Pediatric EM Morsels Pediatric Emergency Medicine Education Fri, 12 Sep 2014 20:10:44 +0000 en-US hourly 1 Intussusception & Altered Mental Status Fri, 12 Sep 2014 20:10:38 +0000 Evaluating the child with altered mental status can be very challenging.  As with adults, there are a myriad of potential etiologies and it can be difficult to prioritize the order...

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Intussusception Altered Mental Status

Evaluating the child with altered mental status can be very challenging.  As with adults, there are a myriad of potential etiologies and it can be difficult to prioritize the order of the evaluation.  Does this patient have an intracranial process or maybe just simple hypogylcemia?  Or maybe we need to consider serious bacterial infections and intoxicants instead?

Many of you will recall the mnemonic “TIPS AEIOU” [Trauma, Infection, Psych, Space Occupying Lesion, Alcohol, Electrolytes, Insulin, Opiates, Uremia] to help consider a number of the potential etiologies of altered mental status.  I use this often, but it is important to remember that along with “infection” and “insulin” the “I’s” also stand for “Intussusception.”


Intussusception Basics

  • Occurs when one segment of bowel telescopes into the adjacent segment.
  • Second most common abdominal emergency (appendicitis is #1).
  • Most often this occurs near the ileocecal valve.
  • Most are idiopathic.
  • ~5% are associated with lead points or disease


Intussusception Presentation

  • “Classic” presentation (Abdominal Pain, Currant Jelly Stools, and vomiting) is only seen in 20%- 33% of cases.
  • 75% without obviously bloody stools will have positive occult blood.  
    • Great reason to check heme occult for the vomiting child without diarrhea.
  • Abdominal Mass is commonly found (when looked for).
  • Fever, anorexia, diarrhea, and dehydration can be seen and can lead to misdiagnosis.
  • Many cases are missed upon initial evaluation — we must always remain vigilant!


Intussusception and Altered Mental Status

  • Along with the classic and common presentations, patients with intussusception may also present with altered mental status.
  • This altered mental status is often thought of as the child being inconsolable.
    • Most practitioners will have intussusception high on the DDx in the child with inconsolability and vomiting.
  • Additionally, significant somnolence and lethargy can be seen with intussusception!
    • Numerous cases have been reported that highlight this fact.
    • Cause of the lethargy is unclear.
    • Presence of lethargy does not, necessarily, portend a worse outcome (but does contribute to delayed diagnosis, which can lead to more morbidity/mortality).
  • Cases of intussusception and altered mental status often also have history of:
    • Vomiting,
    • Heme-positive stool,
    • Abdominal Pain,
    • or Abdominal Mass


POCUS and Altered Mental Status

  • So how can Point of Care Ultrasound (POCUS) help with the evaluation of altered mental status in a child?
  • POCUS can be used to AUGMENT the physical exam.
    • Studies have shown the POCUS can be used by emergency practitioners (in a variety of locales) to rule-in the diagnosis of intussusception.
    • The evaluation should not (yet) be used to rule-out the diagnosis; however, it’s utility can help prioritize the next most appropriate step.
      • For instance, consider the 18 month old presenting with lethargy and episodes of non-bilious emesis.  You perform POCUS:
        • If consistent with intussusception, then call your surgeon and your radiologist.
        • If not consistent with intussusception, it may still be present, but you may want to get that Head CT and give antibiotics before getting abdominal imaging.


Moral of the Morsel

Altered Mental Status?  Augment your exam with POCUS.  It may be intussusception.



Halm BM. Reducing the time in making the diagnosis and improving workflow with point-of-care ultrasound. Pediatr Emerg Care. 2013 Feb;29(2):218-21. PMID: 23546429. [PubMed] [Read by QxMD]

Gingrich AS1, Saul T, Lewiss RE. Point-of-care ultrasound in a resource-limited setting: diagnosing intussusception. J Emerg Med. 2013 Sep;45(3):e67-70. PMID: 23777777. [PubMed] [Read by QxMD]

Stolz LA1, Kizza H, Little K, Kasekende J. Intussusception detected with ultrasound in a resource-limited setting. Lancet. 2013 Jun 8;381(9882):2054. PMID: 23746905. [PubMed] [Read by QxMD]
Raymond-Dufresne É1, Ghanayem H. Towards evidence-based emergency medicine: best BETs from the Manchester Royal Infirmary. BET 2: Can emergency physicians safely rule in or rule out paediatric intussusception in the emergency department using bedside ultrasound? Emerg Med J. 2012 Oct;29(10):854-5. PMID: 23038721. [PubMed] [Read by QxMD]

Birkhahn R1, Fiorini M, Gaeta TJ. Painless intussusception and altered mental status. Am J Emerg Med. 1999 Jul;17(4):345-7. PMID: 10452429. [PubMed] [Read by QxMD]

Hickey RW1, Sodhi SK, Johnson WR. Two children with lethargy and intussusception. Ann Emerg Med. 1990 Apr;19(4):390-2. PMID: 2321825. [PubMed] [Read by QxMD]

Heldrich FJ. Lethargy as a presenting symptom in patients with intussusception. Clin Pediatr (Phila). 1986 Jul;25(7):363-5. PMID: 3709021. [PubMed] [Read by QxMD]

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Intranasal Analgesia Fri, 05 Sep 2014 12:00:00 +0000 Being flexible and creative are important traits to have while working the ED.  It is also vital to always keep the end result in mind.  Pain control is always an important...

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Being flexible and creative are important traits to have while working the ED.  It is also vital to always keep the end result in mind.  Pain control is always an important endpoint for us to constantly consider.  While most of us would say that we strive alleviate our patients’ pain, there is evidence that we are not great at it.


It’s Complicated

  • Why would we not alleviate pain optimally?  Well, like many things, it is more complicated than us just cruel and sadistic.
  • Certainly, there used to be a perception that pain in kids (especially neonates) was not as important since they wouldn’t remember it. – WRONG.
  • Additionally, there are times when our consultants have “requested” that we didn’t give pain medications (ex, Morphine for Appendicitis). – A MYTH.
  • Of course, we need to always remain optimally educated on the subject (THANKS FOR READING THE PEDEM MORSELS!).
  • But even with a highly educated and compassionate provider, delivering appropriate analgesics in a timely fashion is not easy:
    • You have to evaluate the patient, then write the orders.
    • Often these orders include Intravenous Analgesics (ex, IV Morphine).
    • This, in turn, requires an IV.
      • Now, in a busy ED, a nurse may not be able to promptly jump in that room an place the IV.
      • Placing an IV is also not always an easy task.
    • All of these steps and possible obstructions can easily lead to delayed analgesic administration.
    • Now, despite how compassionate you are… you appear to be cruel!


Intranasal Route – No Need for an IV

  • We all know that the blood supply to the nose is quite robust.
    • Anyone who has bonked their nose knows.
    • Our patients who snort heroine or cocaine also know.
  • The venous drainage from the nose conveniently ends up in the SVC, avoiding the liver (and 1st pass metabolism).
  • The anterior potion of the nose (the Vestibule) is the main site for drug absorption as it has a relatively large surface area and has a good blood supply.
  • Volumes of 0.3 mL are easily tolerated.
    • This requires concentrated solutions of the administered medications.
    • If you need to use larger volumes, you can divide the dose in half and use each nostril.
    • If the volume is still too large, you can administer in separate aliquots separated by 10-15 minutes… or use another strategy (nothing is perfect).


Intranasal Fentanyl to the Rescue

  • Fentanyl is a great example of a medication that works well when given via the intranasal route.
    • It has a low molecular weight.
    • It is lipophilic.
    • It has concentrated versions (50 microgr/mL – 150 microgr/mL).
  • Fentanyl (1-2 micrograms/kg) given via intranasal route has proven to be as efficacious as IV Morphine (0.1 mg/kg).
  • It has also been shown that intranasal fentanyl can be administered more rapidly than IV morphine to pediatric patients in the ED.


A Reasonable Approach (at least I think so)

  • Intranasal Fentanyl can be delivered before even an IV can be placed.
  • Even if you still need an IV (say for the grossly deformed forearm that you know will need procedural sedation), the intranasal fentanyl is still a faster way to get analgesics on board.
    • Yes, it might require some explanation that you are going to squirt pain meds up the kid’s nose and then still place an IV… but the focus is on delivering pain meds quickly.
    • This will likely also help the nursing team trying to get the IV, as now they have a more comfortable and cooperative patient.
    • It also helps speed up the process for getting your X-rays… now you are not waiting for the IV to give the pain meds so that you don’t feel like a sadist getting the xrays.
  • In the end, this also helps you… not feeling like a sadist is very helpful in avoiding compassion fatigue... and will help keep you happier as a physician!






Del Pizzo J1, Callahan JM. Intranasal medications in pediatric emergency medicine. Pediatr Emerg Care. 2014 Jul;30(7):496-501; quiz 502-4. PMID: 24987995. [PubMed] [Read by QxMD]

Dong L1, Donaldson A, Metzger R, Keenan H. Analgesic administration in the emergency department for children requiring hospitalization for long-bone fracture. Pediatr Emerg Care. 2012 Feb;28(2):109-14. PMID: 22270501. [PubMed] [Read by QxMD]

Holdgate A1, Cao A, Lo KM. The implementation of intranasal fentanyl for children in a mixed adult and pediatric emergency department reduces time to analgesic administration. Acad Emerg Med. 2010 Feb;17(2):214-7. PMID: 20070272. [PubMed] [Read by QxMD]

Borland M1, Jacobs I, King B, O’Brien D. A randomized controlled trial comparing intranasal fentanyl to intravenous morphine for managing acute pain in children in the emergency department. Ann Emerg Med. 2007 Mar;49(3):335-40. PMID: 17067720. [PubMed] [Read by QxMD]

Bauman BH1, McManus JG Jr. Pediatric pain management in the emergency department. Emerg Med Clin North Am. 2005 May;23(2):393-414, ix. PMID: 15829389. [PubMed] [Read by QxMD]

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Palpation of Pulse for Cardiac Arrest Fri, 29 Aug 2014 11:00:00 +0000 One of my personal goals is to make my life easier.  Yes, that is easier said than done; particularly given my proclivity for working in the Emergency Department.  The ED is...

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Pulse Check

One of my personal goals is to make my life easier.  Yes, that is easier said than done; particularly given my proclivity for working in the Emergency Department.  The ED is not an easy place to work many times, particularly when faced with truly life-altering events like a pediatric cardiac arrest.  While managing pediatric cardiac arrests is never easy (no matter how clinically skilled you are), the first task of determining whether the child actually does or does not have a pulse would seem to be the easiest.  Sadly, it is not.


Phases of Pediatric Cardiac Arrest

  • Pre-Arrest
    • This is where Injury Prevention has the greatest potential to save lives.
      • The Back to Sleep program, Submersion awareness, and trauma prevention are example.
    • Also where being vigilant for “covert sickness can came in handy (hopefully the Morsels help you with this part).
  • No-Flow
    • This is the Arrest part (obviously).
    • We really need to limit the time spent in this phase!
    • Factors that are known to be associated with survival with good neurologic outcomes are:
      • Having the arrest be witnessed.
        • Obviously, this impacts the time for an AED to arrive, initiation of bystander CPR, etc.
      • Having the duration of CPR be short.
      • Having an initial rhythm that is shockable (much more rare occurrence in children).
      • Younger age.
  • Low-Flow
    • This begins when CPR begins.
    • The goal is to obtain Return of Spontaneous Circulation (ROSC) as well as maintain cerebral perfusion!
    • We know that the basics of CPR (quality Chest Compressions while allowing recoil of the chest wall and minimizing interruptions) are the most important aspects of the resuscitation.
  • Post-Arrest
    • After ROSC is obtained, the body experiences multiple stressors and potential injuries.
    • Post-Cardiac Arrest Syndrome
      • Brain Injury
      • Myocardial Dysfunction
      • Systemic ischemia/reperfusion response (similar to SEPSIS)


Palpation of Pulse is Not Easy

  • If getting out of the No-Flow phase is imperative, then it means that detecting the No-Flow phase is important so that chest compressions can be started promptly.
  • Problem: We aren’t good at feeling pulses!
    • When medical providers were challenged to determine whether a pulse was present in patients (don’t worry, the patients were on ECMO):
      • Only 78% of doctors and nurses correctly determined presence or absence of a pulse.
      • 14% of the time the falsely identified the presence of a pulse!
    • Therefore, 14% of the time when compressions should have been initiated, they would have been delayed.
  • Problem: We need more time… that the kid doesn’t have!
    • We are supposed to detect a pulse within 10 seconds
    • The mean time for rescuers to determine a lack of a pulse was 30 seconds.
    • Interestingly, experienced doctors and nurses are quicker at deciding when a pulse is present, BUT they are not quick at deciding when a pulse is absent!!
    • Essentially, experience helps you to rule-out cardiac arrest, but not rule it in!
  • Palpation of pulse by healthcare providers to diagnose cardiac arrest in infants and children is both time-wasteful and unreliable!” (Tibballs, 2010).


When Should You Start Chest Compressions?

  • It is advocated that the lay-public minimize the importance of palpation of pulse.
  • Lay-person rescuers have been advised to give chest compressions to a collapsed infant/child on the basis of observation of lack of movement, unresponsiveness and inadequate breathing.
  • While skilled professionals (like us) should determine whether there is a pulse, we should also recognize that every second counts and if you are uncertain after 9 seconds, err on the side of being conservative with overcalling a lack of pulse.
    • Essentially, I would rather be wrong by starting chest compressions when the child has a weak pulse that I have not appreciated rather than not starting compressions when they are needed.
    • So make your job easier… stop trying to be perfect and err on the side of being safe… if you aren’t sure there is a pulse after 9 seconds… on the 10th second initiate compressions!!





Sandroni C1, Nolan J; European Resuscitation Council. ERC 2010 guidelines for adult and pediatric resuscitation: summary of major changes. Minerva Anestesiol. 2011 Feb;77(2):220-6. PMID: 21368728. [PubMed] [Read by QxMD]

Tibballs J1, Weeranatna C. The influence of time on the accuracy of healthcare personnel to diagnose paediatric cardiac arrest by pulse palpation. Resuscitation. 2010 Jun;81(6):671-5. PMID: 20227813. [PubMed] [Read by QxMD]

Tibballs J1, Russell P. Reliability of pulse palpation by healthcare personnel to diagnose paediatric cardiac arrest. Resuscitation. 2009 Jan;80(1):61-4. PMID: 18992985. [PubMed] [Read by QxMD]

Sarti A1, Savron F, Ronfani L, Pelizzo G, Barbi E. Comparison of three sites to check the pulse and count heart rate in hypotensive infants. Paediatr Anaesth. 2006 Apr;16(4):394-8. PMID: 16618292. [PubMed] [Read by QxMD]

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Eating Disorders Fri, 22 Aug 2014 11:00:52 +0000   Most of us entered into the practice of medicine to “make a difference.”  {Having read a lot of applicants’ personal statements, I know this to be true.}  The realm...

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Eating Disorder2

Most of us entered into the practice of medicine to “make a difference.”  {Having read a lot of applicants’ personal statements, I know this to be true.}  The realm of Pediatric Emergency Medicine often places us in the most ideal arena to fulfill that calling, but we often are looking at the more dramatic presentations.  Let us not forget that our astute diagnostic skills can be extremely useful even when the presentations are less dramatic.  Patients with Eating Disorders can often present with subtle cues (see Bradycardia) and if you are vigilant, you can make a profound difference — just like you always wanted to do.


Eating Disorders in the ED

  • Prevalence of clinically significant eating disorders in adolescents and adults in the ED is estimated at 16%.
  • Patients with eating disorders have been found to have increased utilization of all healthcare services including the EDs.
  • Although rare in general adult population, eating disorders are one of the most prevalent chronic disorders in teens and young adults.
  • Anorexia Nervous is the third most common chronic condition in adolescent girls – behind obesity and asthma.


Anorexia Nervosa

  • Basics

    • Peak: women – 15-19 years; men – 10-24 years
    • Highest mortality rate of ANY Psychiatric Disorder!
      • Suicide accounts for ~20%
      • Medical causes account for the majority of mortality associated with anorexia nervosa.


  • Associated Conditions

    • High-Level Exercise and Athletic Competition
    • Depression or Anxiety Disorder
    • Substance Abuse
    • Early childhood eating and gastrointestinal problems
    • Perfectionism and self-esteem issues
    • History of sexual abuse
    • “High-concern parenting”


  • Signs and Symptoms

    • Hypotension (SBP <90 mmHg, DBP <50 mmHg)
    • Bradycardia (HR <60 bpm)
    • Brittle nails
    • Thinning hair
    • Fine lanugo hair on side of face and arms
    • Anemia, leukopenia, hypoglycemia, hypophosphatemia – usually only seen with severe disease.


  • Medical Complications

    • Cardiovascular
      • Decreased cardiac muscle from malnutrition leading to decreased heart function.
        • IV fluids need to be given carefully, as pulmonary edema can develop.
      • Bradycardia thought to be due to increased vagal tone.
      • Serious dysrhythmias can lead to sudden death.  Respect Syncope in this patient!
      • Mitral Valve Prolapse develops from diminished cardiac muscle mass with the valve remaining unchanged.
    • Fluid/Electrolytes
      • Serious disorders can occur with Refeeding Syndrome
        • Hypophosphatemia leading to low ATP levels.
        • This impairs muscle contractions in the heart and diaphragm –> arrest.
        • Low magnesium and low potassium also can be altered with refeeding syndrome and cause arrhythmias.
      • Even a bag of D5 Normal Saline (200 kcal) can be deleterious in the patient who only consumes 400 kcal a day.
    • Gastrointestinal
      • Delayed gastric and colonic emptying
      • High risk for gastroparesis, gastric distention, GER, constipation, and SMA syndrome.
    • Skeletal
      • Osteoporosis develops from altered hypothalamic-pituitary axis.
      • Back Pain in this patient should not be dismissed as muscle strain.


Bulimia Nervosa

  • Basics

    • Self-induced vomiting and abuse of diuretics and laxatives are the most common purging mechanisms.
    • Peak: women – 16-20 years
    • Bulimia is more common than anorexia.


  • Associated Conditions

    • Psychiatric Disorders
    • Substance Abuse
    • Childhood obesity
    • Sexual abuse
    • Poor self-esteem
    • Parental substance abuse and obesity
    • Parental expectations
    • Previous dieting


  • Signs and Symptoms

    • Likely have normal body weight.
    • Painless bilateral hypertrophied salivary glands.
    • Poor dentition
    • Russell sign – erosions over the dorsum of the hands from self-induced emesis.
    • Metabolic alkalosis c/w vomiting (with low potassium)


  • Medical Complications

    • Cardiac
      • Binge-Purge subtype is at great risk for hypokalemia and subsequent arrhythmias.
    • Fluid/Electrolytes
      • Metabolic alkalosis, hypochloremia, hypokalemia.
      • Chronic contraction alkalosis and dehydration.
    • Gastrointestinal
      • Odynophagia, hoarseness, dysphagia, heartburn, GER
      • Chronic laxative abuse leading to cathartic colon syndrome (damaged intestinal nerve cells).


SCOFF, but don’t DisMiss it!

  • To help you further refine your concern when your sixth-sense is alarming, you can use the screening tool SCOFF.
    1. Do you ever make yourself SICK, because you feel uncomfortably full?
    2. Do you worry you have lost CONTROL over how much you eat?
    3. Have you recently lost more than One Stone (14 pounds) in a 3 month period?
    4. Do you believe yourself to be FAT when others say you are too thin?
    5. Do thoughts and FEARS about food and weight dominate your life?
  • 2 or more “Yes” answers is suggestive of an eating disorder.



  • If the patient is medical stable, then disposition should still include social work and psychiatric consultation to provide resources.
  • Particular attention should be paid to the potential for suicidal risk (suicide is frequent with patients who have eating disorders).
  • Helping to establish to referral to a eating disorder specialist would be ideal so that all of the medical and comorbid states can be addressed.
  • Admission should be considered for those with:
    • Adolescent with bradycardia < 50 bpm (Adult < 50 bpm)
    • Syncope (potentially concerning for an arrhythmia)
    • Severe electrolyte derangement
    • Psychiatric disorder concurrent
    • Suicidal ideation


Trent SA1, Moreira ME, Colwell CB, Mehler PS. ED management of patients with eating disorders. Am J Emerg Med. 2013 May;31(5):859-65. PMID: 23623238. [PubMed] [Read by QxMD]

Dooley-Hash S1, Banker JD, Walton MA, Ginsburg Y, Cunningham RM. The prevalence and correlates of eating disorders among emergency department patients aged 14-20 years. Int J Eat Disord. 2012 Nov;45(7):883-90. PMID: 22570093. [PubMed] [Read by QxMD]

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Catecholaminergic Polymorphic VTach Fri, 15 Aug 2014 12:00:13 +0000 Honestly, one of the best aspects of writing the Ped EM Morsels weekly is that I benefit from learning (or re-learning) something each week. This week is a great example...

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PolyMorphic VTach

Honestly, one of the best aspects of writing the Ped EM Morsels weekly is that I benefit from learning (or re-learning) something each week. This week is a great example of that phenomenon. We do not often have to care for the pediatric cardiac arrest, but when we do we take comfort in our advanced training and can rely on some of the basic concepts and recommendations (AHA Resuscitation Guidelines). What happens, though, when our advanced life support training steers us in the wrong direction? Let us consider the unusual case of Catecholaminergic Polymorphic Ventricular Tachycardia.

Catecholaminergic Polymorphic VTach: Basics

  • Rare, but important cause of syncope or sudden death in kids.
    • Mortality as high as 35% by age 30 years when untreated.
    • Worse prognosis for those who present earlier in life.
  • Malignant arrhythmogenic disorder that is characterized by:
    • Structurally normal heart,
      • Unlike Hypertrophic Cardiomyopathy.
      • Unlike Arrhythmogenic Right Ventricular Dysplasia
    • Normal baseline ECG (some may have borderline long QTc),
      • Unlike Long QT Syndrome
      • Unlike Short QT Syndrome
      • Unlike Brugada Syndrome
      • Unlike Wold-Parkinson-White Syndrome
    • Polymorphic VTach induced by:
      • Exercise or
      • Emotional Stress or
      • Other cause of Increased Catecholamines (ex, illicit substances)
  • Generally presents between ages of 7 and 9 years.
  • Uncommon to present before age 2 years.


Catecholaminergic Polymorphic VTach: Genetics

  • Family history of exercise-related syncope, seizure, or sudden death is reported in 30% of cases.
  • Caused by gene mutations.
    • Likely several genes involved, but two are known (RyR2 and CASQ2)
    • Both encode of proteins that regulate intracellular calcium!
  • It is recommended that other family members are tested and treated if found to have the genes.


Catecholaminergic Polymorphic VTach: Presentation

  • Typically will present with syncope and/or “seizure.”
    • Often initially misdiagnosed as either seizure or benign cause of syncope.
    • Mean delay in correct diagnosis is ~ 2 years.
  • Resting ECG is normal.
  • There is progressive ventricular ectopy as the heart rate increases.
    • Between 100-120 beats per minute there is increasing complexity.
    • First isolated PVCs evolve to bigeminy and then runs of nonsustained VTach.
    • Eventually, sustained VTach and Polymorphic VTach are observed.


Catecholaminergic Polymorphic VTach: Daily Therapy

  • It is recommended that ALL phenotypically and genotypically diagnosed individuals receive therapy.
    •  Beta-Blockers
      • 1st line
      • Nadalol is often used
    • Implantable Cardioverter Defibrillator (ICD)
      • Used for those who fail medications or for those who present with an aborted cardiac arrest.
      • Should be used concurrently with beta-blockers to avoid electrical storm caused by the adrenergic surge from the shocks.
    • Flecainide
    • Verapamil
    • Left Cardiac Sympathetic Denervation
  • Also recommended that they avoid competitive sports or other stimulants.

Catecholaminergic Polymorphic VTach: ACUTE Therapy

  • Managing a patient with CPVT who is in VTach can be tricky.
  • The most important step is recognizing that the patient has Catecholaminergic Polymorphic VTach.
    • Family history is integral!
    • Previous history of syncope or seizure can raise suspicion for it as well.
  • Standard use of Epinephrine during the resuscitation can be counterproductive.
  • IV beta-blockers is considered first choice, similar to VTach storm of other etiologies.
  • Given that it is Polymorphic VTach, it would also be reasonable to administer Magnesium, but this would be aimed at possible Prolonged QTc.


Moral of the Morsel

  • This represents a significant challenge for us in the Emergency Department. It is rare and can present in a benign fashion (syncope). Even those who are thorough and obtain an ECG may be inappropriately reassured by the normal ECG.
  • The patient who has had a SYNCOPAL event deserves consideration for multiple entities (ex, Prolonged QTc, SVT) and should have a screening ECG.
  • Ask about family history!  You can’t outrun your genes.
  • Ask about prior syncopal events that were associated with exciting or stressful situations.
  • Don’t always assume wellness just because the patient is young.



Leenhardt A1, Denjoy I, Guicheney P. Catecholaminergic polymorphic ventricular tachycardia. Circ Arrhythm Electrophysiol. 2012 Oct;5(5):1044-52. PMID: 23022705. [PubMed] [Read by QxMD]
Pflaumer A1, Davis AM. Guidelines for the diagnosis and management of Catecholaminergic Polymorphic Ventricular Tachycardia. Heart Lung Circ. 2012 Feb;21(2):96-100. PMID: 22119737. [PubMed] [Read by QxMD]

Heiner JD1, Bullard-Berent JH, Inbar S. Deadly proposal: a case of catecholaminergic polymorphic ventricular tachycardia. Pediatr Emerg Care. 2011 Nov;27(11):1065-8. PMID: 22068070. [PubMed] [Read by QxMD]

van der Werf C1, Zwinderman AH, Wilde AA. Therapeutic approach for patients with catecholaminergic polymorphic ventricular tachycardia: state of the art and future developments. Europace. 2012 Feb;14(2):175-83. PMID: 21893508. [PubMed] [Read by QxMD]

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Von Willebrand Disease Fri, 08 Aug 2014 12:00:55 +0000 Discussion of bleeding and bleeding disorders always garners attention. We have recently covered hemophilia, ITP, and hemorrhagic disease of the newborn, but let us turn our attention to the most...

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Von WIllebrand

Discussion of bleeding and bleeding disorders always garners attention. We have recently covered hemophilia, ITP, and hemorrhagic disease of the newborn, but let us turn our attention to the most prevalent bleeding disorder: Von Willebrand Disease.  Certainly, making the diagnosis of von Willebrand disease is not necessarily a common goal in the ED, but knowing how to deal with it is!


Von Willebrand Disease Basics

  • Inherited bleeding diathesis.
    • Estimated to affect as much as 1% to 2% of the population (adults and kids).
  • Caused by either too little von Willebrand Factor or von Willebrand factor that is defective.
  • The function of Von Willebrand factor is to help:
    • Bind platelets to injured endothelium
    • Stabilize factor VIII.
  • Von Willebrand is generated in the endothelial cells.


Von Willebrand Disease Types

  • TYPE 1
    • Partial Deficiency of von Willebrand Factor
    • Most common type – >70% of cases.
    • Autosomal DOMINANT
    • Usually leads to MILD BLEEDING
  • TYPE 2
    • Defective von Willebrand Factor
    • Has 4 subtypes, depending upon the specific defect.
    • May be autosomal Recessive or Dominant.
    • Severity varies between the subtypes, but more severe than Type 1.
  • TYPE 3
    • Complete Deficiency of von Willebrand Factor.
    • Autosomal RECESSIVE.
    • More Serious presentations.


Von Willebrand Disease Presentations

  • Most often presents with mucocutaneous bleeding.
  • Commonly seen:
    • Epistaxis
    • Easy Bruising
    • Menorrhagia
  • Type 3 may present with serious bleeds:
    • Hemarthrosis
    • GI Bleeds


Von Willebrand Disease Diagnosis

  • When you are considering a new diagnosis of a bleeding disorder, it is important ask:
    • Age of onset – often presents early, but may be missed until later in life.
    • Location of bleeding
    • Spontaneous bleeding?
    • Family history – obviously… you can’t outrun your genes.
    • Hemostatic Challenges (trauma or surgery) – a major inherited bleeding D/O is unlikely in a patient who has had an uneventful surgery in the past.
  • There are bleeding scoring systems to help determine likelihood of bleeding disorders… but they are not validated in kids.
  • Initial Work-Up
    • CBC
    • Coagulation Studies
    • Von Willebrand Specific Studies
      • vWF Antigen
      • vWF activity
      • Factor VIII level
    • Unfortunately, normal tests do not rule out the diagnosis completely.
    • Involving a hematologist is necessary.


Von Willebrand Disease Treatments

  • Desmospressin (DDAVP)
    • Synthetic analog of vasopressin
    • Promotes release of vWF from endothelial cells.
    • Patients with Type 1 often respond well, but type 2 and 3 often do not.
    • Can be given SubQ or IntraNasal, but IV is more effective.
    • Complications = hyponatremia, facial flushing, headache, tachyphlaxis and hypo/hypertension.
  • Plasma-derived vWF and Factor VIII
    • Humate-P
    • Goal is to achieve vWF:RCo > 30% for minor bleeds and >50% for major bleeds.
    • Loading doses:
      • Minor Bleed – 30-50 IU/kg
      • Major Bleed – 40-60 IU/kg
  • Cryoprecipate
    • Contains vWF and FVIII)
      Use only when vWF concentrate is not available.
      1 bag/6 kg body weight.
  • Adjuncts
    • Aminocaproic acid
      • 100-200 mg/kg (max of 10 grams)
      • Followed by 50-100 mg/kg/dose (max of 5 grams) q 6 hrs.
    • Tranexamic acid
      • 25-50 mg/kg q 6-8 hrs.
      • Absorbed from the buccal mucosa and secreted in saliva!
        • Can treat oral bleeding with a mouth-wash of TXA!
        • Crush tablets in 10-15ml of water and have patient hold that in their mouth for 5 min before swallowing.
      • Has longer half-life, more potency, and lower toxicity than Aminocaproic acid and is preferred.


Cooper S1, Takemoto C. Von Willebrand disease. Pediatr Rev. 2014 Mar;35(3):136-7; discussion 137. PMID: 24585817. [PubMed] [Read by QxMD]
Bansal D1, Oberoi S, Marwaha RK, Singhi SC. Approach to a child with bleeding in the emergency room. Indian J Pediatr. 2013 May;80(5):411-20. PMID: 23269640. [PubMed] [Read by QxMD]

Singleton T1, Kruse-Jarres R, Leissinger C. Emergency department care for patients with hemophilia and von Willebrand disease. J Emerg Med. 2010 Aug;39(2):158-65. PMID: 18757163. [PubMed] [Read by QxMD]

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Sinusitis Fri, 01 Aug 2014 12:00:50 +0000 The ART of medicine is much more difficult to learn than the science of medicine; however, it is through becoming comfortable with the “grey areas” that we often experience our...

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The ART of medicine is much more difficult to learn than the science of medicine; however, it is through becoming comfortable with the “grey areas” that we often experience our greatest ability to help others.  It is also what prevents robots from taking our jobs.

One “grey area” that we constantly explore is that of antibiotic administration.  Now, this would seem like a very well defined area and not one of nuance – if there is a bacterial infection, give antibiotics; if there is not, do not.  Unfortunately, we know that it is not that clear cut.  The treatment of Acute Otitis Media, which can be complicated by Mastoiditis,  is a good example of the need to do complex Pro-Con equations to determine the best plan for a specific patient.  While there may be purulent material present, exposing the patient to antibiotics is not necessarily the best plan always (see Serum Sickness).  Another excellent example of this is sinusitis in children.


Acute Bacterial Sinusitis “Diagnosis”

  • In 2013, the clinical diagnosis of Acute Bacterial Sinusitis in children was revised.
  • Admittedly, the research pertaining to Sinusitis in children was often undermined by varied definitions of sinusitis, so this is hopefully helpful.
  • Acute Bacterial Sinusitis can be clinically diagnosed when a child who has an acute upper respiratory tract infection (URI) presents with:
    1. PERSISTENT illness – any nasal drainage, or DAYtime cough, or both lasting > 10 days WITHOUT IMPROVEMENT; or
    2. WORSENING course – worsening or new onset of nasal discharge, DAYtime cough, or new fever; or
    3. SEVERE onset AND PURULENT Nasal drainage – concurrent fever > 102.1F (>38.9C) AND purulent rhinorrhea for at least 3 consecutive days.


Key Words of Sinusitis

  • Just to be clear… there are some keywords that cannot be overlooked when considering this diagnosis:
    3. SEVERE
  • These are the only tools that we have to help us make this diagnosis.  More importantly, these are the words that can help us not over-diagnose it!
  • There is NO lab test.
  • There is NO radiographic test.
  • There is NO reliable physical exam finding.

Typical Time Course of an URI

I understand; there is nothing exciting about talking about a URI.  It is common.  It is simple.  It can be accurately diagnosed by grandparents and managed effectively by them.  So why do I torture you, an experienced clinician, with this?  Because, it is what makes the above make some sense.

  • A URI is typically characterized by nasal symptoms (congestion and/or discharge).
    • Most often the nasal discharge starts as clear and watery.
    • Over time, the discharge may become thicker and more mucoid or even purulent for several days.
    • As the URI resolves, the nasal drainage usually becomes less mucoid and clears.
  • Fever tends to occur early in the illness.
    • Often fever occurs before respiratory symptoms are prominent.
    • Usually resolves in the first 1-2 days.
  • The total duration is often 5-7 days.


The Tricky Part

  • Kids love to collect different URIs sequentially!
  • Parents will not necessarily perceive that two separate viral illnesses have occurred… they just know that their child has been sick for “2 weeks straight.”


My General Approach

  • Ok, take this for what it is…
  • Start off with the knowledge that only ~6-7% of children will meet criteria for Sinusitis.
  • Know that the benefit of antibiotic therapy in treating sinusitis only seems to be apparent in those more severe symptoms and when the more strict criteria are applied.
  • Know that the benefit of antibiotic therapy in preventing suppurative complications (orbital cellulitis or intracranial abscess) is unproven.
  • Focus on the history.
    • Spend a little more effort in helping the family sort out if this “2 weeks” of illness is really two separate URIs.
    • Consider the time course and the onset of fever.  Fever that occurs after illness has started is not typical for an URI.
    • Purulent rhinorrhea occurring during the onset of fever is also odd for an URI.  3 days of purulent snot and high fevers should make you think about sinusitis.
  • Have the parents help you!
    • Shared decision making can be very powerful… especially with these grey areas of medicine.
    • Discuss the potential for sinusitis, but how there is no definitive way to diagnose it.
    • Discuss how antibiotics may help some, kids, but can also cause harm (ex, diarrhea, allergy, toxic epidermal necrolysis, etc).
    • A period of OBSERVATION for those with persistent symptoms can be very helpful in sorting out the ambiguous cases.
    • Don’t just throw antibiotics at all kids with “persistent symptoms” please!!  They all do not have sinusitis.


Treatment for Sinusitis

  • Sinusitis defined by Persistent Symptoms – antibiotics OR Observation period for 3 days.
  • Sinusitis defined by Worsening Symptoms or Severe and Acute symptoms – antibiotics.
  • Antibiotic Options
    • 1st line = Amoxicillin
      • 45mg/kg/day divided BID is sufficient if you have low antimicrobial resistance.
      • 90mg/kg/day divided BID (max of 2 grams per dose) in areas with abx resistance.
    • Augmentin (80-90mg/kg/day of the amoxicillin component) can be used in those with moderate or severe illness or in those < 2 years of age.
    • Ceftriaxone 50mg/kg IM dose x 1
      • If clinical improvement is seen at 24 hours, then transition to Oral abx.
      • If clinical improvement is not seen at 24 hours, then parental abx may be required.
    • Penicillin allergic?
      • Consider cefdinir, cefuroxime, or cefpodoxime.



Hersh AL, Jackson MA, Hicks LA; American Academy of Pediatrics Committee on Infectious Diseases. Principles of judicious antibiotic prescribing for upper respiratory tract infections in pediatrics. Pediatrics. 2013 Dec;132(6):1146-54. PMID: 24249823. [PubMed] [Read by QxMD]

Smith MJ. Evidence for the diagnosis and treatment of acute uncomplicated sinusitis in children: a systematic review. Pediatrics. 2013 Jul;132(1):e284-96. PMID: 23796734. [PubMed] [Read by QxMD]

Wald ER1, Applegate KE, Bordley C, Darrow DH, Glode MP, Marcy SM, Nelson CE, Rosenfeld RM, Shaikh N, Smith MJ, Williams PV, Weinberg ST; American Academy of Pediatrics. Clinical practice guideline for the diagnosis and management of acute bacterial sinusitis in children aged 1 to 18 years. Pediatrics. 2013 Jul;132(1):e262-80. PMID: 23796742. [PubMed] [Read by QxMD]

Chandran SK1, Higgins TS. Chapter 5: Pediatric rhinosinusitis: definitions, diagnosis and management–an overview. Am J Rhinol Allergy. 2013 May-Jun;27 Suppl 1:S16-9. PMID: 23711033. [PubMed] [Read by QxMD]

Wolf G1, Anderhuber W, Kuhn F. Development of the paranasal sinuses in children: implications for paranasal sinus surgery. Ann Otol Rhinol Laryngol. 1993 Sep;102(9):705-11. PMID: 8373095. [PubMed] [Read by QxMD]

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