The most common aetiology of heart failure in previously well children is myocarditis. A review of 62 cases whose final diagnosis was viral myocarditis showed that common features included:
multiple visits / evaluations before the diagnosis was made
initial misdiagnosis as respiratory disease (eg. pneumonia, asthma)
presenting symptoms of shortness of breath, vomiting, poor feeding, lethargy, fever
signs included hepatomegaly (50%), tachypnoea, respiratory distress
although a normal heart rate for age was found in 41(66%) patients, ALL patients had an abnormal ECG
Most had abnormal chest x-rays
The take home messages regarding this rare disease are that initial misdiagnosis is common, do not expect a resting tachycardia, look for hepatomegaly, CXR signs, and particularly ECG abnormalities. Pediatric myocarditis: presenting clinical characteristics Am J Emerg Med. 2009 Oct;27(8):942-7
An ECG pattern is described in chest pain patients which signifies proximal LAD artery occlusion found at angiography: precordial ST-segment depression at the J-point followed by peaked, positive T-waves. Lead aVR displays also displayed slight ST-segment elevation in the majority of cases.
A letter in response points out that this finding was first reported in 1947. Persistent precordial “hyperacute” T-waves signify proximal left anterior descending artery occlusion Heart 2009;95;1701-1706
A derivation then validation study on adults with blunt torso trauma found the absence of the following factors to be associated with a very low risk of significant (intervention-requiring) abdominal pathology and such patients were unlikely to benefit from abdominal CT scanning:
GCS score less than 14
costal margin tenderness
abdominal tenderness
femur fracture
hematuria level greater than or equal to 25 red blood cells/high powered field
hematocrit level less than 30%
abnormal chest radiograph result (pneumothorax or rib fracture)
Clinical Prediction Rules for Identifying Adults at Very Low Risk for Intra-abdominal Injuries After Blunt Trauma Ann Emerg Med. 2009 Oct;54(4):575-8
In a manikin study of CPR, there was a decrease in mean depth of chest compressions when the height of the bed was over 20cm above the knee height of the nurse doing the compressions.
The study has several limitations, but serves as a helpful reminder that adjusting the height of the bed to suit the rescuer is an option not to be forgotten. At least for those areas where manual CPR is still performed. Effects of bed height on the performance of chest compressions Emerg Med J. 2009 Nov;26(11):807-10
After intubation it is critical to securely fasten the tracheal tube so it does not dislodge during transfer. Dedicated devices are available for this although mostly cloth tape is used.
Different knots have been compared although not found be significantly different in terms of security1. One favoured knot, which is easy to learn and to teach, is the lark’s head (also called cow’s hitch)2.
The tape is folded in half so there is a loop at one end and two free ends at the other. The loop is wrapped around the tube and the two free ends are fed through the loop, and then taped around the patient’s head. It has been suggested that this results in the tape gripping the tube over the widest possible area, thereby reducing the potential for slippage and displacement.
Easy! larks head knot
1.The insecure airway: a comparison of knots and commercial devices for securing endotracheal tubes BMC Emerg Med. 2006 May 24;6:7 Open Access
2. A knotty problem resolved Anaesthesia. 2007 Jun;62(6):637
Airway
Basic airway management in adults
Basic airway management in children
Tracheal intubation in adults
Tracheal intubation in children
Rapid sequence induction in adults
Rapid sequence induction in children
Surgical airway
Securing tracheal tubes in adults
Securing tracheal tubes in children
Breathing
Non-invasive ventilation in adults
Using a portable ventilator
Basics of mechanical ventilation
Breathing systems in the emergency department
Asthma case
Pneumothorax case
Pneumonia case
ARDS case
Circulation
Post cardiac arrest case
Basic echo
The hypotensive patient
Vasoactive drugs in the ED
Disability
Seizures in adults
Seizures in kids
VP shunt case
Neuroprotection in the ED
Sepsis
Sepsis: definitions and basics
Interhospital transport
A derivation then validation study was done on over 40000 children with head injuries to identify factors associated with clinically important brain injury. Prediction rules based on history and examination findings were developed for children younger than two years and for children two years and older. Both rules had high negative predictive values and may be useful tools in supporting the decision not perform a head CT. Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study Lancet. 2009 Oct 3;374(9696):1160-70
In most cases either the modified Brook formula or the Parkland formula was used for burned military casualties in Iraq and Afghanistan over the three years covered in this study.
The modified Brooke formula is 2mls x body surface areas burned (BSAB) x weight.
The Parkland formula is 4mls x body surface areas burned (BSAB) x weight.
Both formulas estimate the first 24 hour fluid requirements from the time of the burn, with half the amount given in the first 8 hours.
In this study which compared outcomes between the Brooks and Parkland groups, there were no differences in clinical outcomes. In both groups many patients were overresuscitated in terms of urine output goals. The authors’ main conclusion is that burns resuscitation can be successfully accomplished with lower initial fluid volumes. Take home message: individualise fluid resuscitation to patient’s clinical response, and avoid the ‘fluid creep’ of unphysiologic resuscitation management. Resuscitation of severely burned military casualties: fluid begets more fluid J Trauma. 2009 Aug;67(2):231-7
The International Society for Paediatric and Adolescent Diabetes (ISPAD) has published new comprehensive guidelines, including those for diabetic ketoacidosis.
Their summary:
• DKA is caused by either relative or absolute insulin deficiency.
• Children and adolescents with DKA should be managed in centers experienced in its treatment and where vital signs, neurological status and laboratory results can be monitored frequently
• Begin with fluid replacement before starting insulin therapy.
• Volume expansion (resuscitation) is required only if needed to restore peripheral circulation.
• Subsequent fluid administration (including oral fluids) should rehydrate evenly over 48 hours at a rate rarely in excess of 1.5 – 2 times the usual daily maintenance requirement.
• Begin with 0.1 U/kg/h. 1 – 2 hours AFTER starting fluid replacement therapy
• If the blood glucose concentration decreases too quickly or too low before DKA has resolved,
increase the amount of glucose administered. Do NOT decrease the insulin infusion
• Even with normal or high levels of serum potassium at presentation, there is always a total body deficit of potassium.
• Begin with 40 mmol potassium/L in the infusate or 20 mmol potassium/L in the patient receiving fluid at a rate >10 mL/kg/h.
• There is no evidence that bicarbonate is either necessary or safe in DKA.
• Have mannitol or hypertonic saline at the bedside and the dose to be given calculated beforehand.
• In case of profound neurological symptoms, mannitol should be given immediately.
• All cases of recurrent DKA are preventable.
Full guidelines available here
Other ISPAD guidelines available here
