packing
Apply ribbon gauze in accordion-like manner
TXA soaked foam or gauze may be attempted, though a 2021 RCT (NoPAC) showed no difference in efficacy when compared with placebo.
Posterior Epistaxis:
90% of epistaxis is anterior. Only consider posterior packing if anterior packing methods have failed
Rapid Rhino makes a 7.5 and 9cm device to tamponade posterior bleeds
Can apply a Foley catheter with 30-cc balloon if dedicated posterior packing not available
Advance transnasally until visualized in posterior oropharynx
Inflate balloon with 5-7cc of saline; retract 2-3cm until lodged in post nasopharynx
Inflate with additional 5-10cc of saline to complete the pack
Keep packing for 72-96 hours, <48 hours associated with increased re-bleed.
Disposition:
Anterior Epistaxis
If not anticoagulated, CBC stable, and no evidence of ongoing bleeding, can be discharged home
ENT or ED follow-up in 2-3d for removal of nonbiodegradable packing
Admit if bilateral packing, symptomatic anemia, or anemia requiring transfusion
Posterior Epistaxis
Recommend admit on telemetry
Posterior packing causes vagal stimulation, which can predispose to bradycardia, arrhythmia and respiratory failure.
The Fussy and Undifferentiated Sick Infant WITH Dr. Chang
History and physical exam is paramount for the evaluation of sick infants
In 1991, there was a prospective cohort study of 56, afebrile, healthy infants who presented to the ED for crying
61% had a “serious underlying pathology” which was defined as 2 out of 3 pediatricians agreeing that the diagnosis required prompt treatment or had potential for adverse events if not diagnosed
This included otitis media, GERD, herpangina, and while not necessarily life threatening, a diagnosis for the fussy infant was found
More importantly his study found that
In 20% of cases, the diagnosis was revealed by history
In 40% of cases, the diagnosis was revealed by physical examination
In 13% of cases, there were major clues to the diagnosis on physical examination
Pediatric Assessment Triangle = Appearance/Work of Breathing/Circulation
Appearance “TICLS”
Tone: Babies are typically in a flexed tone, adducted, like a baby boxer. 6 months, sit up, control head. If they seem limp, that’s something to be concerned about
Interactiveness: How is the child interacting with his or her environment? Does the 2-month-old have a social smile?
Consolability: Scared, but comforted? If not consoled by parents, it’s a medical emergency until proven otherwise
Meningitis – paradoxical consolability. Upset when being held/carried, calm when laid flat giving irritated meninges a break
Look/gaze: Are they following you? Can tell whether a child tracks or is giving you the thousand-yard stare
Speech/Cry
Vigorous cry – great
High-pitched, blood-curling, soft whimper – something is wrong
Work of Breathing
Chest Rise – are they breathing? Retractions? Nasal Flaring? Grunting as a last stitch effort to auto-PEEP?
Stridor, wheezing?
Tripoding?
Circulation
Children are vasospastic, they change their vascular tone quickly depending on volume status or environment
Pale, mottled, blue, grey
History
Parents are very reliable, but recognize that in non-verbal children, exam trumps history
What do babies do?
Eat – eat what, how much, how often, formula – how is it being mixed?
Vomiting – How much? Is this bilious emesis and a surgical emergency we should worry about? Should you be getting a POC glucose since the younger the baby, the higher the risk for hypoglycemia?
Are they drawing up their legs 2/2 to pain?
Where do the parents think the pain is coming from?
Sleeping? Jittery?
Quiet / Not-interactive?
Peeing/pooping – does everything work? Are they hydrated?
Cry
Ask the parents what do they mean by “fussy”
Ask about onset, duration, frequency of crying
Associated symptoms – are they hungry? Thirsty? Tired? Do they look in pain?
Infants hit their peak amount of time per day of crying by the second month of life - on average 3 hours per day
Differential Diagnosis for crying/fussy infant = “IT CRIES” (Infection, Trauma, Cardiac, Reflux/Rectal/Reaction, Intussusception, Eyes, Surgical/Strangulation)
Infection
UTI - Babies may be fussy and crying because they have dysuria, but unable to tell you. Like we mentioned before, urinalysis is the only test that has been found to be helpful in the care of a fussy infant.
Meningitis is much less common, but morbidity is higher
Cannot use the absence of meningismus in an infant. May or may not see fever, fussiness, irritability, or poor appearance.
Candidiasis – You must look in the diaper area
Irritant Contact Diaper Dermatitis (IDD) - result of warmth, urine, moisture, friction, feces, and possibly secondary infection all mixed together
Thrush
Perianal Streptococcus – cellulitis around the anus. Spread the buttocks - Beefy red rim of cellulitis. Streptococcus likes anywhere that is warm, moist, unexposed like the perianal area. This needs good diaper care plus cephalexin.
Herpangina – look for those while blister like ulcers in the back of the throat
Acute Otitis Media
Jacquet’s Dermatitis
Rare variant of irritant diaper dermatitis - punched out ulcerations, crater like borders
Associated with liquid stools, chronic diarrhea, incontinence, occlusive plastic diapers, poor hygiene, infrequent diaper changes – especially underserved patients in poor social situations, which is why it’s so critical to screen for social determinants of health in the ED
Treatment is similar to that of irritant diaper dermatitis
Controlling moisture
Frequent diaper changes and application of barrier ointments
Inflammation tends to respond to topical low-potency corticosteroids, and secondary infection will respond to topical antifungal/antibacterial (mupirocin) agents.
In severe cases, oral antibiotics may also be indicated.
Granuloma gluteale infantum: Another complication of irritant diaper dermatitis
Uniform reddish/purplish ovoid shaped nodules
Unusual inflammatory response to long standing irritation (prolonged use of steroids or bad candidiasis)
Typically resistant to barrier creams, antifungal agents, or topical steroids
Keep the area cleaned, dry, and moisturized. Candida should be treated with an antifungal. The nodules spontaneously regress within 1–2 months without any active treatment, often leaving an atrophic scar.
Trauma
Birth trauma
Caput Succedaneum
“Tends to happen with prolonged, difficult delivery -> constant pressure -> pitting edema in head
Baby gets a serosanguinous fluid collection right under the skin, but above the periosteum and galea, hence swelling crosses midline and suture lines
Benign, 1-2% deliveries. Anticipatory guidance – will regress in a few weeks, rarely calcifies, rarely infected.
Cephalohematoma
Subperiosteal bleed due to rupture of vessels BENEATH the periosteum
Right after delivery, usually 2/2 to forceps or vacuum delivery
Swelling does NOT cross suture lines
May cause indirect hyperbilirubinemia due to absorption of blood
Monitor – resolves in a few week, but if it is erythematous or fluctuant it can become an abscess -> Transfer for I&D
Subgaleal bleeds
Mortality rate is up to 15%
Due to vacuum-assisted delivery, develops 12-72 hours after
Blood here accumulates in between the galea and the periosteum of skull, crosses suture lines
Head has a large swollen area, easily moves to the dependent part of the head. It is a sloshy, amorphous, shifting fluid collection. This is life threatening. Baby scalp has sheared slightly from skull, nothing stops/tamponades the bleed.
Early recognition is important for survival. Rapid loss of blood with potential loss of 20-40% of neonate’s blood volume and hemorrhagic shock
Resuscitate, transfuse, transfer to NICU for possible surgical evacuation
This is the neonate that can present to you fussy, or not eating, or limp. Can present to you in hemorrhagic shock which you will be noticing with persistent tachycardia, poor perfusion/pale
Accidental
Non-accidental
You must think of NAT in the fussy, seemingly well appearing infant. Have a high index of suspicion and always be alert
More than 45 percent of deaths from child abuse occur among children younger than 12 months
Abusive head injury is the most common cause of death and long-term disability resulting from physical child abuse.
This is why every infant needs a full, thorough, skin exam, mouth, GU, palpate all bones, and range every joint.
Pay close attention for patterned marks, bruising in non-mobile infant or in unusual places, bite marks, or inconsistent history
Cardiac
SVT
Look for no beat to beat variability, get EKG. IV, monitors
Tx:
“Diving reflex” - put some ice water inside gloves or plastic bag, and place it for 15-30 seconds over the infant’s eyes. This cold environment -> profound vasoconstriction -> blood shunting to core
Knee to chest position, or even rectal stimulation with a thermometer. If these maneuvers don’t work, give adenosine.
Adenosine (0.1-0.2 mg/kg)
Be cautious with adenosine in heart transplant patients, they can have prolonged sinus pauses due to denervation from the autonomic nervous system.
1/3 to half the normal dose and be prepared to pace if needed.
Up to 25% of children with congenital heart disease can present with SVT.
CHF
Baby may have an undetected congenital heart defect that isn't known prenatally or abnormal coronary artery defects
Look for sacral edema, or low lying liver edge that may clue you in
Myocarditis
Most often viral
Tachycardia out of proportion to presentation and a generally ill appearance
Often misdiagnosed as sepsis. You may notice the child in progressive respiratory distress with more fluids given. Always reassess every patient after you give them a bolus.
Reflux/Rectal/Reaction
Reflux
Rule out true vomiting - forceful explosion, and bilious emesis
Careful with parents potentially doubling feeds
Frequent vomiting with discomfort, difficulty feeding or weight loss - could be GERD - outpatient workup is safe
However, forceful vomiting, must consider pyloric stenosis. Look at the growth chart, look at whether the baby is hungry, get that ultrasound or transfer to the nearest pediatric center.
Rectal / Anal fissure
Look for laceration, tears, or crack in anal canal
From forceful valsalva, chronic constipation
Small, benign fissures at midline 12 and 6 o clock -> counseling.
NOT benign patterns: Off midline (lateral) like at 4 or 8 o clock or multiple fissures -> you have to think about penetration - enemas, suppositories, thermometers, child abuse.
Reactions
Consider anaphylaxis, allergic reactions to food, to new medicines, something in the environment, or other reactions due to something mom is taking if baby is breastfeeding
Be mindful that hives can be subtle in patients with darker skin, and look carefully, touch the patient’s skin to feel for any raised bumps
Intussusception
Most around 18 months of age. Approximately 60% of children with intussusception are <1 year old
It is the most common cause of intestinal obstruction in this age group
2 main presentations
Pain, fussiness, crying
Lethargy - from crushed GI neurons releasing endorphins
Consider it in any infant or toddler that presents with emesis and altered mental status
The triad of bilious emesis, abdominal mass, and blood per rectum is seen in <10% of cases
On Ultrasound – you will see a “target” or “donut” sign, representing layers of intestine within intestine
Linear probe ~5-6cm
Start at RLQ and do either a picture frame pattern (transverse -> sagittal -> transverse), or the lawnmower pattern going up and down patient’s abdomen
Ileocolic intussusception will be >3cm
Eyes
Infection: periorbital cellulitis, conjunctivitis
Glaucoma
Underdiagnosed in infants, In Western countries, the incidence is 1 in 10,000 to 30,000 births
40% develops in birth
85% are diagnosed within the first year of life.
Untreated will affect optic nerve -> blindness
”Clinical Triad" of symptoms including excessive tearing, photophobia and abnormal eyelid contraction (blepharospasm) due to the increased IOP that leads to corneal edema, irritation, and pain
Admit these patients, they are surgically managed primarily
Corneal abrasion
Can happen from sharp finger nails
Fluorescein the eyes
Treat with erythromycin ointment which will sooth the eyes and prevent infection
Of note, in 2010 there was a study published in Pediatrics where they saw that 50% of patients presenting for a well child check in clinic had a corneal abrasion. Maybe old, healing, or asymptomatic
Surgical
During the first month of life, if you have a baby presenting to you with vomiting, it’s important to ask about birth history, if it’s bilious. Check for distension of the abdomen, inconsolability. Again, afebrile does not equal not sick, and they may be presenting to you early on in their disease course where they are still not looking “sick” enough.
Bowel perforation
Babies with necrotizing enterocolitis can present with fussiness, distended abdomen, and they are at risk for bowel perforation
While premature infants are at higher risk, 10% of full-term infants can get NEC
Volvulus:
Approximately 1/3 of children with malrotation present before one month of age with the life-threatening complication of volvulus
The most important job we have is early recognition in the baby who is having bilious vomiting and appears to be in pain, or a baby with failure to thrive, resuscitation, pediatric surgery consult
Abdominal X-Ray: distended stomach, paucity of little to no gas in the rest of the GI tract
Infants may initially appear well, it may take hours before there may be some blood in the stool due to ischemia/necrosis of the bowel
Pyloric stenosis:
Usually between 2-5 weeks of life
Recognized early these days given the ultrasound capabilities, so not enough time for pylorus to hypertrophy and for you to feel that olive mass in the abdomen
These babies will be fussy and hungry
Inguinal hernia - firm bulging mass, can auscultate for peristalsis or see it on ultrasound
Can present at any age with 50% of premature infants and 10% of full-term infants at risk.
May have intermittent bulging, or be incarcerated or strangulated
While in adults hernias are not generally an emergency, in infants, hernias can incarcerate more easily, so all babies need a surgical consult to determine if they need admission for urgent management
Torsion: If you feel a mass in the scrotum, think of testicular torsion
Hair tourniquet – they require a thorough exam, if you don't look for it, you will miss it.
You may see sausage digits with swollen toes or fingers. They can be wrapped around the foreskin, labial, or ear lobe
Tx: Depilatory beauty cream (if you can see the hair) or numb up, then use an 11 blade. Swelling will remain for a couple hours.
Colic: must follow rule of 3’s
3 weeks – 3 months
≥ 3 hours per day
≥ 3 days per week
≥ 3 weeks straight
Mnemonic for “sick’ infants = THE MISFITS
Trauma
Heart Disease / Hypovolemia
Endocrine Emergencies
Metabolic
Inborn Errors of Metabolism
Seizures
Formula Problems
Intestinal Disasters
Toxins
Sepsis
Heart Disease
For any baby in respiratory distress, particularly in the < 3 months of age, you must consider a cardiac etiology as part of your differential
If you give a bolus, always reassess right after and see if the child is responding. If they aren’t responding, be careful in giving more fluids and overloading them especially if CHD is in the differential.
Remember you’ll typically start with a 10cc/kg bolus in a neonate, and a 20cc/kg bolus in an older infant specifically because of this reason – because you can always give more fluids, but it’s harder to take it back.
Endocrine Emergencies
Congenital adrenal hyperplasia
Typically presents in 3-5 weeks of age (again, that first month) with very nonspecific symptoms of altered mental status and shock
Ambiguous genitalia
Mineralocorticoid deficiency -> hyponatremia and hyperkalemia
Glucocorticoid deficiency -> hypoglycemia and metabolic acidosis
Tx: Supportive: Fluids, steroids
Congenital hypothyroidism
Poor tone, poor feeding, poor suck
Neonatal Thyrotoxicosis
Typicially due to transplacental passage of thyroid-stimulating immunoglobulin (TSI) from a mother with Graves disease.
You may see high output failure
Listen to the lungs, feel for the liver
Metabolic
DiGeorge syndrome with hypocalcemia and seizures
Hypocalcemia can be seen in infants of diabetic mothers, premature infants, hypoxic ischemic encephalopathy
Puking young babies -> hypoglycemia easily. Do not use D50 – it will blow up their veins due to the hypertonicity.
D10 bolus -> hang dextrose containing maintenance fluids
D10 = 5 ml/kg
D25 = 2 ml/kg (can use above 2 years of age)
Inborn Errors of Metabolism
Consider ordering ammonia, glucose, ketones, lactate, if all normal, likely not an inborn error of metabolism
If your patient is hypoglycemic correct with D10 bolus. Follow it with D10 maintenance fluids.
For severe metabolic acidosis, pH <7 -> sodium bicarbonate is reasonable until transfer -> hemodialysis
For severe hyperammonemia, consider giving sodium benzoate or sodium phenylacetate which are nitrogen scavengers -> transfer may need dialysis
Seizures
Neonatal seizures can be notoriously subtle – the differential is broad from infection, primary seizure disorder, trauma, electrolyte abnormalities depending on rest of history
Look for little repetitive movements of the arms, called “boxing” or of the legs, called “bicycling”
Formula Problems
There are 3 forms of formula
Ready to Feed Formula
Concentrated Liquid Formula
Mixed with 1:1 with water
Powdered Formula
1 scoop to 2 fluid ounces of water (60mL)
Powdered formula is the cheapest and most affordable for families
Hard times sometimes prompt parents to dilute formula dangerous hyponatremia, altered mental status, and seizures.
Conversely, concentrated formula can cause hypovolemia if you’re not getting enough fluid intake
Regular formula is 85% water.
No baby in the first month should have any ”extra” water because too much can lead to seizures.
Toxins
Sulfonylureas
Opioids
Sodium channel blockers
Calcium channel blockers
Clonidine
Camphor
Oil of Wintergreen
Sepsis
