How to clear Pediatric C-Spines (Dr. Okugo):
- Generally can start with lateral neck +/- AP films and odontoid views in older kids
- NEXUS criteria is useful especially > 8 years old
- In a patient with torticollis after trauma, think about atlanto-axial rotary displacement
- Kids <8 years old, think more higher C spine injuries: Occipital to C3
- Kids >8 years old, think more lower C spine fractures (C5-C6)
- Odontoid fractures are the most common C-spine fractures in pediatric patients
- Trisomy 21 children- predisposed to Atlanto-axial instability
- On lateral view, widened prevertebral space can be a clue that there is an be injury (swelling, edema, ligamentous injury)
- Normal space for C2: 6mm
- Normal space for C6: 14mm (22mm in adults)
- Hangman’s fracture:
- hyperextension injury
- Fractures of bilateral pedicles of C2
- Unstable C-Spine fractures:
- Jefferson- burst fracture of C1
- Bilateral Facet Dislocation
- Odointoid Type II (base of dens), Type III (involves vertebral body of C2)
- Atlanto-axial/Atlanto-Occipital Dislocation/Any Fracture Dislocation
- Hangman
- Teardrop (Central Cord)- avulsion fracture of anteroinferior vertebral fragment
Total Body Dolor (Dr. Mukherji):
- Click here to hear entire talk
- Order a CK in all your patients with total body dolor
- Causes of Rhabdomyolysis:
- SSTIs
- Toxins
- Meds
- Trauma (crush injury)
- Endocrine
- Electrolyte
- Factors that predict Acute Renal Failure from elevated CK:
- Age
- Dehydration
- Acidosis
- To prevent kidney injury:
- Fluids
- Consider bicarbonate drip (sodium load, fluid, and makes urine alkaline)
- Alternatively, can give 3 amps bicarb in D5Water
- Most Common Drug in Rhabdomyolysis: Alcohol (or really any cause of AMS and being on the ground)
- Legionella is most common bacteria that causes rhabdomyolysis
- Rhabdomyolysis in kids: ID/soft tissue infections
- Case 1: 52 y/o M “hurts all over” after a night of partying
- BP: 148/92, HR: 118, RR: 28, SpO2: 93%, Temp: 102.2F, Pain: 13/10
- Answer: EtOH, Molly, or cocaine- passed out and developed rhabdo & aspiration PNA
- Case 2: 40 y/o M AMS- As per EMS, “I think he took something” and has brown goop all over teeth
- BP: 108/68, HR: 58, RR: 12, SpO2: 90%, Temp: 100.3F, Pain: ?/10
- Answer: K2 can lead to goop on teeth (because pass out with K2 on teeth) and developed rhabdomyolysis
- Rare but can lead to DIC (especially bad in setting of rhabdomyolysis)
- Case 3: 5 y/o F with parents saying “Meningitis! Pain all over and now she can’t walk”
- BP 94/60, HR 92, RR 22, SpO2: 100%, Temp-99.8F, Pain: 11/10
- Answer: Viral myositis (MC: influenza)
Necrotizing Fasciitis and Other Skin Infections (Dr. Perera):
- Click here to watch entire talk
- Get a fingerstick for all your cellulitis patients
- Don’t need Bactrim with Keflex for all cellulitis, especially if you are not suspecting MRSA or seeing pus
- No data to support this but:
- Consider a dose of longer acting IV antibiotic (ex: inadequate access to pharmacies) but outcomes are the same
- Probenecid prevents excretion of beta lactam rings- consider Probenecid 500mg with first 2 doses keeps tissue levels higher
- NSAIDs decrease inflammation and may make cellulitis look better within a day
- 1997 study: Adding Steroids decreased time of healing by 1 day in cellulitis
- Cat Bite– cover for Pasteurella with Augmentin
- Dog Bite– don’t always need antibiotics but most people give Augmentin (or Doxycyline)
- Macaque monkey bite- cover for B virus infection with Valacyclovir/Acyclovir
- Shark bites- cover for Vibrio with Bactrim/Doxycycline
- Necrotizing fasciitis– ONLY way to treat with OR
- “Your job as an ER doc is to convince others that this is in fact necrotizing fasciitis”
- Don’t wait for bullae or expanding redness to make the diagnosis
- If all else fails- Bedside Finger Test:
- Anesthetize with lidocaine locally
- Make incision a little above redness
- Go about 2cm down to deep fascia
- Use finger to probe at the level of the deep fascia
- Positive Test for Nec Fasc:
- Lack of Bleeding
- Malodorous “dishwater pus”
- Lack of resistance to blunt finger dissection
- Here’s a YouTube clip demonstrating the bedside finger test in a patient with negative X-ray and CT findings