Welcome to Wednesday Wrap Up! Here is a summary of what we learned in conference today:
Dr. Wiener on Pediatric Toxicology Pearls:
- For a few toxins, one pill is potentially deadly in a child
- Patients with ingestions of TCAs, camphor, and clonidine can often be discharged if asymptomatic (including normal ECG) in the ED.
- Observe / Admit for: Atropine, MAO-I, opioid, calcium channel blocker, beta blocker, and sulfonurea exposure; these may have delayed onset of symptoms
- Even for unintentional exposure of nontoxic substance, look for signs of abuse or neglect- especially if the child ≤ 6 months old
- Mothballs can be distinguished by floatation in water
- Camphor always floats
- Paradichlorobenzene always sinks (and smells like a urinal cake)
- Naphthalene sinks in fresh water and floats in salt water
- Iron ingestions concerning if >15mg/kg ingested or serum level > 500mcg/dL (use deferoxamine)
- Check a 48-hour coagulation panel after rat poison ingestion (super-warfarin)
- Hydrocarbons cause aspiration pneumonitis (can be delayed 4-6 hours) and halogenated hydrocarbons can cause dysrhythmia
Dr. Moran on Abdominal Ultrasound
- Use ultrasound as an extension of your physical exam (POCUS)
- Sonographic small bowel obstruction – use curvilinear probe, lawnmower technique across abdomen
- >2.5cm bowel loop
- Decreased / absent peristalsis
- Back/forth stool movement
- Keyboard sign: finger-like projections that represent plicae circulares
- Tanga sign (it’s a type of underwear?!)
- Sonographic Appendicitis – use linear probe, or curvilinear in obese patients
- Landmarks: Iliac crest (lateral), iliac artery (medial), psoas muscle (posterior)
- Appendix > 6mm diameter (outer wall to outer wall)
- Non-compressible tubular structure
- “Ring of Fire”
- No peristalsis
- Edema and/or free fluid
- Operator-dependent and high specificity but lower sensitivity (can rule in if positive but cannot rule out if negative)
Dr. Peralta on Task-Switching in the ED:
- ED docs are distracted and interrupted A LOT
- We are “task switchers” more than multi-taskers
- Task switching takes more time, produces lower quality work, and increases workload (redundancy returning to initial task)
- Short-term memory = Working memory is limited, unable to manage frequent, simultaneous, competing stimuli or information resulting in poorer performance
- Develop effective task switching by recognizing risks, finding a role-model, debriefing, simulation, and graduated responsibility (i.e. junior role to senior role to pre-attending to attending)
Dr. Schnitzer on Critical Care - Thyroid Storm:
- Always keep thyroid on your differential for tachycardic patients, especially in A-Fib
- Treatment = Blockade
- Beta blockade of symptoms
- PTU or methimazole to block action thyroid hormone
- Steroids to block conversion of hormone
- Iodine (after an hour of other treatments) to block further thyroid production
- “Hail Mary” treatments: plasmaphoresis, ECMO, or even surgery
- Consider esmolol in the sick tachycardic patient for its rapid on/off effects
- Consider cardioversion in the unstable a-fib patient for the extra atrial filling that may be needed
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Kylie Birnbaum
Emergency Medicine Resident at Kings County Hospital / SUNY Downstate
@KBirnbaumMD
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