Emergency Bear Treats

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2014-09-17T20:03:00.001-04:00

Dear readers,

We've migrated to a new site: www.pemacademy.com. You will be redirected automatically.

There you will find new cases, interesting articles, and learning tools. Thank you for reading these last few years and we hope to see you at PEMAcademy.

Pemfellows.blogspot.com - Under Renovation

2014-07-14T16:41:00.000-04:00

Hot Seat Readers,

The Hot Seat will be going on a summer vacation for renovation and upgrading.

We will be back with more cases, a different layout and URL, and other PEM learning tools.

Here's what we've done over the last few years:
Pageviews: Over 13,000

40 Hot Seat Cases

26 Different attendings on the Hot Seat

199 total comments

3 Institutions (Children's National, INOVA Fairfax, and Johns Hopkins)

Most frequent participants: Dave Mathison, Paul Mullan, Jennifer Chapman, Dewesh Agrawal, Rasha Sawaya, Sabah Iqbal, Jamil Madati

Future site will include:
Hot Seat
ECG
Best Articles
Article of the Week
Ultrasound
C-MAC
Potential for Author Profiles/Portfolios
Sky's the limit! What do you want it to include?

The goal is to have a real-time, user-friendly educational tool.

If you have comments or suggestions, please include them below in the comment section.

Thanks for your participation and check back later this summer for our new look.

Please share your opinions by clicking on “comments” below. It’s easiest if you’re also logging into your gmail account but you can do it without as well. Just select “Name/URL” from the drop down menu, write your name, and click “submit.” You can also post anonymously although this seems less fun. To read posted comments, click on “comments” below and scroll up.

About the Hot Seat. Hot Seat cases are written by PEM fellows at Children’s National, Inova Fairfax, and Johns Hopkins. The Hot Seat Attending is a selected faculty member who comments on the case without knowing the outcome. Emily Willner is the faculty mentor for the series.

Hot Seat Case #40 Denouement: 3 yo with bloody stools

2014-07-03T17:53:00.004-04:00

By Sonny Tat, Children's National
with Shilpa Patel, Children's National

The Case
This is a case of a 3 year-old healthy female with abdominal pain and bloody stools who presents with blood at the anus and anemia. The challenge in this case is how to approach this patient with an ultrasound negative for intussusception and how to address access issues (a common problem). For a complete case presentation, please click here.

Here's How You Answered Our Questions
What is your next diagnostic step in the ED?
Less than 3 years PEM experience (fellows, PAs/NPs, pediatricians) n=9

More than 3 years PEM experience (PEM attendings, pediatricians) n=7

Attendings and fellows agree that the next diagnostic step would be an abdominal x-ray. Interestingly, 22% of fellows would get an abdominal CT, while none of the attendings thought a CT the next step. Approximately 14% of attendings thought a barium enema might be beneficial, while none of the fellows chose that imaging modality.

You have been unable to establish IV access despite multiple attempts. What is your access plan?

Less than 3 years PEM experience (fellows, PAs/NPs, pediatricians) n=8

More than 3 years PEM experience (PEM attendings, pediatricians) n=7

The majority of providers would continue to attempt a non-EJ IV, followed by an EJ IV. This patient is sick, but stably so at the moment. She definitely needs access, but the majority of providers felt they could take the time to get an IV. Only 12.5% of fellows (and no attendings) felt an IO was necessary. No one wanted PICU admission for a central line. At this time, the patient doesn’t truly need ICU care.

Clinical Reasoning
Dave Mathison and Shilpa Patel (Hot Seat Attending) gave excellent responses to this case. For their complete comments, click here.

“it's super, super important to differentiate painless versus painful rectal bleeding. and make sure it's actually blood.”

“typically, PAINLESS rectal bleeding is either juvenile polyp or a Meckels. period. in this patient who has a drop in Hb with normal indices yet is well appearing....sounds like a Meckel's. and if this were the case, i would admit for a meckel's scan since the patient is minimally tachycardic with a low Hb and question of active bleeding. always good idea to get a PT and PTT to look for other coagulopathies, although this is not a presentation of acute hemophilia. and never a bad idea to put in an EJ, although probably not necessary if BP is normal and kid looks fine.”

“now PAINFUL rectal bleeding… think about infectious colitis versus inflammatory bowel disease versus vasculitis etc. so send the culture, ESR/CRP. If inflammatory markers are negative, this points more towards anatomic (meckels, polyp). If positive this supports one of these inflammatory or infectious conditions… I do like to get an abdominal XR, especially in a 3yo where ingestion of foreign material is possible… rectal obstruction can cause gaseous distention (pain) and bleeding from local trauma. same goes with constipation, although pretty HARD (no pun intended) to get your Hb down so much with constipation/tears.”

-Dave Mathison, Children's National

From the Hot Seat
by Shilpa Patel, Children's National Medical Center

Although lower GI bleeding in children may be indicative of a serious illness, usually it is not. Our very own Stephen Teach published a retrospective review of 109 cases (?his fellow’s project – pretty awesome) in which only four had life threatening diagnoses (https://www.dropbox.com/s/b53127f2haoqj43/1-s2.0-S0196064494703507-main.pdf) – three cases of intussusception and a single case of Meckel’s diverticulum.

The first step in the approach to GI bleed is to determine if it is truly blood. In our case, given the low hemoglobin and gross blood at the anus on exam, we should assume it is blood. The second step is to try to distinguish between upper and lower GI bleeding. Classic teaching is that bright red blood in/on stool is usually lower, however in an infant (short intestinal transit time), bright red blood could be from a massive upper GI bleed and quickly lead to hemodynamic compromise). Whereas melena, or dark blood is classically more proximal (this could be blood that is swallowed from the nose/ingested). Red stool (though it is dark) with gross blood at the anus in our patient is probably lower GI.

I’m going to use SPI(T) (which Sonny introduced to us a few weeks ago as a teaching technique in the ED) to organize my DDx and will try to limit it to younger children since our patient is 3 years old.

S Serious

P Probable

I Interesting

T Treatable

DDX:

S: Serious

Intussusception – Though this has already been ruled out (US has a negative predictive value of 99.5% with a good sonographer), our patient's presentation, a 3 yo with intermittent severe abdominal pain sounds concerning. Blood in stool is a late finding in intussusception. The currant jelly stool is associated with necrotic bowel and I would expect the patient to appear more ill. Thinking creatively, the bloody stools in our scenario could be related to a lead point for intussusception (a bleeding polyp or diverticulum) causing the bleeding and the intermittent abdominal pain AND the telescoping could be intermittent (giving us a negative ultrasound when the child is comfortable).

Meckel’s diverticulum – usually described as “painless” bleeding (just blood and no stool), though our child reports abdominal pain. It can also be associated with complications (obstruction or perforation) and majority of the patients are younger than 2 years old. As Meckel’s can lead to rapid painless blood loss and hemodynamic compromise, ensuring that the patient is hemodynamically stable is very important. Our patient is anemic and should be watched. At this point, I don't think I would get a Meckel scan on our patient.

Underlying coagulopathy – normal INR is reassuring along with normal platelets. HUS can present with GI bleed but is unlikely given normal platelets and normal Creatinine.

Volvulus (w/Malro) – would expect the child to be sicker with an abnormal aXR, or have bilious emesis (though she did have emesis x 2 earlier in the day). If she had bilious emesis, would consider an AXR.

P: Probable

Infectious colitis – Our patient has crampy abdominal pain, it is associated with multiple stools and had vomiting earlier -fits the bill. We should ask a travel/exposure history, send a second set of cultures and follow up on the stool cultures sent by the primary care doctor. Would also be good to know if she was on antibiotics (C. Diff colitis) Something that goes against this is the lack of fever and perhaps a normal wbc….

Mnemonic for infections that cause bloody stools: YEECCSS!

Y – Yersinia

E – Ecoli

E -Entamoeba histolytica

C – Cdiff

C- Campylobacter

S- Shigella

S – Salmonella

HSP – Our patient had a URI two weeks ago, has abdominal pain with LGI bleed, is the right age (majority of cases present between 3-5) and has normal renal function labs (at least for now, as 50% of HSP eventually have renal involvement). But…our patient does not have rash…which is fairly common…however I don’t think lack of rash rules it out…we need a scope.

IBD – 3 is a little young for onset of IBD though not impossible; the child has crampy abdominal pain with multiple blood stools (and classic relief of pain with bloody stool); rectal UC (more than Crohns) presents with LGI bleeding like this. The borderline low MCV of 79, microcytic anemia, could be suggestive of chronic GI blood loss or could be some underlying iron deficiency anemia. Also, there are no skin tags on rectal exam.

Juvenile (Rectal) Polyps – usually presents with bright red blood and is often painless. Can be a lead point for intussusception or volvulus so therefore could have abdominal pain with presentation. These can be anywhere in the GI tract (upper or lower) and hence it could be dark red blood if a bit more proximal. A rectal exam may allow the palpation of a rectal polyp (and these can pop out – often confused with rectal prolapse - I recently saw a case).

Gastric ulcer – could cause pain and bleeding; would be worried about perforation with significant bleed, but our patient looks well. Usually eating makes the pain worse (compared to better after eating with a duodenal ulcer). Would be good to know if she was on NSAIDs for any other reason.

Anal fissures - common but not likely in our patient given dark red stools and anemia…usually more benign

Allergic colitis: Eosinophillic proctitis can cause lower GI bleed (or upper GI if severe eosinophillic/allergic esophagitis)…would expect this to be more chronic

I: Interesting

Portal hypertension: There was a case report of a child with undiagnosed idiopathic portal hypertension presenting with an esophageal varices and bleed – highly unusual but interesting – though unlikely in our well appearing patient with intermittent bleeding and no HSM. Variceal bleeds are more rapid and quickly destabilize.

Gastrointestinal Duplication – can ulcerate, perforate or form fistulas, causing lower GI bleed. Very uncommon…we need a scope to diagnose this. I guess this could cause pain if ischemic.

Tumors/Malignant polyps and Vascular Malformations …very rare, again would need a scope

T: Treatable

Of the list above, many are treatable. I would use this question....to assist me in my management.

Management

For our patient, I agree with the testing that has already been done. I would follow up with the PCP regarding the stool cultures and probably send another set. I would send a type and cross, make sure I have solid access and admit the patient for observation given the low hemoglobin and ongoing blood loss. If IV access was difficult I would consider an EJ. Also, I would discuss this patient with the PICU as GI bleed can lead to rapid hemodynamic instability; and with GI to consider scoping.

The Denouement
by Sonny Tat, Children's National

The patient continued to have intermittent pain so underwent a repeat abdominal ultrasound four hours later to evaluate the possibility of intermittent intussusception. This ultrasound demonstrated a thick walled cystic structure below the umbilicus with mild hyperemia without signs of intussusception. There was point tenderness at this location on ultrasound exam.

This patient remained hemodynamically stable and was admitted to the surgical service for further observation and diagnostic evaluation.

The patient had a nuclear medicine study showing radiotracer uptake below the umbilicus (figure 2). She then underwent a diagnostic laprascopy that was converted to an open resection of a Meckel’s Diverticulum. The patient had an uncomplicated post-operative course. Her final pathology showed heterotopic gastric tissue, consistent with Meckel’s Diverticulum.

Please answer the two quick questions below. The data helps inform our future case design. Thanks for participating.

Like the Hot Seat? Don't miss a case. Subscribe for email updates of new posts by adding subscribing in the field at the top of this page or by clicking here.

The Hot Seat is a recurrent online case series aimed at facilitating asynchronous sharing of PEM knowledge and experience. Faculty are placed on The Hot Seat and publish their opinions without knowing the case or its outcomes. Cases are based on real cases and written by PEM fellows at Children's National in DC, Johns Hopkins in MD, and INOVA Fairfax in VA to highlight teaching points. Emily Willner is the faculty advisor for the Hot Seat.

Hot Seat Case #40 Response by Shilpa Patel

2014-06-24T18:03:00.002-04:00

Although lower GI bleeding in children may be indicative of a serious illness, usually it is not. Our very own Stephen Teach published a retrospective review of 109 cases (?his fellow’s project – pretty awesome) in which only four had life threatening diagnoses (https://www.dropbox.com/s/b53127f2haoqj43/1-s2.0-S0196064494703507-main.pdf) – three cases of intussusception and a single case of Meckel’s diverticulum.

S Serious

P Probable

I Interesting

T Treatable

DDX:

S: Serious

Underlying coagulopathy – normal INR is reassuring along with normal platelets. HUS can present with GI bleed but is unlikely given normal platelets and normal Creatinine.

P: Probable

Mnemonic for infections that cause bloody stools: YEECCSS!

Y – Yersinia

E – Ecoli

E -Entamoeba histolytica

C – Cdiff

C- Campylobacter

S- Shigella

S – Salmonella

Anal fissures - common but not likely in our patient given dark red stools and anemia…usually more benign

Allergic colitis: Eosinophillic proctitis can cause lower GI bleed (or upper GI if severe eosinophillic/allergic esophagitis)…would expect this to be more chronic

I: Interesting

Gastrointestinal Duplication – can ulcerate, perforate or form fistulas, causing lower GI bleed. Very uncommon…we need a scope to diagnose this. I guess this could cause pain if ischemic.

Tumors/Malignant polyps and Vascular Malformations …very rare, again would need a scope

T: Treatable

Of the list above, many are treatable. I would use this question....to assist me in my management.

Management

Hot Seat #40: 3 yo with bloody stools

2014-06-23T21:17:00.000-04:00

By Sonny Tat, Children's National
with Shilpa Patel, Children's National

The Case

3 year-old previously healthy girl presents to your ER with abdominal pain and bloody stools. The patient had abdominal pain starting yesterday. After a few hours, the patient had a bowel movement with dark red blood, which may have eased the pain. She had two or three more episodes of bloody stool and intermittent abdominal pain yesterday. Today she went to the PMD who sent stool studies and sent her home. She is in the ED today because of persistent abdominal pain that puts her in the fetal position that is temporarily relieved by bowel movements that are associated with dark blood. She has had emesis x 2 today that is non-bloody, non-bilious.

ROS: No fevers, rash, constipation, sick contacts, or change in diet. URI two weeks ago.

Exam: VS Afebrile, HR 119, RR 22. BP 97/57

Well-appearing, active, smiling, no distress

Chest CTAB, heart RR, no murmurs or gallops

Abd ND/NT, no masses. Rectal exam shows gross blood at the anus

Labs/Rad:

Hemoglobin 8.8 WBC 11.7 Platelets 302 MCV 79

Na 139 K 3.4 Cl 106 CO2 22 BUN 11 Cr 0.4

INR 1.1

Ultrasound is negative for intussusception

Questions for you:

How would you approach this case? Please share your opinions by clicking on “comments” below. It’s easiest if you’re also logging into your gmail account but you can do it without as well. Just select “Name/URL” from the drop down menu, write your name, and click “submit.” You can also post anonymously although this seems less fun. To read posted comments, click on “comments” below and scroll up.

Come back later for the denouement of this case

Hot Seat Case #39 Denouement: 5 yo at OSH who “doesn't look right”

2014-05-29T17:22:00.003-04:00

by Katie Donnelly, Children’s National
with Paul Mullan, Children's National, on the Hot Seat

The Case
This is a case of a 5 yo girl being transferred from an OSH because she “doesn’t look right” who has tachypnea and emesis. The challenge in this case is how to approach a patient with initial findings of hepatosplenomegaly and leukocytosis.

For a complete case presentation, please click here.

Here's How You Answered Our Questions

In light of this CXR, would you order any additional studies while awaiting the results of the bloodwork?

Less than 3 years PEM experience (fellows, PAs/NPs, pediatricians) n=10

More than 3 years PEM experience (PEM attendings, pediatricians) n=12

PEM providers of all years experience agreed. The majority would obtain an EKG. Several would also get an ECHO with Cardiology consult.

Case continues: You receive a call from the lab with a critical WBC 800,000. The CMP is still pending. You go to assess the patient, who is clinically unchanged.

One more question for you

What is your next management priority?

Less than 3 years PEM experience (fellows, PAs/NPs, pediatricians) n=9

More than 3 years PEM experience (PEM attendings, pediatricians) n=12

PEM providers with less than 3 years experience gave a normal saline bolus and started 1.5 x MIVFs (no potassium, as worried about tumor lysis). One person stated that "other" for tumor lysis labs. PEM providers with more than 3 years experience ordered 1.5x MIVFs followed by NS bolus/"other". Three people put "other" for "more labs (LFTs, LDH, uric acid)," "I-stat electrolytes and gas," and "consider rasburicase."

Clinical Reasoning

Thank you to the several attendings that left very insightful comments about this case! Overall themes include the need to obtain tumor lysis labs (iStat lytes, gas, LDH, uric acid, Ca, Phos, Mg, CMP). Additional excellent discussion topics include the use of rasburicase vs allopurinol. Also, in the setting of hyper-leukocytosis, one should think about PICU admission for central line access and leukapheresis. For complete comments, click here.

“If the WBC is really 800K (not 80K), with huge hepatosplenomegaly, this is leukemia until proven otherwise… With WBC that high, the serum K level is much more accurate on a non-spun specimen (such as from an I-Stat instead of sending to the lab), as leukemic WBCs are typically "leaky". Rasburicase is better than allopurinol in this setting in getting uric acid under control”. - Dewesh Agrawal, Children's National

“One of the big risks of hyper-leukocytosis is sludging, which can lead to high-output cardiac failure or stroke. My next step would be to get the kid to a place where he/she could get a big honkin' 7F line in the groin for an exchange transfusion [plasmapheresis]…You can do some hemodilution with IVF but have to be careful not to give any bulky fluids (PRBCs) since they can precipitate stroke. Rasburicase is super $$$$, so not sure the role if the patient is getting exchanged regardless.” – David Mathison, Children's National

“Plasmapheresis is when plasma is removed and donor plasma is given. Used in TTP, HUS, Autoimmune diseases , Good pastures etc.” VS. “Exchange transfusion is where you remove blood (not plasma) and replace it with good donor blood example : sickle cell with acute chest syndrome where blood removed from sickler and transfused again with normal blood” – Breanna Barger, Johns Hopkins

“The highest priority is plasmapheresis, so moving her to the PICU is the focused goal… no longer recommended to alkalinize the urine because of the risk of precipitating Ca-phos product.” – Jennifer Chapman, Children's National

“Can't ignore a WBC of 800k… If blasts are seen, you have your diagnosis. While waiting for plasmapheresis and transfer to the PICU, giving a NS bolus would probably be beneficial for the marked leukocytosis. Perhaps check an EKG (+/- ECHO) before doing so to make sure you're not fluid overloading a 'sick' heart… and calls to the Hem/Onc, Cardiology.” – Jamil Madati, Children's National

From the Hot Seat
by Paul Mullan, Children's National

DDx for HSM that's likely cancer-related with that WBC and mediastinal mass:

- Leukemia, Lymphoma

- Neuroblastoma

- Hepatic cancer (less common than above types; screen with alpha-fetoprotein and CT).

- Histiocytic (these are hard to remember but I have an assortment of specific findings I look for and if I don't see at least a couple of these, this falls lower on ddx: cytopenias or cytopenic suggested symptoms noted, skin findings papular or seborrheic, diabetes insipidus symptoms, lymphadenopathy, loose teeth - although that picture suggests maybe some loose ones!).

The hyperleukocytosis (>50-100K WBC) pushes me toward the dx of ALL in a major way (esp Tcell ALL with that mediastinal mass ugliness on CXR), so the oncology fellow is on their way in from home to look at the slide, but in the ED at this moment I'm worried about potential for leukostasis (that is, when hyperleukocytosis causes symptoms which can affect many organ systems) - so by system, what to worry about, and what to do about it...

1. CNS: increase ICP, bleed, seizures, AMS, focal deficits, CVA, coma; no signs of this now in this patient; continue to monitor.

2. Blood/Lytes:

a.Tumor lysis syndrome (TLS) ; this usually begins after chemo starts but can occur prior to chemo. CMP might be pending, but double check that it's not being done and in meantime add some more labs: Istat with lytes, uric acid, LDH, CBC, T&S, DIC panel. Reducing wbc can happen with chemo, leucopheresis, or hydroxyurea but this will happen in ICU so not really our acute issue right now. Prophylaxis and treatment for TLS (according to most recent American Society of Clinical Oncology guidelines - by Coiffier B,et al JCO 2008;26(16): 2767-2778.) is two fold:

1st: Hydration with D5 1/4 NS at 3L/m2/day with goal of equal ins and outs; if already oliguric or in renal failure, d/w renal/onco on how they prefer to hydrate.

2nd: Uric acid reduction. Two choices: allopurinol and rasburicase. The ASCO guidelines recommend first determining if patient is low risk, intermediate risk, or high risk; another fun article (Brit J Hem 2010;149:578-586) details this risk classification, but assuming this is leukemia, the >100k puts this pt in high risk zone regardless of leukemic subtype or LDH level. High risk patients get rasburicase (medium risk gets allopurinol or rasburicase; low risk gets nothing but monitoring); given contraindication to rasburicase is G6PD, definitive testing for this condition is recommended. Rasburicase is expensive but cost effectiveness studies show that it decreases ICU days, renal failure incidence, etc. and ends up saving money.

- As Jen stated, alkalinization is no longer recommended - it was never proven effective and can increase precipitation of CaPhos crystals in urine.

- Hyperuricemia: can lead to uric acid crystallization in kidneys --> acute renal failure; see uric acid reduction tx above.

- Hyperkalemia (can also be spurious from leukemic blast degradation; Istat is most accurate), worry about EKG changes that lead to VT/VF/arrest; treat if >6 with standard hyperK tx and NO iv or po potassium intake.

- Hyperphosphatemia: leads to n/v/d (worsens hydration state which is key for TLS) and can cause lethargy/seizures which makes one think of CNS leucostasis symptoms and thus complicates the workup; if Ca x Phos is >70, can get CaPho precipitation in kidneys; therapy is hydration and phosphate binders (calcium carbonate, aluminum hydroxide) ; if severe or not decreasing, then hemodialysis.

- Hypocalcemia: can lead to cramps/tetany and worse cases hypotension/arrhythmias. If symptomatic, given ca gluc 50 mg/kg IV slowly with ekg monitoring.

b. DIC and thrombocytopenia; except for the photo that shows bleeding around the gums (vs tartar?), no indication of this for now, but have sent the labs above.

2. Lungs: hypoxemia (can get false low pO2 on ABG because leucocytes use up the O2), respiratory distress (made worse in her by this mediastinal mass on CXR - I would NOT get a chest CT as laying these patients down can precipitate resp failure - I would sit her up in bed, add O2 by NRB facemask, and see if this helps her tachypneic state.

3. Renal failure: from the uric acid or ca-phos deposition; if oliguric or in renal failure, discuss with renal about IVF and diuretic management

4. Cardiac failure (get an EKG; heart failure is still a possibility with the HSM and tachypnea, but I would not necessarily get cards to the ED unless EKG was abnormal; myocarditis a possibility as a secondary infection, but unlikely as a primary one with >800k wbc, unless lab called and said white count was a lab error)

5. Less common in ED: GI (bleeds, abd pain), priapism, clitoral enlargement, dactylitis, many others.

Disposition is certainly to the ICU in this symptomatic child with high interventional needs.

The Denouement
by Katie Donnelly, Children’s National

The case was modified somewhat for the Hot Seat presentation and the actual case follows:

This 5 year old female initially presented to an referring hospital with a WBC count of 300 and a chest x-ray that was concerning for cardiomegaly. Repeat CBC at our institution (less then 8 hours later!) was notable for a WBC of 803 with 81% blasts, a hemoglobin of 6.4 and platelets of 30. Her uric acid was 8.6 and her LDH was 3,522. Her potassium was initially reported as 20, repeat of 4, the erroneous result was attributed to her massive leukocytosis. She had a bedside ultrasound which showed normal heart size and function and hepatosplenomegaly. Her repeat chest XR above was concerning for an anterior mediastinal mass. She was started on hyperhydration with one and a half times maintenance fluids without potassium and rasburicase for hyperuricemia. She was admitted to the PICU. Hematology and Transfusion Medicine were consulted and the patient underwent leukapheresis given her significant risk for stroke which reduced her WBC count to 500. Her peripheral flow cytometry was consistent with Acute T-cell Lymphoma and she has started chemotherapy.

Please answer the two quick questions below. The data helps inform our future case design. Thanks for participating.

Hot Seat Case #39: 5 yo at OSH who “doesn't look right”

2014-05-19T09:08:00.001-04:00

by Katie Donnelly, Children’s National
with Paul Mullan, Children's National, on the Hot Seat

The Case

You receive a call from a referring hospital asking about transferring a 5 year old child. She had been seen at the hospital 2 weeks prior for fever and started on amoxicillin for AOM. She returned to the ED because her mother noted she was breathing faster than normal and she was having some vomiting. She is no longer having fevers. On their exam her respiratory rate is in the 40’s but her lungs are clear and her abdomen is mildly distended. They have tried but were unable to obtain blood, though they do have IV access. A CXR was obtained which they report shows no pneumonia. They are worried that she just “doesn’t look right” and ask for transfer to your institution for further evaluation.

On arrival to your ED:

T of 37.1 HR 121 RR 40 BP 94/60 O2 sat 98% on room air

GEN: Alert, well developed for age. Seems uncomfortable, moving around the bed

SKIN: No petechiae or ecchymosis noted

HEENT: Normocephalic, atraumatic, neck supple, mucus membranes moist

CV: Regular rate and rhythm, no murmur

RESP: Lungs clear to auscultation bilaterally

ABD: Soft but distended abdomen, palpable hepatosplenomegaly

NEURO: Alert, moves all extremities

LYMPH: No LAD

You send labs and then review the single view chest XR obtained at the outside hospital (shown below).

Questions for you (answer according to your PEM experience)

Case continues: You receive a call from the lab with a critical WBC 800,000. The CMP is still pending. You go to assess the patient, who is clinically unchanged.

One more question for you

How would you approach this case? Please share your opinions by clicking on "comments" below. It is easiest if you're also logged into your gmail account but you can do it without as well. Just select "Name/URL" from the drop down menu, write your name, and click submit. You can also post anonymously although this seems less fun. To read posted comments, click on "comments" below and scroll up.

Come back later for the denouement of this case

About the Hot Seat. Hot Seat cases are written by PEM fellows at Children's National, Inova Fairfax, and Johns Hopkins. The Hot Seat Attending is a selected faculty member who comments on the case without knowing the outcome. Emily Willner is the faculty mentor for the series.

Hot Seat #38 Denouement: 11 yo girl with headaches

2014-05-15T16:02:00.001-04:00

by Sylvia Ansah, Johns Hopkins
with Moh Saidinejad, Children's National, on the Hot Seat

The Case

This is a case of an 11 y/o obese female presenting with intermittent, increasingly severe headaches x 2 months. Her initial exam showed no focal neurological deficits, intact sensation, normal gait and sharp optic disc margins. The case focuses on treatment and diagnostic dilemmas. Mohsen, our Hot Seat attending for this case, uses the case as a reminder of the broad differential diagnosis for headaches and also gives great rationales for clinical decision making. For the full case presentation, click here.

Here's How You Answered Our Questions
What medication strategy would you order initially to treat her headache?
LESS than 3 yrs PEM experience (n=16)

MORE than 3 yrs PEM experience (n=6)

With regards to medication strategy, it is interesting to note the varying preferences among experience of providers. 56.3% of providers with less than 3 years experience would start with a bolus/ketorolac/metoclopramide PLUS diphenhydramine. This is compared to the 16.7% of providers with more than years experience. On the other hand, 50% of PEM providers with more than 3 years experience preferred bolus/ketorolac PLUS metaclopramide or similar. This indicates that many of our more experience providers are opting to eliminate diphenhydramine from their migraine cocktails. In the less than 3 years experience group, equally split (12.5%, n=2 each) were IV fluid bolus with ketorolac, bolus/ketorolac PLUS metaclopramide or similar, or a different medication plan. Only one person (in the less than 3 years experience group) chose a trial of triptan only. In both groups no one would start with a PO analgesic (ibuprofen, acetaminophen).

If your patient does NOT respond to your medication plan, rate your likelihood of obtaining a CT this visit:
LESS than 3 yrs PEM experience (n=13)

MORE than 3 yrs PEM experience (n=7)

In terms of the utility of head CT, the responses were split in both groups. The majority of providers with less than 3 years experience were split between likely and somewhat likely getting a head CT (38.5%, n=5 each). Providers with more than 3 years experience were split between not likely, somewhat likely and very likely getting a head CT (28.6%, n=2 each). None of the providers with less than 3 years experience were very likely to get a head CT.

Case continues: She receives an IV “migraine cocktail” with improved symptoms, and is sent home with instructions for NSAID restriction and with Benadryl and Compazine q 12 hours prn headache. She returns one week later with worsening generalized headache, eye pain (left greater than right), and neck pain for the past few days. She has tried acetaminophen, ibuprofen, and Excedrin with no relief. + occasional nausea, no emesis. Headache is worse when patient bends over.
T: 36.3 HR 77 RR 18 BP 116/67 O2 saturation 100%
Exam is unchanged.

Do you think this patient must have an LP prior to leaving the ED?
LESS than 3 yrs PEM experience (n=13)

MORE than 3 yrs PEM experience (n=7)

The majority of both groups (76.9% and 71.4%) would do an LP prior to the patient leaving the ED, but would perform a CT first. Of the providers with less than 3 years experience, 7.7% (n=1) would get an LP but believed a CT was not necessary beforehand. None of the providers with greater than 3 years experience shared this opinion. One provider in the greater than 3 years experience group would wait for MRI and then LP.

Clinical Reasoning
A great thank you to Dave and Jim for your comments. Below is an excerpt of a few clinical reasoning pearls but reading their comments in full is recommended.

“When difficult to localize to anything other than "headache" and if symptoms not classically migranous, this often means........use IV meds but if not improved, CT and LP.” – Dave Mathison, Children’s National
“The standard of care would require and examination of the optic disks.” – Jim Chamberlain, Children's National

“Either a J-tip, EMLA, or addition of an IV pain med are usually necessary [for LP] in this age group. …I do use ketamine and there is plenty of evidence that there is not a significant increase in intracranial pressure. But if doing the LP for the number (OP) I don't think it's worth the risk.” – Dave Mathison, Children’s National

From the Hot Seat
by Moh Saidinejad, Children's NationalLooking at the facts in the case:
1) Obese 11 year-old female with headaches
2) Headaches are intermittent and have been going on for a couple months
3) Looks like no associated symptoms (photophobia, neck stiffness, etc...)
4) Taking NSAIDs around the clock - probably too much
5) Nothing exciting on the family history or physical exam - assuming the fundoscopic exam with sharp disk margins are complete and reliable

I agree with a lot of what Dave said.

DDX:
A) Idiopathic Intracranial hypertension (obesity, possible Polycystic ovaries, maybe retinoids for acne? We don't have a medication history though, or acne hx.
B) Sinusitis and sinus headaches - one nugget of information I learned long time ago is that sinus headache definitely gets worse with bending forward as in this case.
C) Other headache types (migraines, stress headaches, cluster or tension headaches).
D) Infectious - Encephalitis, meningitis (viral first, then other causes). If it were bacterial, it probably would not have dragged on two months without serious problems. Included in there is brain abscess
E) Mass- either benign (e.g. meningioma) or malignant - includes posterior fossa tumors,) Other masses such as pituitary adenomas, CA, etc..
F) Intracranial anatomical issues (large CSF obstructing cysts, AVM, sinus thrombosis).
G) Post concussive (very prolonged) headache – not likely here.
H) Everyone's favorite: Psych stuff: somatization, conversion, malingering (drug seeking - less likely in an 11 year old), psychological stress from bullying, etc...
I) Medication induced headache from too much NSAIDs

At this stage, I would first make sure that I get a great exam myself, including the fundoscopic exam, motor, sensory, and gait.

* I would do a CBC with differentials, a BMP (pituitary, craniopharyngiomas as Dave mentioned) checking Na. K, Cr and a UA (fishing for DI)
IF LABS ARE OKAY TO ALLOW IVF
* Then, I would try migraine headache protocol (IVF, ketorolac, metoclopramide or even ondansetron which is supposed to have headache as side effect, but works with migraines). I know I said that too much NSAID headache is on my differentials, but I really want to see what the response to migraine protocol is.
IF NO RESOLUTION OF PROBLEM,
*I would do a head CT (first a non-contrast plain CT to evaluate for mass, bleeding, ventricular size, and status of the sinuses)
IF NO ANSWER FROM THE CT
* Then I would do an LP. I honestly don't think the latest literature supports the caution about ketamine and increased ICP. I would actually like ketamine as single agent for its amnestic, analgesic, and sedative properties, if it looks like local lidocaine and j-tip is not sufficient.
IF NOTHING EXCITING ON THE LP

ASSUMING NO MASSES, NO CSF PLEOCYTOSIS, PROTEIN ELEVATION, AND NOTHING TO SUGGEST SINUS DISEASE
* I will be back to one of the other types of headaches mentioned.

What am I missing? I assume this kid is not immune compromised, and has no foreign travel to prompt exotic etiologies. At this point, I have reached the end of my 2-3 hours of ED evaluation and the patient either needs to be discharged with outpatient follow up or be admitted. I vote for neurology, but if gen med takes them, great.

If discharge:
* I would try to get the neurology appointment expedited
* Also refer them back to PCP to consider outpatient psych evaluation if all medical issues come up empty.

Would I try to get an MRI/MRA during the ED visit to get a better look at posterior fossa and other structural details, and the cerebral vasculature and look for microaneurysms? Maybe, if I can get one done very quickly, but this should be able to be done as outpatient, especially if we have the negative CT in the bag.

What do I think are the top 4 on my list?
1) Sinus headache
2) Idiopathic Intracranial hypertension
3) Migraine headache
4) A mass

Since this is hot seat and the case is probably more on the extreme side, I would go with brain mass.

The Denouement
by Sylvia Ansah, Johns Hopkins
The patient presented to the emergency room twice secondary to a history of headaches and nausea over one month, with the headaches becoming more severe and constant. She went to the ED for her second time with worsening headaches and blurred vision, and vital signs were relatively stable. She appeared in no acute distress initially, but had worsening headaches upon lying down and complained of 10/10 pain. There was questionable papilledema by the ED attending and confirmed papilledema by ophthalmology. She underwent a MRI on the second visit to the ED, which demonstrated obstructive hydrocephalus and Chiari I malformation. She had no previous history. She was admitted by neurosurgery and she had placement of a VP shunt with a strata programmable valve set at 2.0. She tolerated procedure well, and was in stable condition on intravenous antibiotics. During her postoperative course, her vital signs remained normal. There was no bradycardia and she remained afebrile throughout her postoperative course. Her blurry vision and headaches resolved status post VP shunt placement. She was discharged home on the first postoperative day, tolerating her diet without difficulty.

Please answer two quick questions below. The data helps inform our future case design. Thanks for participating.

Like the Hot Seat? Don't miss a case. Subscribe for email updates of new posts by adding subscribing in the field at the top of this page or by clicking here. The Hot Seat is a recurrent online case series aimed at facilitating asynchronous sharing of PEM knowledge and experience. Faculty are placed on The Hot Seat and publish their opinions without knowing the case or its outcomes. Cases are based on real cases and written by PEM fellows at Children's National in DC, Johns Hopkins in MD, and INOVA Fairfax in VA to highlight teaching points. Emily Willner is the faculty advisor for the Hot Seat.

Hot Seat #38: 11 yo girl with headaches

2014-04-27T23:53:00.001-04:00

by Sylvia Ansah, Johns Hopkins
with Moh Saidinejad, Children's National, on the Hot Seat

The Case

11 y/o obese female presents with complaint of intermittent headaches x 2 months, now with increasing frequency. Headache involves her “entire head” “pounding”, at worst 10/10. The headache lasts “a few minutes” then resolves. No associated tinnitus, photophobia, phonophobia, vision changes, or nausea/ vomiting . Currently headache is a 5/10. NSAIDs last taken 3 hours ago. Patient has seen her PCP for this headache and was placed on NSAIDs, which she is taking every 4- 6 hours. Pain seems to respond to the medication initially, but then headache returns after NSAIDs have worn off.

Mother states patient infrequently wakes up with a headache. No fevers, neck pain , runny nose, nasal congestion. She has been keeping a headache diary but not food/fluid intake intake diary in conjunction. Patient does not drink any caffeine and takes approximately 64 ounces of water per day. Mother and patient have been actively working on healthier diet and lifestyle. Patient has an upcoming appointment with a neurologist but has worsening headache.

PMH: Not significant
PSH: Adenoidectomy
FH: Maternal side- history of various CA, but no brain tumors
SH: Lives at home with mom.

Vital Signs T: 36.6 HR 73 RR 20 BP 104/67 O2 Saturation 100% RA Wt. 88kg
Gen: Well appearing, well nourished, no acute distress, does not appear uncomfortable
HENMT: NC/AT, normal Tms bilaterally, normal nasal exam no evidence of swollen turbinates or rhinorrhea, MMM, oropharynx clear
Eyes: PERRL, Optic disc margins sharp
CV: WNL
RESP: CTAB, normal WOB
GI: soft, non-tender, non-distended, no hepatosplenomegaly
Neuro: No focal neurological deficits, sensation intact, normal gait

Questions for you (answer according to your PEM experience)
Case continues: She receives an IV “migraine cocktail” with improved symptoms, and is sent home with instructions for NSAID restriction and with Benadryl and Compazine q 12 hours prn headache. She returns one week later with worsening generalized headache, eye pain (left greater than right), and neck pain for the past few days. She has tried acetaminophen, ibuprofen, and Excedrin with no relief. + occasional nausea, no emesis. Headache is worse when patient bends over.

T: 36.3 HR 77 RR 18 BP 116/67 O2 saturation 100%
Exam is unchanged.
One more question for you
How would you approach this case? Please share your opinions by clicking on "comments" below. It is easiest if you're also logged into your gmail account but you can do it without as well. Just select "Name/URL" from the drop down menu, write your name, and click submit. You can also post anonymously although this seems less fun. To read posted comments, click on "comments" below and scroll up.

Come back later for the denouement of this case

About the Hot Seat. Hot Seat cases are written by PEM fellows at Children's National, Inova Fairfax, and Johns Hopkins. The Hot Seat Attending is a selected faculty member who comments on the case without knowing the outcome. Emily Willner is the faculty mentor for the series.

Hot Seat #37 Denouement: 18 month-old with increased work of breathing

2014-04-17T17:39:00.001-04:00

by Jason Woods, Children's National
with Maybelle Kou, Inova Fairfax, on the Hot Seat

The Case

This is a case of an 18 month-old boy with respiratory distress. His initial exam was not unlike many patients we see in the ER in the winter. But after a nebulizer treatment, he became worse clinically. This prompted a chest x-ray showing cardiomegaly. Maybelle, our Hot Seat attending for this case, uses the case to illustrate what novice learners can get from this and also goes through the reasoning behind some of the hard management decision. For the full case presentation, click here.

Here's How You Answered Our Questions
What is your first step in management?
Less than 3 years PEM experience (n = 11)

Greater than 3 years PEM experience (n = 9)

The split on this question was between starting this child on albuterol 7.5 mg with atrovent or just albuterol 2.5 mg without atrovent. The less than 3 years PEM experience group was evenly split between the two options, with a smaller fraction going with albuterol 7.5 mg without the atrovent. At this point, this patient's clinical course seems consistent with bronchiolitis. We know that there are no evidence-based therapies that are effective in bronchiolitis in the ER. The debate here seems to be whether you try a single 2.5 mg albuterol (as allowed for in the 2006 AAP bronchiolitis guidelines) or consider this more like asthma since this 18 month-od child has had multiple episodes of respiratory distress and is on budesonide. Those with greater than 3 years of PEM experience seem to side more with the "treat like asthma" camp. One person in the greater than 3 years PEM experience group pointed out that he or she would start with oxygen rather than any of these aerosolized therapies. Of note, this patient's oxygen saturation was 98% on room air.

Do you order a steroid with your initial therapy?
Less than 3 years PEM experience (n = 10)

Greater than 3 years PEM experience (n = 7)

The response numbers here are small but based on responses, both groups are similarly split on giving this child steroids. Most would not give steroids, although the numbers are relatively close. This is interesting given that in the prior question the majority of those with greater than 3 years of PEM experience would give albuterol 7.5 mg and atrovent. In practice does this mean we are treating these bronchiolitis patients with multiple episodes somewhere between bronchiolitis and asthma?

The patient doesn't get better with your initial therapy of albuterol. In fact, the patient seems more tachypneic and poorly perfused with worsening vital signs and 94% on RA. And here is the x-ray you get because of worsening clinical symptoms.

Of the following, what is your next management priority?
Less than 3 years PEM experience (n = 15)

Greater than 3 years PEM experience (n=10)

This x-ray shows cardiomegaly, perhaps explaining the respiratory distress in this patient. More on that later from our Hot Seat commentary and Jason. This question brings up the contentious debate about the role of fluids, diuretics, and inotropy in potential heart failure. In the less than 3 years PEM group, the largest group would start a dopamine drip with the next largest group giving a diuretic. The greater than 3 years PEM group is evenly split between dopamine and a diuretic. Only one person (in the less than 3 years PEM group) would give a normal saline bolus.

Clinical Reasoning
A great thank you to Dave, Paul, and Simon from Australia for your comments. Below is an excerpt of a few clinical reasoning pearls but reading their comments in full is recommended.

"Big red flag on wheezer that this isn't asthma is puffiness/edema. But given the damage is done with the albuterol, what next?" -Paul Mullan, Children's National

"Re-evaluating perfusion is a must for deciding inotropes....need a better sense of central vs. peripheral perfusion. And a little fluid (5-10ml/kg) is important to fill the tank." -Dave Mathison, Children's National

"Figure out quickly if this kid is warm or cold, wet or dry. Exam didn't tell us about warmth/perfusion/cap-refill initially, but second exam said he's "cold" (other cold signs in general are AMS, narrow pulse pressure, thready pulses)." -Paul Mullan, Children's National

"Next, is he wet? - yes (wet signs in general are: edema, crackles, wheezing, cxr pulm edema seen in him I believe with vessel fullness beyond the 2/3 mark laterally, elevated JVP, HSM)." -Paul Mullan, Children's National

"If this is all pericarditis, then you can try to decrease afterload while preparing the child for a pericardial tap/drain. Intubating these kids is bad news because you'll drop the preload amidst tamponade physiology. So i'd have dopamine and a big needle on hand while waiting for a CICU bed/eval." -Dave Mathison, Children's National

"If this is function (myocarditis/cardiomyopathy), then there are fewer life-saving interventions we have as ED docs before the kid crashes. These are the PEM-docs worst nightmares. Inotropic combos like epinephrine/milrinone or epi/dopa are good.....so is good ol' dobutamine. But these are all arrhythmogenic and risky." -Dave Mathison, Children's National

"I wouldn't attempt intubation unless I had central access either with a femoral line or IO." -Dave Mathison, Children's National

"The expression I was taught was "warm them up (improve cardiac output with milrinone as an inotrope/vasodilator) then dry them out (with lasix)." But this kid is circling the drain, will certainly die if you do nothing, and if you haven't heard from cardiology, it's time to get aggressive so you'll probably do both at once."
-Paul Mullan, Children's National

Paul is also sharing with us a pediatric acute heart failure treatment algorithm that was created by the Evidenced-Based Outcomes Center at Texas Children's Hospital. It is downloadable as a PDF. Thank you to Paul and Texas Children's for sharing.

From the Hot Seat
by Maybelle Kou, Inova Fairfax

Wow, Paul and David, you guys are always here first: you must spend all day on the computer.

Since the audience has probably read their responses already let me add a few more things to think about.

Can you imagine a novice level history being given to you here?

My recent enlightenment exercise is to encourage all medical trainees to paint a descriptive picture of the patient; not just a succinct history that includes pertinent positives and negative ROS, but also to communicate a good visual. All folks in an ED should know from the doorway if the child is sick or not sick. Give your trainee this expectation and hopefully it will pay forward and get you into the patient’s room before they crash. Documentation also should contain pertinent negatives. AND DO NOT COMMIT THE ED SIN OF PREMATURE CLOSURE.

Luckily we have direct bedding otherwise I would be concerned that in the middle of cough and cold season, this little one would sit out front for a bit, especially if the child were still bundled up in multiple layers of clothes. As I try to remind trainees as they go into the umpteenth patient with a cough: don’t miss myocarditis in a sea of bronchiolitis. But I can also extrapolate (having trained in general emergency medicine) as to my suspicions of this not being primarily a respiratory illness: decreased urine output, respiratory distress in the setting of swollen eyes could also point to a cardiac or renal process.

Missing details from THE CASE:
1. Blood pressure. I know. It is not a favourite vital sign to obtain. Most screaming children will have one, but for the puffy, fussy toddler with a dry diaper...I want it and I want it now.
2. Skin: Turgor/Cap refill? Can assess in seconds, easy test to do. TOUCH the patient. Are they cool and clammy? Children need to be undressed.
3. Cardiac exam: FEEL for thrills or heaving. Listen for gallops or rubs (not mentioned here but in the spirit of what seems to be a sick kid with resp distress….)
3. Neuro: “grossly normal for age”. Sounds like an EMR clickbox. Again, I encourage learners to describe the passive neuro exam. If the child is sitting limply in mom’s lap breathing at 62 (vs fighting every device known to man while sucking voraciously on a pacifier,) there is a problem.

Initial assessment: Respiratory distress with VS concerning me for imminent respiratory failure BUT WITHOUT A BLOOD PRESSURE I CAN’T SAY DEFINITIVELY THEY ARE IN SHOCK.
DDX: Bronchiolitis, pneumonia, cardiac: myocarditis with or without effusion, unknown CHD, renal disease, sepsis, hypothyroidism.
Management: Move ASAP to a resuscitation room, just in case.
A: Consider hi-flow nasal cannula to titrate for sats above 95%. Consider Bi-Pap if you have it.
B: One can attempt a breathing treatment here (as is done with many adults with “cardiogenic” asthma) but one needs to be wary of the sympathomimetic effects that can occur. More strain, less gain. (While we’re in the RAD territory, in a child with steroid dependent asthma, one could argue that the reason to give a steroid here is more for stress dosing although I am sure this might be controversial).
C: Establish IV access: i-stat lytes (glucose and potassium), as well as VBG. IO if you can’t get venous. TSH and free T4 as well as cardiac panel including troponin.
Fluids: controversial if you suspect congestive heart failure but if the patient is in shock, treat with a 5-10 cc/kg bolus.
Bedside ultrasound to assess size, ventricular function and rule out effusion and tamponade. EKG to rule out ischemic changes.

When the XR comes back (if you are not blessed with an ultrasound) with a heart the size of a football, confirming your suspicion of cardiogenic shock, I hope you have already called your PICU team/prepared transport.

Pressor considerations:
Depends on what you have at your place. If you are in a community ED and need to transfer, remember dobutamine is not a bad choice and readily available unless pt is crashing and you need EPI. Don’t be afraid to IO but do use local anesthetic if possible. As Paul and David mentioned, this is the sort of patient to optimize cardiac output BEFORE attempting intubation, and you also need to be careful about meds. Adjunct airway and difficult airway algorithms apply. Non-invasive positive pressure ventilation would be really great here as long as the patient is not too far gone.

The Denouement
by Jason Woods, Children's National

Please note that the progression of illness in this case was changed to facilitate the Hot Seat discussion. The actual patient never deteriorated and in the ED remained only tachypneic.

In the ER at presentation, based on her reported history, this patient was initially treated with a single 2.5 mg albuterol neb. She was not given steroids due to the lack on convincing clinical features (very soft symptoms of URI, no definitive wheeze, no other personal or familial atopic history). The eyelid swelling that the mother described was not present in the ED. A chest x-ray was not pursued initially as she had no crackles, no murmur, no focality to exam, and had normal pulses. She was not responsive to albuterol and on further questioning the mother reported that for several days her urine output had been decreasing. Chest X-ray showed dramatic cardiomegaly. Once this was obtained the mother then reported (after initially denying any family history) that the patient had a half-brother with left ventricular non-compaction and a maternal history of idiopathic myocarditis in childhood. EKG showed only sinus tachycardia but no ventriculomegaly. Echo showed significant dilation of both the LV and RV, with severely decreased LV function, mitral regurgitation, and LA dilation. Based on poor LV movement and echo appearance she was diagnosed with LV non-compaction.

Interestingly NEITHER the consulting cardiology fellow or the CICU attending heard crackles or murmurs, or felt abnormal pulses on initial exam. These were variably documented at later times. The patient spent 18 days in the CICU but did not require any significant procedures and was discharged home on diuretics, Lisinopril, and Carvedilol. She has been referred to Genetics and has tolerated outpatient management for several months.

Like the Hot Seat? Don't miss a case. Subscribe for email updates of new posts by adding subscribing in the field at the top of this page or by clicking here. The Hot Seat is a recurrent online case series aimed at facilitating asynchronous sharing of PEM knowledge and experience. Faculty are placed on The Hot Seat and publish their opinions without knowing the case or its outcomes. Cases are based on real cases and written by PEM fellows at Children's National in DC, Johns Hopkins in MD, and INOVA Fairfax in VA to highlight teaching points. Emily Willner is the faculty advisor for the Hot Seat.

Hot Seat #37: 18 month-old with increased work of breathing

2014-04-01T14:00:00.002-04:00

by Jason Woods, Children's National
with Maybelle Kou, Inova Fairfax, on the Hot Seat

The Case

18-month-old female presents with a 3-day history of cough and fussiness. Today she developed tachypnea and retractions. She has been taking less PO than usual since the illness started, and parents are concerned because she had not urinated in the previous 8 hours. She has been less active than usual. She has a hx of reactive airways disease dx by her pediatrician due to several prior episodes of respiratory distress, and is prescribed budesonide and PRN albuterol- however, her nebulizer machine is broken so she has not received any meds for a week. On additional ROS, no noted fevers. Mother notes that patient’s eyes looked “puffy” this morning when she awoke, without discharge.

PMH: RAD as above
IMM: UTD
NKDA

VS: T 37.3 HR 154 RR 62 Sat 98% ORA
Gen: awake, alert, but fussy
Skin: No rash
HEENT: EOMI, PERRL, bilateral upper eyelids mildly swollen, conjunctivae clear
Resp: tachypneic, with belly breathing, suprasternal and subcostal retractions, diminished at bilateral bases without crackles, +very mild intermittent scattered expiratory wheezes
CV: tachycardic, regular rhythm, no murmur, femoral pulses present x 2
Abdomen: soft, non-tender, non-distended, with no organomegaly
GU: Normal female anatomy
MSK: moves all extremities, no edema
Neuro: Grossly normal for age

You prepare to give a respiratory treatment.

Questions for you:

The patient received albuterol 2.5 mg nebulization treatment and did not improve. On re-evaluation, she appears tired, pale, and less interactive. You note that she is very tachypneic with unchanged respiratory distress. Extremities are cool. You order an EKG, x-ray, and place a call to cardiology. Cardiology is stuck in the CICU planning to place a different patient on ECMO and will evaluate your patient as soon as possible. The x-ray is shown below.

Her new vital signs are: RR 70 | HR 175 | BP 72/40 | 94% on room air.

You are planning to arrange ICU admission and establish IV access.

How would you approach this case? Please share your opinions by clicking on "comments" below. It is easiest if you're also logged into your gmail account but you can do it without as well. Just select "Name/URL" from the drop down menu, write your name, and click submit. You can also post anonymously although this seems less fun. To read posted comments, click on "comments" below and scroll up.

Come back later for the denouement of this case

About the Hot Seat. Hot Seat cases are written by PEM fellows at Children's National, Inova Fairfax, and Johns Hopkins. The Hot Seat Attending is a selected faculty member who comments on the case without knowing the outcome. Emily Willner is the faculty mentor for the series.

Hot Seat #36 Denouement: 17 yo with chest pain

2014-03-24T11:26:00.001-04:00

The Denouement has been updated with added information on the clinical course.

by Hassan Chaudhary, INOVA Fairfax
Desiree Seeyave, Children's National on the Hot Seat
Case edited by Emily Willner

This is a case of a 17 yo with acute onset, radiating chest pain with SOB. Chest pain is a frequent presentation but this case had worrisome clinical features for some people. For a complete case presentation click here.

Here is the EKG in question:

Here's How You Answered Our Questions
What does this EKG suggest?
LESS than 3 yrs PEM experience n=12

MORE than 3 yrs PEM experience n=11

The distribution between pericarditis, early repolarization, and acute MI were similarly distributed between the the two experience groups. Most people thought this EKG reflected pericarditis with the smallest percentage thinking that this was an acute MI.

If you consult cardiology, what is your specific consult request?
LESS than 3 yrs PEM experience n=9

MORE than 3 yrs PEM experience n=12

The largest portions of people in both groups wanted an emergent cardiology evaluation based on the history, exam, and EKG findings. But the second largest portion of people in both groups wanted only a non-emergent evaluation just prior to discharge. Another slightly smaller subset was comfortable with waiting until the cardiac enzymes to make a decision. Presumably, this means that results of cardiac enzymes would determine the level of concern for this patient.

Clinical Reasoning
Thank you to Dave and Jennifer for offering your opinions. One person thought it looked like an inferior MI while the other thought perhaps pericarditis. Desiree, our Hot Seat attending this week, breaks down what is worrying and reassuring about this patient, offers her approach to chest pain, gives her interpretation of the EKG, and notes the concern with using nitroglycerin and inferior wall MI. For their complete comments click here.

What does it look like?
"I'm no expert, but it looks like an inferior MI to me. I would go down the STEMI pathway and get the kid out of my ED in a timely fashion (to a place where he could potentially get a therapeutic cath)." -Dave Mathison, Children's National

"Quick ddx for pericarditis: viral (large majority), autoimmune illness (SLE, JIA), uremia, MI. He is adopted, so ask about TB status. Ask about exposure to histoplasmosis- as we learned yesterday, ask about barns and caves. Bacterial: he would be much sicker and febrile." -Jennifer Chapman, Children's National

A diagnostic and management approach
"My practical approach would be: IV, nitro-, morphine, oxygen, CXR." -Dave Mathison, Children's National

Labs: cbc, esr, crp, cmp, cardiac enzymes, no blood cx, ?viral titers for coxsackie, EBV, influenza, echovirus, HIV (check this with Cards, but probably not necessary). CXR. Echo from Cardiology colleague, may try myself first. -Jennifer Chapman, Children's National

Too call or not to call cardiology
"I wouldn't consult cardiology because I don't have a question for them." -Dave Mathison, Children's National

"Since the patient is uncomfortable but otherwise shows no tachycardia and no narrowed pulse pressure and no hypotension, I don't feel urgency about consulting Cardiology, but would put them in the loop while waiting for labs." -Jennifer Chapman, Children's National

From the Hot Seat
by Desiree Seeyave, Children's National

Red flags in the history of this patient that point to a possible cardiac cause of pain include:
1. Sudden onset
2. Radiation to the neck
3. “pressure”-like (I think ischemia with all of these)
4. SOB

Factors that point to a noncardiac cause include:
1. It started at rest
2. Worse with laying down (typical of pericarditis)
3. No diaphoresis
4. No syncope

The denial of substance abuse does not preclude getting a urine drug screen as cocaine, marijuana and amphetamines are well known to cause coronary vasospasm, angina, and ischemia.

Obtaining an EKG +/- CXR in most pediatric patients with chest pain are “low risk, high yield” in terms of ruling out pathology of the heart and lungs, as well as giving parental and patient reassurance if these are normal.

His VS are stable, with a bradycardia that may be normal due to his age and gender. The lack of reproducible chest wall tenderness raises another red flag for me, however not all cases of muscular pain have chest wall tenderness. The normal cardiovascular exam and lack of hepatomegaly is reassuring but does not rule out cardiac causes of chest pain.

The EKG shows normal sinus rhythm, HR 54, normal left inferior axis, normal PR interval, normal QTc of 0.34, and normal QRS duration of 0.08 seconds. The morphology of the QRS complex shows Q-waves in leads II, III and aVF, as well as ST elevation in these leads as well as aVR, aVF, V2-6. Pathologic Q-waves are > 0.04 seconds in duration and > 25% of the total QRS amplitude, hence the Q-waves seen in III and aVF seem to be pathologic.

The inverted T waves in leads V1 and V2 are normal for age. The other T waves have normal morphology. There is normal R-wave progression from V1 to V6. There is also a deep S wave in V1, Q-wave in III but no T-inversion in III (the S1Q3T3 pattern typical of PE, but seen in only about 20% patients), and no R-axis deviation or diffuse T-wave inversions that are more typical of PEs.

The pattern shown on EKG could indicate an inferior wall MI (Q-waves in III and aVF, ST elevation in II, III and aVF), however the diffusely elevated ST elevation in most leads could indicate an inflammatory process such as pericarditis vs benign repolarization with J-point elevation seen commonly at this age. The lack of tachycardia or any other arrhythmias are reassuring but do not definitively rule out an MI.

Since the EKG points to a possible inferior wall MI, I would rule this out first. I would obtain cardiac enzymes, urine drug screen and inflammatory markers of ESR/CRP while consulting cardiology emergently. A CXR should be done to assess for cardiomegaly which could be due to dilated cardiomyopathy, a pericardial effusion, or pulmonary causes of chest pain such as pneumothorax.

The acute treatment of acute MI includes MONA (morphine, O2, nitroglycerin, aspirin). The patient should be placed on O2 to optimize cardiac muscle oxygenation and pain control with morphine if needed to decrease anxiety and improve cardiac coronary perfusion. I would consider giving nitroglycerin after cardiology consultation as nitrates in inferior wall MIs can precipitate profound hypotension. Although rare, cardiac ischemia in children can occur from undiagnosed coronary abnormalities such as ALCAPA or ALCA from the right coronary sinus, or coronary fistulas. Getting cardiology on board early to perform ECHO and cardiac catheterization is essential to preserving cardiac muscle and function.

If the cardiac enzymes are normal, they should be repeated in 3 hours, and serial EKGs should be obtained. If there is elevation in ESR/CRP, this may point to peri/myocarditis. If all the labs are normal, then the diffuse ST-elevation may just be caused by early repolarization and the patient can be reassured. If he continues to have chest pain and SOB despite proper pain medication with NSAIDS, further workup may be needed e.g. to rule out a PE.

Denouement
by Hassan Chaudhary, Inova Fairfax

This patient initially presented to an outside ED with the above EKG which was interpreted as infero-lateral STEMI. He had received aspirin, nitro and morphine at the outside hospital prior to his transfer. His troponin was positive at 0.72 ng/mL (normal less than 0.01), myoglobin was 271 ng/mL (normal less than 96), and CKMB was 37.4 ng/mL (normal less than 3.6). At the time of transfer, he was mostly pain free. A repeat EKG still showed significant infero-lateral ST segment elevations (more prominent than in other leads). At our hospital when it was repeated, the troponin I was 13.37 ng/mL (normal less than 0.09). He was seen by cardiologist and, in consultation with them and an adult Cardiologist, the decision was made to take him to cath (with an adult interventional cardiologist) for possible intervention in presumed STEMI. His coronaries were normal on cath other than a non-signifcant LAD muscle bridge, though he did have mild global hypokinesis noted, and some ectopy (run of Vtach), when they were injecting the LAD with contrast, that spontaneously resolved.
The patient was admitted to the pediatric intensive care unit where he remained pain free. A cardiac echo was performed the following day and was found to be normal with no cardiac artery anomalies. Infectious disease was also consulted for possible infectious causes, but none were identified. His troponin peaked at 19.87 ng/mL and on the day of discharge was 6.7 ng/mL. An electrocardiogram on discharge showed resolution of ST segment elevations with flipped T-waves in the inferior leads. The patient was discharged from the PICU after 2 days on famotidine and ibuprofen. The patient followed up with cardiology and infectious disease. In follow up with cardiology one week after discharge, the patient reported no new or recurrent symptoms. Echocardiography was normal. The EKG still showed inverted T waves in leads III and aVF, and the patient was ultimately thought to have myopericarditis.

Like the Hot Seat? Don't miss a case. Subscribe for email updates of new posts by adding subscribing in the field at the top of this page or by clicking here.
The Hot Seat is a recurrent online case series aimed at facilitating asynchronous sharing of PEM knowledge and experience. Faculty are placed on The Hot Seat and publish their opinions without knowing the case or its outcomes. Cases are based on real cases and written by PEM fellows at Children's National in DC, Johns Hopkins in MD, and INOVA Fairfax in VA to highlight teaching points. Emily Willner is the faculty advisor for the Hot Seat.

Hot Seat #36: 17 year old with chest pain

2014-03-12T17:01:00.001-04:00

by Hassan Chaudhary, INOVA Fairfax
with Desiree Seevaye, Children's National

The Case

17 year-old male with no PMH presents with 1 hour of chest pain. Pain began when he was sitting down, and is now 9/10, left sided and radiates to left neck, and is “pressure-like.” Pain is worse with laying down. + mild subjective SOB. No nausea, vomiting, diaphoresis, headache, syncope, URI, cough. Denies substance use.
Famhx: Adopted

PE:
36.4C, HR 56, RR 16, BP 121/53, 100%RA, wt 84kg

Gen: Alert and oriented
HEENT: WNL
Cardiovascular: RRR, No murmurs, gallop, or rubs
Respiratory: CTAB, normal work of breathing, No chest wall tenderness
Abdomen: Soft, NT, ND, +BS. No organomegaly
Musculoskeletal: No extremity edema or tenderness
Neurological: A&O X3, no focal deficits

You obtain an EKG.

Questions for you

How would you approach this case? Please share your opinions by clicking on "comments" below. It is easiest if you're also logged into your gmail account but you can do it without as well. Just select "Name/URL" from the drop down menu, write your name, and click submit. You can also post anonymously although this seems less fun. To read posted comments, click on "comments" below and scroll up.

Come back later for the denouement of this case

About the Hot Seat. Hot Seat cases are written by PEM fellows at Children's National, Inova Fairfax, and Johns Hopkins. The Hot Seat Attending is a selected faculty member who comments on the case without knowing the outcome. Emily Willner is the faculty mentor for the series.

SPIT to teach in the ED

2014-03-11T11:43:00.000-04:00

by Sonny Tat
Children's National

Teaching at the bedside in the ED can be challenging. We're often pressed for time and its hard to gauge the level of your learner. Maneesha Agarwal, a 3rd year PEM fellow in Charlotte, NC suggests in a recent post on the PEMNetwork blog that one approach might be to broaden the differential and SPIT.

Serious
Probable
Interesting
Treatable

According to Maneesha, here's how the technique works:

The learner comes up with at least one unique diagnostic possibility for each letter of SPIT for the patient in question.
You can discuss it as part of the patient presentation or even after reviewing the triage summary before seeing the patient.
It can vary depending on your learner and personal style.
Some even have learners write down their responses on an index card prior to discussion!

SPIT is a quick, interactive way to help the learner to get into the PEM mindset by thinking broadly and specifically. Check out the post, read the example, and see if SPIT works for you and your learners.

Hot Seat #35 Denouement: 6 mo with fever

2014-03-05T22:47:00.000-05:00

by Mordechai Raskas, Children's National
with Jennifer Anders, Johns Hopkins on the Hot Seat

The Case
This is a case of a 6 month-old boy with 2-3 days of persistent high fevers and dehydration. The challenge in this case is how to approach this moderately ill-appearing patient with an abnormal UA. For a complete case presentation, please click here.

Here's How You Answered Our Questions
What's your plan for initial rehydration?
Less than 3 years PEM experience (fellows, PAs/NPs, pediatricians) n=14

More than 3 years PEM experience (PEM attendings, pediatricians) n=11

The hydration plan breakdown is fairly similar between the less than 3 years PEM experience and greater than 3 years PEM experience. Most people would go straight to IV fluid bolus in this patient. Dave discusses in his comments his hesitation with giving zofran to a 6 month-old, limiting it's use to those with straight-forward acute gastroenteritis. Jennifer, the Hot Seat attending, says that while she is a proponent of PO hydration, the clinical scenario here warrants IV hydration.

If you order initial studies, what is the highest priority study?
Less than 3 years PEM experience (fellows, PAs/NPs, pediatricians) n=15

More than 3 years PEM experience (PEM attendings, pediatricians) n=11

There is a difference in what the less than 3 years PEM experience would prioritize compared to the greater than 3 years PEM experience. A larger proportion of the less than 3 years group would get a CBC and blood culture while a larger proportion of the greater than 3 years group would do no studies initially. The proportion of catheterized urine and chest x-ray are similar. One person in the less than 3 years experience group said, ">Cef for the UA, sure, but the VS must be addressed." It brings up the question of if you're going to give ceftriaxone to this child, do you first need a blood culture in the case that it's urosepsis? Do you rely on the white blood cell count to guide your management?

Clock ticks, time passes
The patient fails a PO challenge and is given a NS bolus. He remains tachycardic between 190-210, and a second bolus is given. Urine and blood work are obtained. Urine sediment is visible and it is orange in color, UA demonstrates protein 3+, bilirubin 2+, trace ketones, nitrite negative, leuk esterase 3+, RBC 0, WBC 82.
CBC shows WBC 7, HGB 11.1, PLT 317.
Chem Na 135, K 4.2, Cl 101, CO2 19, BUN 18, Cr 0.4, Glu 14

What is your next step?
Less than 3 years PEM experience (fellows, PAs/NPs, pediatricians) n=13

More than 3 years PEM experience (PEM attendings, pediatricians) n=8

The groups again diverge here, more so than usual. A larger proportion of the greater than 3 years experience group would most next like to give ceftriaxone for pyeloneprhitis and admit. In contrast, the less than 3 years group had about a third that wanted to get LFTs next. Jennifer, our Hot Seat attending, provides us with a reference for the utility of LFTs in myocarditis in her discussion.

Clinical Reasoning
This case spurred an excellent discussion on fever in a 6 month-old. It touched on the common, likely, and worrisome. As a whole, the four respondents--including our Hot Seat attending--gave us an excellent analysis that will likely come in handy the next time we are faced with such a patient (which is probably tomorrow). For their complete comments, click here.

How to Piece It Together
"I like to play devil's advocate to convince myself why this child is anything other than "fine". So here are some of the questions I would ask myself:
1) Does this patient have a routine superinfection?
2) Should I get a cath urine?
3) Should I give zofran to a 6 month-old?
4) Does this child have real tachycardia?
5) If I hadn't drawn a blood culture and then got that urine result...do I need one?
6) What should I do with the urine result?
7) Does this patient have incomplete Kawasaki because of high fever, red eyes, rash, and pyuria?
8) What should I do if the patient has persistent tachycardia despite rehydration and defervescence?"
-Dave Mathison, Children's National

"I just can't shake the feeling that this is Kawasaki. In this age group (i think <1yo), we don't need to wait for the 5 days of fever, plus he has conjunctivitis and rash." -Rasha Sawaya, Children's National

Urine and URI
"My one thought was that seeing that the baby was most likely viral and URI-y (and I;d suspect that the fevers were false - a bad thermometer), I probably would not have cath'd a circumcised male over 6 mo who had somewhat of a source for the fever (URI)... he is the 3-5% of children with fever and URI symptoms who will still have a culture positive UTI. " -Sabah Iqbal, Children's National

About that Tachycardia
"I'm curious about the HR after the second bolus. If it hasn't fallen to a totally acceptable level for an infant, I'm jumping to EKG and CXR. Even in the face of the UTI and viral URI. Myocarditis scares the living daylights out of me." -Sabah Iqbal, Children's National

"Tachycardia is a big red flag in this child. He's definitely not going home, and not going to the floor unless I see that better after my NS boluses." -Rasha Sawaya, Children's National

From the Hot Seat
by Jennifer Anders, Johns Hopkins

My initial impression is that the infant described is somewhat ill and has fairly nonspecific complaints. He has a total of 3 days of fever, with an impressive maximum temperature of 106. He has upper respiratory symptoms of cough, runny nose, eye discharge and some sort of rash. He is described as having poor intake and relatively little urine output with an interesting description of orange colored urine. The physical exam description adds little, with the exception of tachycardia. He is very tachycardic for a child described as “lying quietly in grandmothers arms”.

This is the kind child that I want to lay eyes on myself after presented by a trainee. The differential diagnosis ranges from fairly benign (e.g. viral syndrome with sinus tachycardia in the presence of fever) to life threatening conditions including sepsis or myocarditis. I may strongly believe in oral rehydration, and would try to encourage this baby to take a bottle. However, given the degree of tachycardia and his listlessness I would proceed with an IV bolus.Given that the summary assessment is "you assess that the patient is at least mildly dehydrated", I will presume that the child does not appear toxic. At this point I would not do additional studies but would reassess after hydration.

After the clock ticks and time passes, we have a child who is even more tachycardic with a heart rate around 200. I am now more concerned and would proceed with workup to screen for both septic shock and myocarditis. Assuming the child has not developed respiratory distress or hypoxia I would provide another 20 cc/kg fluid bolus. At a minimum I would send a CBC, chemistry panel, blood culture and urinalysis and culture. I would also ask for an electrocardiogram and chest x-ray.

Reviewing the results provided, there is pyuria, proteinuria and bilirubinuria. I would begin empiric antibiotic for UTI while awaiting culture, but this doesn't feel like pyelonephritis. White blood cell count is normal from the blood. Kidney function appears normal on the metabolic profile. The pyuria could potentially be sterile pyuria of Kawasaki disease - but this would be a strikingly incomplete case with only 3 days fever and only rash of the 5 criteria, in addition normal white blood cell count is not consistent with acute Kawasaki disease.

The infant may have hyperbilirubinemia secondary to a liver disease or biliary obstruction, and I would like to see transaminase and alkaline phosphatase levels from a chemistry profile. Liver dysfunction could also be secondary to myocarditis and poor cardiac output. Myocarditis can be extremely difficult to catch, especially in infants. A nice discussion of emergency department presentations of acute myocarditis was published by Freedman et al. in 2007. In that patient population, AST was elevated a majority of patients. In addition to EKG and chest x-ray, I generally draw transaminases when I am screening for myocarditis. Of course, echocardiography is the gold standard test and a bedside ultrasound may be another potential screening tool before calling in the specialists.

I expect to admit this child to the hospital however am not yet convinced whether he needs ICU or floor care. If all my studies come back normal, I will admit him to the floor for fluids and antibiotics while awaiting culture results. If his tachycardia does not resolve with fluids, I think he needs an echocardiogram.

The Denouement
by Mordechai Raskas, Children's National

Due to bili in the urine, LFTs ordered and showed T. Bili 3.7, conjugated bili 3.0, ALT 194, AST 78. Additionally, CRP 9.1, ESR 60. CXR was normal. EKG shows sinus tachycardia. Blood and urine cultures were obtained, ceftriaxone is given. Pt admitted to PICU for closer monitoring in setting of unclear diagnosis and significant tachycardia despite 40cc/kg NS IVFs and defervescing. Cardiology consulted and initially wanted to hold off treating for Incomplete Kawasaki given only day 3 of fever. However, PICU requested treatment and Echo when tachycardia persisted despite normal EKGs and appropriate fluid replacement. Echo showed prominence and ectasia of left main coronary artery. Pt given aspirin, IVIG, had a repeat fever, and given a second dose of IVIG. During this time pt developed mucosal changes, swelling of the feet bilaterally, and HgB dropped to 9.8. Fever resolved and pt was discharged 5 days after presenting to the ED. 2 and 6-week follow ups with cardiology showed no abnormalities on Echo; ectasias had resolved and no aneurysm formation.

Please answer the two quick questions below. The data helps inform our future case design. Thanks for participating.

Like the Hot Seat? Don't miss a case. Subscribe for email updates of new posts by adding subscribing in the field at the top of this page or by clicking here.

The Hot Seat is a recurrent online case series aimed at facilitating asynchronous sharing of PEM knowledge and experience. Faculty are placed on The Hot Seat and publish their opinions without knowing the case or its outcomes. Cases are based on real cases and written by PEM fellows at Children's National in DC, Johns Hopkins in MD, and INOVA Fairfax in VA to highlight teaching points. Emily Willner is the faculty advisor for the Hot Seat.

Hot Seat #35: 6 month old with fever

2014-02-26T10:38:00.000-05:00

by Mordechai Raskas, Children's National
with Jennifer Anders, Johns Hopkins

The Case
6 month-old male was seen yesterday and diagnosed with a URI, discharged with instructions for supportive care and return precautions, and now presents again with his grandmother who is concerned for 2-3 days persistent fever and cough. Per report he had a temperature of 106.2 two days ago, 102.5 yesterday, and 102.8 today. In addition to cough, grandmother also notes 1 day of runny nose, bilateral eye discharge, non-pruritic rash on his arms and legs. Today PO intake has dropped sharply, 1 episode of emesis of milk only, and only 2 wet diapers in the past 18 hours with an orange coloring noted on the diaper with the urine.

PMH: eczema
PSH: circumcision
Immunizations up to date, including 6 month
No meds
No allergies

PE:
T 38.7 HR 180 RR 36 O2 Sat on RA 99% Wt 7.3kg
Gen: lying quietly in grandmother's arms
Skin: rough erythematous patches on face (grandmother states baseline) and scattered erythematous macular/ papular lesions on arms and legs throughout (new)
Head: anterior fontanelle soft and flat
Neck: no lymphadenopathy
Eyes: EOMI. injected conjunctiva bilaterally. no discharge noted.
ENT: lips dry, no oral lesions, TMs mildly injected, not bulging
Cardiac: tachycardia, no murmur, cap refill less than 2 sec, extremity pulses 2+ and equal
Lungs: CTAB, non labored respiratoins
Abd: soft, NT, ND, no organomegaly
GU: circumcised, no visible lesions
MSK: moves all extremities
Neuro: no focal deficits

You assess that the patient is at least mildly dehydrated and decide on an initial plan for rehydration.

Questions for you

In this immunized, circumcised 6 mo boy, do you order any initial studies?

Clock ticks, time passes
The patient fails a PO challenge and is given a NS bolus. He remains tachycardic between 190-210, and a second bolus is given. Urine and blood work are obtained. Urine sediment is visible and it is orange in color, UA demonstrates protein 3+, bilirubin 2+, trace ketones, nitrite negative, leuk esterase 3+, RBC 0, WBC 82.
CBC shows WBC 7, HGB 11.1, PLT 317.
Chem Na 135, K 4.2, Cl 101, CO2 19, BUN 18, Cr 0.4, Glu 142

How would you approach this case? Please share your opinions by clicking on "comments" below. It is easiest if you're also logged into your gmail account but you can do it without as well. Just select "Name/URL" from the drop down menu, write your name, and click submit. You can also post anonymously although this seems less fun. To read posted comments, click on "comments" below and scroll up.

Come back later for the denouement of this case

About the Hot Seat. Hot Seat cases are written by PEM fellows at Children's National, Inova Fairfax, and Johns Hopkins. The Hot Seat Attending is a selected faculty member who comments on the case without knowing the outcome. Emily Willner is the faculty mentor for the series.

February 2014's Weekly Articles

2014-02-25T18:20:00.000-05:00

Week of Feb 3: By Alyssa Abo

This week's article is the "Effect of Bedside Ultrasound on Management of Pediatric Soft-Tissue Infection". I'm sure you're not surprised that I would choose an ultrasound article.

I was reminded of this article this week because of a case I had in the ED. A young boy presented with cellulitis on his leg, and his mother reported draining the abscess at home. Based on my clinical exam, I thought there was no underlying fluid collection, but I was suspicious and grabbed the ultrasound machine. Low and behold, there was a residual abscess that needed drainage.

This article highlights the use of bedside ultrasound for soft tissue infections. It demonstrates that the sensitivity and specificity of detecting a drainable fluid collection is higher with ultrasound than clinical exam alone.

I hope this article will encourage all of you to scan with Joanna and myself so you too can ultrasound and determine cellulitis vs drainable fluid collection (once we credential you of course... and then you can bill too!)

Week of Feb 10: By Sabah Iqbal

As I was taking a call from a random hospital the other night, I just WISHED I could see the baby... I couldn't really define exactly how that would have changed my management for that baby, at that moment, but still, the idea of seeing a patient in consultation seemed like a really good idea...

And then I stumbled upon this article from Pediatrics last year: Telemedicine consultations and medication errors in rural emergency departments.
In short, it showed that for rural hospitals in N California, having a telemedicine consult (as opposed to a phone consult or no consult) resulted in fewer medication errors. While this is compelling, I wonder if the real answer is below the surface - are the decreased medication errors because the consult-doc is spending more time with the calling-doc? Is she looking at the patient? Is she providing a new, better, and potentially, different diagnosis than the calling-doc suggested? Was the consult doc staying online while the calling-doc ordered the medications? Was there more of a double-check?
I also found it interesting that errors occurred more frequently with trainees who were not primary peds trained - and that made me a bit worried about the calls I take from PAs at OSH... Again, it would be so neat to be able to see the patient on a video...

So, maybe this is the wave of the future for us as emergent consults...

Week of Feb 17: By Jim Chamberlain

For those of you who are at all concerned about the quality of pediatric care and unexplained variation, click on this week's article: Dartmouth has been gathering evidence of unexplained variation in care for about 20 years, and this is their most recent report from December 2013.

This is a detailed analysis of pediatric care in northern New England.

The variation in care by Hospital Service Area is substantial, even after adjusting for age, gender, and proportion of population receiving Medicaid. A few highlights:

Inappropriate use of antibiotics for upper respiratory infection is lowest in cities where there is a major pediatric hospital. Radiation exposure, including chest x-rays and CAT scans of the head and abdomen, is lowest in cities where there is a major pediatric hospital.
If you are a child in northern New England, you have a risk of tonsillectomy that varies fourfold depending on where you live; your risk of hospitalization is twice in some cities what it is in other cities
Use of the emergency department is twice in some cities what it is in other cities
The correlation between prescribing medications for ADHD and providing the recommended follow-up visits showed a correlation coefficient of zero. The implication is that physicians are prescribing ADHD medications willy-nilly without any systematic process for follow-up
The variation in use of antibiotics among cities is 1.8 fold

In summary, there is still a lot of unexplained variation in pediatric care.

Lest we become complacent and think that this is a problem "out there," take a look at some of our benchmarking graphs for quality in our own emergency department. We still have nearly 10-fold variation in some of our diagnostic testing, such as x-rays for asthma and laboratory testing for RTU patients.

Food for thought….

Week of Feb 24: By Monica Goyal

This week's article was published in this month's Pediatrics and titled, "Management of Febrile Neonates in US Pediatric Emergency Departments."

I chose this article for 2 reasons:

1) I thought it was interesting that even among pediatric emergency departments there is considerable variation with respect to diagnostic testing, antibiotic administration, and admission rates for febrile infants aged 0-28 days. In this study, which was conducted using the PHIS database, 1/3 of febrile infants did not receive recommended management. And this number may even be higher if we were to take into account treatment provided in community, non-pediatric EDs.

2) As this was a study using a large administrative database, this is a shameless plug to support large database research and to attend a conference on conducting research with large databases on March 12th at noon, 5th Floor, Main, Classroom A.

Hot Seat #34 Denouement: Teenager with calf pain

2014-02-24T23:59:00.003-05:00

by Lenore Jarvis, Children's National
with Rick Place, Inova Fairfax, on the Hot Seat

The Case

This is a case of a 14 year-old girl with worsening calf pain. The challenge is in how to risk stratify these teenagers and how to move forward with the evaluation. For a complete case presentation, click here.

Here's how you answered our questions
Would you order a D-dimer on this patient?
Less than 3 years PEM (n=13)

Greater than 3 years PEM

The majority of both sets of providers would not have gotten a d-dimer on this patient, although a sizable minority would order one. See the clinical reasoning and Hot Seat response below on more of that discussion.

Would you use the Wells Criteria to risk stratify this patient?
Less than 3 yrs PEM (n=13)

Greater than 3 years PEM (n=13)

The majority of both provider groups would not use the Wells criteria for risk stratification of this patient, with a fairly even split between either feeling its not useful in kids or just not generally not using it at all for management decisions. At the same time, about one third would use the Wells criteria. One other conceivable choice we didn't give was whether you thought that Well criteria didn't apply in this patient because the PE risk is low (thanks for making that note and mentioning PERC, Priya). If you're not sure which way you'd go personally, read below for an excellent discussion on the use of the criteria and risk stratification.

For those interested, an online Wells calculator can be found here (thanks for the link, Paul).

What imaging would you order FIRST for this patient?
Less than 3 years PEM (n=13)

Greater than 3 years PEM (n=11)

The Greater than 3 years PEM experience group gave us the first unanimous vote in the history of the Hot Seat. All 11 respondents would order a duplex ultrasound on this patient. For the Less than 3 years PEM group, most would order an ultrasound although a few people would either go with nothing or X-ray first. As both Emily and the Hot Seat attending mention in their commentary, how would the calculus change if you didn't have 24/7 ultrasound availability? Would you use resources to transfer this patient for an ultrasound?

Clinical Reasoning
Click here to read the excellent commentary in full. Below are excerpts on several themes for this case.
Is this an adult or a pediatric patient?
"While most of the DVT and PE literature is in adults, this adolescent is adult habitus and physiology (that is - can get pregnant - and worth checking urine-hcg right now in ED)." -Paul Mullan, Children's National

Risk stratification of this patient
"The Well's Criteria is really used for patients in which DVT/PE is high on the differential. Those patients are already stratified to "likely to have a DVT/PE". This patient is not in that population." -Priya Gopwani, Children's National

"Her only risk factor for a DVT is obesity and therefore possible sedentary lifestyle. But she hasn't been completely immobilized. Also, check her for pregnancy (incr coagulable state)." -Jennifer Chapman, Children's National

"This is a patient who is "unlikely to have a DVT", or "low suspicion", so something like the PERC criteria may be more appropriate here. The PERC criteria are:

No Hypoxia — SaO2 >95%

No unilateral leg swelling

No hemoptysis

No prior DVT or PE

No recent surgery or trauma

Age less than 50

No hormone use

No tachycardia

Patients that meet ALL of the PERC criteria do not need further testing/imaging to eval for DVT or PE" -Priya Gopwani, Children's National

The diagnostic approach
"D-dimer not helpful since pre-test probably already high enough. If negative, first talk with the ultrasonographer to assess whether they were adequately able to see the entire vasculature and that the attending reviewed the images as well; if still negative, get an xray to r/o bone tumor." -Paul Mullan, Children's National

"Plain films to look for lytic lesions or the sunburst pattern of osterogenic sarcoma. Highest yield test will probably be an ultrasound, to look for a fluid collection- blood or pus. Duplex scan will need to be done since a DVT has the risk of extension and embolization. Labs: CBC, ESR, CRP, coags, BCx only if antibiotics are given for any reason." -Jennifer Chapman, Children's National

"What I would do is:

r/o DVT. Of course we're all going to do an US, so a D-dimer doesn't add anything here.

do labs for hypercoagulable (in case it's a DVT) and add CK and CBC/CRP to point towards potential infectious or muscle etiology

do XR to exclude bony origin

repeat clinical exam..........everything else (soft tissue tumor, cyst, hematoma, phlebitis, etc) should be differentiated on physical exam to dictate further workup. all of this can be followed outpatient."

-Dave Mathison, Children's National

"Would a D-dimer help you decide whether or not to transfer her to a site with immediately available ultrasound? Or is your level of concern for DVT so high that you would transfer regardless (as Dave said: "Of course we'll all do an US")?" -Emily Willner, Children's National

"I think you have to consider more systemic problems here. Why does a 14yo F have 1+ pitting edema bilaterally? She's too young for true venous stasis. Is her heart functioning? Her kidneys? Is her albumin zero? Or is this an inaccuracy in our physical exam and this is actually non-pitting edema?" -Priya Gopwani, Children's National

"IF she did not have the swelling, and IF she only had tenderness, and IF she only had symptoms for 1-2 days, and IF you were in a low resource setting without ultrasound, she would score 1 point (low risk) and you could consider starting with a d-dimer (if negative - send home with instructions to f/u if not resolving or PE signs; if positive - refer elsewhere for u/s)" -Paul Mullan, Children's National

From the Hot Seat
by Rick Place, Inova Fairfax
[Dr. Place is returning to pediatric emergency medicine in Fairfax after a year and a half treating mostly adults in New Zealand so has some unique insights on evaluating pulmonary embolism]

I would approach this patient with the primary intent of answering the question: what can I not afford to miss on this patient...on this visit.

Like many problems in medicine, the etiology could be something you simply can't prove, like a strained muscle (which is clearly not the case here, as it might be in real life). So testing must be directed at eliminating things that you CAN identify, things that are of relatively immediate clinical importance. The most obvious question is whether this patient has a DVT. As noted, the patient has no known risk factors, although some (adolescent) studies suggest that obesity may be a minor risk factor.

One approach when deciding whether to pursue further evaluation is to use the Well's criteria. Decision aids can be useful, but only when applied to the right patient. For instance, when deciding whether to send a d-dimer to identify (or rather to exclude) PE, I will rely on the PERC rule. But the PERC rule should ONLY be used in patients with a low pretest probability. Otherwise it is invalid. Similarly, I am more likely to use the Well's criteria to exclude further evaluation rather than help me to decide whether to drive further workup. In other words, if my pretest probability is reasonably low, and I do not want to image a patient or get stuck with a false positive test (i.e. d-dimer), I will use the decision rule to justify my medical decision-making (in case I am wrong). This may not be exactly how the Well's criteria is intended, but this is how I would use it.

(There is not room here for a complete discussion of decision rules, but many rules are subjective enough from the start that you can get the answer you want simply by interpreting the data the way you want. For instance, in a prior comment the patient is scored as 2, with one for tenderness and one for swelling. I would score the patient as zero. The swelling is not confined to the affected leg and the tenderness is not specifically localized to the deep venous system). My point is that I use decision aids as a guide, not a rule. In this case, I score the patient at zero but still believe the patient is at reasonable risk of DVT.

In this case, the patient has no clear alternative reason for calf pain, and a "low probability" Well's score still gives you a 3% probability; I would not say that my concern for DVT is exceptionally low. Furthermore, exam is of very limited utility in this patient, forcing us to rely even more heavily on diagnostic testing to sort this out.

If I had 24/7 ultrasound or unlimited resources (e.g. at Fairfax), I would probably go straight to doppler ultrasound to evaluate this patient. It may answer the question positively, or if not, may provide additional information, such as an abscess, hematoma, soft tissue mass, or Baker's cyst (in adults). (Incidentally, in Invercargill, after hours, we would risk stratify the patient and give a shot of enoxaparin and bring them back the next day for a sonogram. If they risk stratified low, I might still bring them back but pass on the LMWH).

I would also order a d-dimer on this patient as ultrasound has good but limited sensitivity for calf DVT (particularly in an obese patient). It is extremely good for proximal venous thrombosis but less sensitive for distal clots (the diagnosis of interest here). If the Doppler was negative (i.e. for proximal DVT), one would need to consider a repeat sonogram in a week or two as 30% of distal DVTs will migrate proximally. One advantage of a negative doppler AND a negative d-dimer is that the need for a follow up ultrasound is probably unnecessary.

Finally, since this patient could have practically anything (especially given that she is a hot seat patient) and since exam is so incredibly limiting, I would likely expand my workup to include screening labs for inflammatory markers (CBC/CRP) which might help suggest a myositis or osteomyelitits and an Xray to exclude occult fracture, some weird bony problem like malignancy or bone cyst (less likely given the calf pain).

The Denouement
by Lenore Jarvis, Children's National

This patient was seen at a satellite site where we do not have ready access to ultrasound. The differential diagnosis was electrolyte imbalance, trauma, musculoskeletal, myositis, and DVT. We felt she was "Moderate Well’s," but looking back, one could also make the argument for "Low Risk" or not applicable to peds. I'm interested to see what people have to say about this point. D-dimer, CBC, ESR/CRP, chemistry, CK were order and within normal range. D-dimer was at the upper limit of normal, though. XR normal. We questioned whether to send the main campus for US with Doppler to evaluate for DVT. A brief literature search concluded that D-dimer not sensitive in pediatrics. We sent the patient to the main campus for an ultrasound via private vehicle. That ultrasound was negative and the patient was discharged with a diagnosis of musculoskeletal related pain with instructions for supportive care with continued motrin. The patient has not returned to our ER to seek care since being discharged.

Editors Note: This is a great illustration of the amount of learning that can be had from a seemingly simple decision dilemma. Since we don't see pulmonary embolism and DVT often in PEM, it's helpful to hear from a wide range of experiences and refresh our memory on available decision rules.

The Hot Seat is a recurrent online case series aimed at facilitating asynchronous sharing of PEM knowledge and experience. Faculty are placed on The Hot Seat and publish their opinions without knowing the case or its outcomes. Cases are based on real cases and written by PEM fellows at Children's National in DC, Johns Hopkins in MD, and INOVA Fairfax in VA to highlight teaching points. Emily Willner is the faculty advisor for the Hot Seat.

Hot Seat #34: Teenager with calf pain

2014-02-11T19:52:00.000-05:00

by Lenore Jarvis, Children's National
with Rick Place, Inova Fairfax, on the Hot Seat

The Case

14 yo morbidly obese F presents to the ED with right calf pain for 2 weeks that has gotten progressively worse. The pain is throbbing/cramping, 8/10 intensity, with no radiation. She feels like there is a “knot” in the back of the right calf. The patient is now walking with a limp. The family thinks the leg is swollen. The is no erythema. Intermittent motrin has not helped. She denies numbness or tingling, SOB/CP, hemoptysis. She has been afebrile. She has no recent illnesses, trauma, immobilization. She is not on hormonal birth control and is not a smoker. There is no past medical history or family history of hematologic problems, DVT or cancer.

EXAM: 37.1C, HR 84, RR 20, 98% RA, weight 122 kg

General: Appropriate for age. Cooperative.
Skin: No rash. No erythema.
Cardiovascular: Regular rate and rhythm. No murmur or gallop. Normal peripheral perfusion. Extremity pulses 2+ b/l.
Respiratory: Lungs clear to auscultation. Respirations non-labored. Breath sounds are equal. Symmetrical chest wall expansion.
Chest wall: No tenderness.
Musculoskeletal: Normal AROM/PROM. Normal strength. No deformity. Tenderness to palpation of right mid-posterior calf. No palpable cord. Difficult to appreciate edema due to patient's body habitus. Calves measure 51cm b/l. 1+ pitting edema b/l. No erythema noted.
Neurological: Alert. No focal neurological deficit observed. Normal sensory observed. Walking with limp 2/2 to right calf pain.
Lymphatics: No lymphadenopathy

Questions for you

How would you approach this case? Please share your opinions by clicking on "comments" below. It is easiest if you're also logged into your gmail account but you can do it without as well. Just select "Name/URL" from the drop down menu, write your name, and click submit. You can also post anonymously although this seems less fun. To read posted comments, click on "comments" below and scroll up.

Come back later for the denouement of this case

About the Hot Seat. Hot Seat cases are written by PEM fellows at Children's National, Inova Fairfax, and Johns Hopkins. The Hot Seat Attending is a selected faculty member who comments on the case without knowing the outcome. Emily Willner is the faculty mentor for the series.

Hot Seat Denouement #33: Vomiting and weight loss

2014-02-06T23:39:00.001-05:00

by Liz Quaal Hines, Johns Hopkins
with Rasha Sawaya, Children's National, on the Hot Seat

The Case

This is a case of a 4 month-old girl with history repaired TGA, intact ventricular septum with vomiting after feeds and clinical dehydration without diarrhea. For the complete case presentation, click here.

Here's how you answered our questions

How much fluid do you order for your initial bolus in this baby with cardiac history?
LESS than 3 years PEM experience (n=13)

MORE than 3 years PEM experience (n=10)

Everyone either wanted to give 10 ml/kg or 20 ml/kg fluid bolus. No one wanted to give 5 ml/kg. A larger percentage of those with less than three years of PEM experience would give a small bolus to start whereas the greater than 3 years PEM experience group had a larger percentage who would start with the standard 20 ml/kg bolus. This discussion is reflected in the comments below in the section on "Fluids in cardiac patients."

What is your NEXT priority in this patient?
LESS than 3 years PEM experience (n=11)

Greater than 3 years PEM experience (n=8)

No one was interested in stopping the NS bolus to wait for repeat lab results. Otherwise, there was a fairly even split in both groups between getting a STAT EKG next or not worrying about the EKG and going to the bolus next. The question is which will kill first, the hypovolemia or potential for arrhythmia? Of note, one person with more than 3 years PEM experience noted that he or she would get urine electrolytes, which include urine Na and osm.

Clinical Reasoning
About hypernatremia
"I hope everyone made the diagnosis of hypernatremia before the critical lab results were revealed. Decreased activity and "doughy" skin together in an infant is pathognomonic for hypernatremia until proven otherwise." -Dewesh Agrawal, Children's National

"In excess solute load, urine Na and Osms will both be high. In hypernatremic dehydration (from lack of sufficient free water intake), urine Na will be low but Osms will be high. In diabetes insipidus, uine Na and Osms will both be low." -Dewesh Agrawal, Children's National

"I'd ask them how they did the formula, but hold off on the formula demonstration for now but pass it on to the inpatient team to assure it's being done right. Let's say you do the demo, you find out and tell them they've done it wrong, and the child dies in the next couple hours during the resuscitation - the parents are always going to think the death was their fault." -Paul Mullan, Children's National

Fluids in cardiac patients
"Keep in mind, most of the cardiac lesions require preload and volume so I would err on the side of giving fluid rather than restricting it. The best way to know is looking at the child's medicines. Unless the child is on obvious afterload reduction (diuretics, calcium blockers, etc)...then odds are that fluid will help and not hurt the child." -Dave Mathison, Children's National

"1st 10 minutes: line, 20/kg bolus push pull, labs including stat VBG with lytes, portable CXR, EKG, call cardiology down with echo machine." -Paul Mullan, Children's National

"He's post TGA - so he should have "normal anatomy" now as his atrial septostomy should have been closed and everything reattached nicely. Except - these TGA kids can have trouble at all of the "connection points" that were repaired - coronaries (can be low flow/stenosed as these were reconnected), aorta (can get AI), thromboses (virchow's triad = stasis + hypercoagulable state + endovascular integrity not perfect; he's got 3 of 3 right now)." -Paul Mullan, Children's National

The differential diagnosis
"Usually diarrhea causes hypernatremia not vomiting. So that's a little suspicious to me.....vomiting and hypernatremia make me think of intracranial things and DI rather than routine hypernatremic hypovolemic dehydration." -Dave Mathison, Children's National

"The money is in asking the caregiver/s to demonstrate how they actually mix the formula -- not just asking how they do it, but to demonstrate it." -Dewesh Agrawal, Children's National

"If he is having any of those cardiac problems, even with perfect formula mixing, he could go into a low cardiac output state --> low GI flow with vomiting --> low renal flow with resultant bump up in K, crt, Na, and bun --> low brain flow with lethargy, etc." -Paul Mullan, Children's National

From the Hot Seat
by Rasha Sawaya, Children's National

First time on the hot seat, “hot” describes it well!

This is how I would run through this case:
With that initial history and physical exam provided I notice the following: A 4 month old, not healthy child, s/p cardiac surgery with complications, still on cardiac medications (hence does not have a perfect cardiac function), who has vomiting, decreased activity, decreased urine output. On exam, VS wnl, definite weight loss, and signs of severe dehydration.

Note: 1st sign of dehydration or shock in kids is tachycardia, this kid is not, but she is on propranolol, which would mask that. I’m not sure what “doughy” skin means. It makes me think of severe decreased skin turgor that I have seen with severe dehydration and malnutrition in underdeveloped countries.

Missing information: what’s the capillary refill (I find it often changes to the worse, before any peripheral pulses changes), and type of feeds and mixing as suggested in above comments with a bit more details about the past 11 days.

What am I thinking at this point? This child is sick and needs immediate resuscitation. I’m not sure what caused this illness: is the vomiting a cause or a symptom, but either way she is severely dehydrated and not in cardiogenic shock (based on exam) and therefore I would say fluids first. I don’t think there is a harm in starting 20cc/kg NS bolus (child is not on meds for heart failure at this point) however I have learnt that everyone else in the ED is scared of this and arguing about 10 vs 20 is not usually fruitful and a waste of time. So I usually go ahead and start with 10cc/kg NS bolus, but given fast, over 15min (if need be faster), while I remain at the bedside if possible, assessing the respiratory status of the child, the liver, the perfusion and if all well, will give another 10cc/kg NS bolus immediately after… and continue as such. I found this puts up less of a fight and everyone is more comfortable with it, without it affecting my management.

Get a D-stick (hypoglycemia is more common than we think in dehydration) and i-stat lytes (if the child is as sick as described).

While all this is taking place, I would wonder, what is causing all this?

Vomiting I have learnt from the cardiologists, can be a sign of heart failure (decreased perfusion to the gut)

Vomiting can also be secondary to hypernatremia, dehydration, or hypernatremic dehydration. What caused the latter? A wrong formulation is possible, though with a home nurse, recent d/c from chronic facility, you would hope everyone at home knows how to mix the formula. Assumptions though I have learnt are our worst enemy in medicine! A new disease would be really unfair to this child, 4 months after recovering from TGA! And why now? I don’t think any of her current meds could be culprits.

This child can still have what any other child can: Gastroenteritis (diarrhea will soon start), gastritis, a UTI (though no fevers) and pyloric stenosis (though it’s a late presentation); More severely volvulus (though abdomen is soft, not distended and vomiting non bilious), intussusception (I’ve seen it at this age, though the child does not seem to be in pain or discomfort).

So what work-up will I start while starting fluid resuscitation?
CXR, EKG to r/o signs of heart failure as they are not always present on physical exam alone (plus every cardiac kid gets these anytime they appear sick), BMP, UA/Ur Cx.

Finally, what will I do with that BMP?
To me, this still looks like hypernatremic dehydration: elevated Na, BUN, Creat (for age, usually it is 0.3-0.4 in infants). The vomiting could have started it, and in a cardiac child, generally not that healthy, and with poorer reserves, it could be enough to tip her off. I would go with my 1st instinct, and treat with more fluids. That would be the treatment of any hypernatremia at this point.

Also to remember: With this Na, she is at risk for seizures. Keep on monitors, have Non-rebreather and BMV at the bedside, and send to the PICU. You will not fix this Na fast enough for the floor!

Denouement
by Liz Quaal Hines, Johns Hopkins

Upon review of the discharge paperwork from the facility, the recipe for the formula was for 34 kcal/oz rather than 24 kcal/oz. Also in consideration was an atypical presentation of pyloric stenosis , and the baby had a pyloric US which was normal. Lab findings were consistent with hypernatremic dehydration. Urinalysis had a high specific gravity (vs low as would be expected in DI—also in the differential for severe hypernatremia dehydration). The hypernatremia was due to inappropriately concentrated formula coupled with vomiting. The hypercaloric formula was sludge-like consistency, making intake difficult as well as causing emesis. The child was admitted and placed on NS fluids with close monitoring of Na levels. She was transitioned to 24kcal/oz formula, patient did very well without additional emesis or hypernatremia.

As a reminder about management of hypernatremic dehydration: Using NS is appropriate as maintenance IV fluid. NS has 154meq/L of Na, which is significantly lower than the patient’s current Na. As the patient’s sodium falls, it would be appropriate to transition to 1/2NS. The rate of fluid administration depends on the chronicity of the hypernatremia. It should be slow when it's chronic and can be faster when it is acute.

Correction: The above denouement was corrected to clarify the lack of a relationship between correction of hypernatremia and central pontine myelinolysis. In addition, we clarified that the rate of hypernatremic correction partially depends on the chronicity of the hypernatremia. Thank you to our readers for your post-hoc commentary. The Hot Seat is a recurrent online case series aimed at facilitating asynchronous sharing of PEM knowledge and experience. Faculty are placed on The Hot Seat and publish their opinions without knowing the case or its outcomes. Cases are based on real cases and written by PEM fellows at Children's National in DC, Johns Hopkins in MD, and INOVA Fairfax in VA to highlight teaching points. Emily Willner is the faculty advisor for the Hot Seat.

Hot Seat #33: Vomiting and Weight Loss

2014-02-02T12:20:00.003-05:00

by Elizabeth Quaal Hines, Johns Hopkins
with Rasha Sawaya, Children's National, on the Hot Seat
Case edited by Emily Willner, Children's National

The Case

4 month-old female infant is brought in by mom for vomiting. Patient is full term with history of transposition of the great arteries with intact ventricular septum s/p repair on DOL 10 with complicated post-op course including ECMO. She had been in a long-term care facility until 11 days ago for “feeding and growing”, and transition to PO feeds with 24 kcal/oz formula. Per mom, she has had two days of non-bloody, non-bilious emesis that occurs after feeds. No diarrhea. Mom reports that while the baby seems hungry, she does not finish her bottles. Per mother, patient is sleepier than usual though does wake and interact. Only 3 wet diapers yesterday (baseline is 6 per day). The visiting nurse referred the baby in for evaluation today.

ROS: No fevers. No rashes. No cough or congestion. No heavy breathing. No sweating. No seizure like activity. No color change or cyanosis.

Medications: Aspirin, Propranolol, Keppra, Prevacid, Erythromycin, Albuterol and Flovent.

Exam: T 37.0 | HR 130 | RR 28 | BP 87/42 | POx 100% RA | 4.7kg (5.14kg at discharge from facility)
General. Quiet infant lying in mother’s arms. Cries with exam, but consolable. Decreased activity.
HEENT. NCAT. Flat fontanel. PERRL, clear sclera. TMs appear normal. Dry lips and sticky mucous membranes, clear oropharynx. Neck supple.
CV. Sternal scar, well healed. Regular rhythm. Normal S1S2, soft systolic ejection murmur. No gallop. Peripheral pulses 2+
PULM. Easy WOB and CTAB.
ABD. S/NT/ND with NABS. No palpable hepatomegaly.
GU. Normal female genitalia.
SKIN. Thickened doughy skin over abdomen. No rashes or lesions.

You order labs and consider your next management steps.

Questions for you (please answer the questions associated with your PEM experience):

You have ordered the above fluids. While waiting for the remainder of yoru studies, you receive a call about a critical lab. The BMP returns as follows:
Na 176 K 6.1 Cl 132 HCO3 24 BUN 62 Cr 0.7 Glu 89

How would you approach this case? Please share your opinions by clicking on "comments" below. It is easiest if you're also logged into your gmail account but you can do it without as well. Just select "Name/URL" from the drop down menu, write your name, and click submit. You can also post anonymously although this seems less fun. To read posted comments, click on "comments" below and scroll up.

Click here for the denouement for this case

About the Hot Seat. Hot Seat cases are written by PEM fellows at Children's National, Inova Fairfax, and Johns Hopkins. The Hot Seat Attending is a selected faculty member who comments on the case without knowing the outcome. Emily Willner is the faculty mentor for the series.

Hot Seat Denouement #32: 2 month-old with new onset cheek swelling

2014-01-20T20:42:00.003-05:00

by Fareed Saleh, Children’s National
with Jennifer Chapman, Children’s National, on the Hot Seat

The Case

An almost 3 month-old boy with new left cheek swelling without a clear precipitant. The swelling is mildly tender without erythema. For a complete case presentation, click here. This was another challenging case, which is reflected in the insightful comments by the faculty and the answers to our multiple choice questions. What would you do if this was your patient? Read on to see if you agree and find out what happened.

Here’s how you answered our questions
Would you perform further imaging during this ER visit?
Less than 3 years PEM experience (n=14)

More than 3 years PEM experience (n=6)

Most people thought that no further imaging was needed. In contrast to those with more than 3 years PEM experience, the under 3 years PEM experience group had some votes for MRI or CT. One person in the under 3 years group said, “I am not sure at this point. I would want info from further labs.” Fair answer. It's a tough spot to be in. One of the more than 3 years group said, “Call plastics or surgery for consult on best further imaging. Also the attending radiologist.” Perhaps someone else has seen something like this?

Following your imaging decision, what is your next management step?
Less than 3 years PEM experience (n=11)

More than 3 years PEM experience(n=6)

This was a mixed bag. The less than 3 years EPM experience group was mostly split between consulting ENT or the “None” option with a few wanting to wait for imaging results or getting a CBC and blood culture. The more than three years experience group was evenly split between labs, ENT, and the “none” option. I think some of the "none" people explain their reasoning below.

Clinical Reasoning
On gathering more data
“It's great to make sure the swelling doesn't cross the angle of the mandible as you'd see with partotitis.” -Dave Mathison, Children’s National

“I would start by asking radiology what differential the US findings (of "free fluid within the soft tissues of the cheek with some small debris, no clear sepatations to suggest abscess, no discernable mass") are most consistent with.” -Dewesh Agrawal, Children’s National

“I guess I'd send coags because it's a boy and theoretically this could be the first presentation of hemophilia if he bled into his cheek. but I've never heard of that.” -Dave Mathison, Children’s National

On what’s the differential for this unusual presentation
“For me, it depends on how much you trust your history. TRUE history (less than 6 hours onset): More likely: salivary gland cyst, blocked salivary duct (stone, infection, mumps), bleed/hematoma, fracture.” -Paul Mullan, Children’s National

“There aren't that many things that cause pain. Fat necrosis does not. Urticaria does not. To me, pain equals: broken bone or clot or infection or contusion.” -Dave Mathison, Children’s National

“Less likely: tumor (name your -oma), infection (abscess, buccal cellulitis, parotiditis; unlikely given not red or hot, but re-examination might find one of these esp as very young infants not always manifesting the rubor/tumor/dolor/calor).” -Paul Mullan, Children’s National

From the Hot Seat
by Jennifer Chapman, Children’s National

To summarize, this is a healthy FT 3mo with 6 hours of one-sided cheek swelling. Possibilities include infection, trauma, congenital anomaly and malignancy. In order:

Infection: even before my time, Hflu caused a classic cellulitis in the cheek from hematogenous spread. The baby’s incomplete immunization against Hflu is his major risk factor for this infection- not race or gender. What supports infection is the relatively rapid onset and the tenderness, while the lack of redness and lack of fever go against it. Other infections: abscess related to a break in the skin and cellulitis related to odontogenic infection- neither is well supported by the physical exam.

Trauma: a not very traumatic cause of this type of exam in older children is popsicle panniculitis- the cold from the popsicle resting inside the cheek injures the fat and causes an inflammatory change. Nothing needs to be done after establishing the history of cold exposure. As for other trauma leading to swelling, the exam doesn’t demonstrate signs of bruising or skin breaks that would make me think of an injury to the cheek.

Congenital anomaly: there are a variety of congenital anomalies that could cause swelling of the cheek, including a cyst within the soft tissue or related to the parotid gland, an adenoma of the parotid gland, a lymphatic abnormality, a hemangioma, probably many others. What would speak against these is the rapidity of onset of the swelling, though sometimes cystic abnormalities do suddenly enlarge with infection or trauma.

Malignancy: rhabdomyosarcomas can arise from any muscle, with the face/neck being a common site (I think the pelvis is most common). But this is much more common in older children/adolescents and I wouldn’t think of it as readily in a 3mo.

How does the US help? The free fluid makes cellulitis and solid tumors less likely. Abscess still not as likely given the exam. So the US leads more towards a congenital anomaly.

Plan: have to commit to whether I think this is an infection- since this is the most serious concern in this young infant. On my bold day, I would not do bloodwork and not admit. I would ask ENT for their input on what might cause this isolated, noninfectious fluid collection. I would also involve the PMD around follow-up and recommended imaging/ENT follow-up. On a worried day, I would get a cbc and BCx and admit for observation, with discussion with the Hospitalist around not starting antibiotics unless the baby develops a fever and around what further imaging might help. In practice, I might phone-a-friend and get another PEM physician’s input.

The Denouement
by Fareed Saleh, Children’s National
The subsequent work-up included further imaging (MRI orbits/face) noted for 'large, heterogenous, lobulated 4 cm mass in the right facial soft tissues. Mass most likely represents a venolymphatic malformation. Also, extensive inflammatory changes surrounding the mass which could be related to recent hemorrhage or superimposed infection.'

See below for representative US and MRI images

Labs drawn included:
CBC noted for leukocytosis (17k), stable H/H (10.2/30.5), platelets of 328k. MCV 64.5.
PT/PTT/INR (14.4/106.3/1.18).
BMP and CRP both were wnl.
Aerobic blood culture was negative.

Of note, after repeated questioning the mother stated her other son from a different father had Hemophilia A that presented with spontaneous bleeding into his scrotum.

Patient was admitted with ENT consulted but deferred surgical intervention. Hematology consulted and levels for Factor VIII (less than 1%) and Factor IX (wnl) were drawn. He was diagnosed with hemophilia A and started on Factor VIII replacement therapy. He was subsequently discharged without incident.

Editor's Note: This is a nice example of medical school hematology in real life. This patient has Hemophilia A, which is a deficiency of Factor VIII. This resulted in an abnormal PTT but relatively normal PT/INR. (Kudos to Dr. Caleb Ward for knowing these facts off of the top of his head when asked during a shift in the ER). For those of you who want the trauma of seeing the coagulation cascade, a good explanation of how it fits into hemophilia can be found here.

The Hot Seat is a recurrent online case series aimed at facilitating asynchronous sharing of PEM knowledge and experience. Faculty are placed on The Hot Seat and publish their opinions without knowing the case or its outcomes. Cases are based on real cases and written by PEM fellows at Children's National in DC, Johns Hopkins in MD, and INOVA Fairfax in VA to highlight teaching points. Emily Willner is the faculty advisor for the Hot Seat.

Debriefing: A case study of the Little Red Hen

2014-01-14T22:45:00.001-05:00

by Sonny Tat

Children's National

David Kessler, who specializes in PEM simulation Columbia University, recently wrote a post for the PEMNetwork.org blog on lessons on debriefing that we can learn from The Little Red Hen. Specifically, he notes several areas of improvement for The LRH when it comes to team leadership. Since Children's National has recently implemented post-resuscitation debriefing, I thought this quick read might spark some reflection.

Hot Seat #32: 2 month-old with new onset cheek swelling

2014-01-12T13:45:00.001-05:00

by Fareed Saleh, Children's National
with Jennifer Chapman, Children's National, on the Hot Seat
Case edited by Emily Willner

The Case

Almost 3 month-old full-term Hispanic baby boy p/w new swelling of his left cheek that started approximately 6 hours prior to arrival. There was no clear precipitant. Per mother, pt has been more irritable since the swelling started but consolable. He is tolerating formula feeds without issue. Good UOP. No other skin findings (rashes, bruises or swelling). No reported fevers. No vomiting/diarrhea. No reported trauma.

Birth-history: full-term born NSVD w/o complication. Mother received prenatal care. NBS negative. +2 mo imm

Exam: T 36.8 R // HR 135 // BP 92/64 // RR 32 // 98% on RA

Pt is comfortable in mother’s arms, interactive and responding appropriately.
HEENT: EOMI. No pharyngeal erythema. Marked swelling noted over right cheek w/o erythema or other skin color change. +TTP. Not warm to touch. Maximal swelling is anterior to parotid gland and does not extend over mandible. Skin is very taut and swollen area feels tense and firm, not fluctuant. No dentition noted. TMs clear b/l.
No cervical LAN
CTAB, normal WOB.
CV exam WNL.
Abd soft, nontender, no HSM.
Skin: atopic dermatitis noted over extremities.
Ext: No swelling, no TTP, pulses 2+ in 4 extremities.

Given the unusual appearance, you obtain an ultrasound showing a collection of free fluid within the soft tissues of the cheek with some small debris, no clear sepatations to suggest abscess, no discernable mass.

Questions for you (answer question associated with your PEM experience)

How would you approach this case? Please share your opinions by clicking on "comments" here or below. It is easiest if you're also logged into your gmail account but you can do it without as well. Just select "Name/URL" from the drop down menu, write your name, and click submit. You can also post anonymously although this seems less fun. To read posted comments, click on "comments" below and scroll up.

Come back later for the denouement for this case

About the Hot Seat. Hot Seat cases are written by PEM fellows at Children's National, Inova Fairfax, and Johns Hopkins. The Hot Seat Attending is a selected faculty member who comments on the case without knowing the outcome. Emily Willner is the faculty mentor for the series.

Hot Seat #31 Denouement: The Double Bounceback

2014-01-09T14:59:00.000-05:00

by Marina Gore, Inova Fairfax

with Nazreen Jamal, Children's National, on the Hot Seat

Case edited by Emily Willner, Children's National

The Case

This is was a case of a 9 year-old boy who came back to the ED three times in a week for various complaints including headache and fever. He has had a recent reassuring head CT and LP showing 300 WBC (90% lymphocytes) and negative viral studies. On exam, he is difficult to arouse and has a limited ROM of his neck on exam. For a complete case presentation, click here.

Here's how your answered our questions

Which of the following is your highest priority next step?

Less than 3 years PEM experience (n=15)

Greater than 3 years PEM experience (n=14)

Both sets of providers had similar priorities. The largest majority of both wanted to repeat the head CT despite it being normal only several days ago. The next largest proportion wanted to give Narcan followed by a segment that wanted to give mannitol or hypertonic saline out of concerns about ICP.

A short while later he is still very somnolent. CT head is grossly unchanged from the one obtained 1 week ago, without abnormalities. Utox +opiate only. CBC, lytes, LFTs and ammonia WNL. You give a dose of Narcan and the patient becomes a more alert, but screams and writhes in pain: "Ow, my head is killing me!"

What is your next management step now?

Less than 3 years PEM experience (n=19)

Greater than 3 years PEM experience (n=15)

The largest proportion of providers in both groups were interested in get a STAT MRI. A larger proportion of providers with less than 3 years PEM experience were being coy and wanted to do none of the options provided compared to the providers with more than 3 years PEM experience. What other options did people have in mind in this situation? On the other hand, a larger proportion of providers with more than 3 years PEM experience wanted to get a blood patch for this patient.

Clinical Reasoning

On the differential diagnosis
"I would worry about: 1- increased ICP, though a nl CT a few days ago is reassuring secondary to an infection abscess missed previously, though doubtful with the initial CSF findings, or bacterial, or worsening viral meningitis 2- Bacterial meningitis potentially caused by the LP done (lack of fevers on tyl 3 Q6 is not the most accurate) 3- Opioid OD (tyl 3 around the clock with pinpoint pupils) 4- CSF leak from previous LP, though the ones I've encountered tend to cause headaches and severe discomfort, but no stiff neck, AMS or abnormal VS." -Rasha Sawaya, Children's National

"Some of the immediate worrisome aspects: bradycardia with hypertension, suggestive of increased ICP; and bradypnea. To take the 2nd one first, the combination of breathing slowly and pinpoint pupils is likely related to the codeine intake. So it makes sense to give Narcan." -Jennifer Chapman, Children's National

On the repeat imaging

"I would start with a repeat CT (because of VS) though one could argue to give the narcan 1st (pinpoint pupils and worsening sx)" -Rasha Sawaya, Children's National

"...given that he is going to be rescanned, I would have chosen a contrast head CT. This would also give the advantage of lighting up the meninges if he has a viral infection (I think)." -Jennifer Chapman, Children's National

On what to do next
"This pt appears to have improved with narcan though pain is worse. This I think could be from opiate withdrawal since he's been taking Tyl 3 for several days. So i would give toradol, get a Pain team consult (methadone? Or too soon?) and have more narcan ready at the bedside as the 1 dose may not be enough for him since he has had opiates in his system for several days now." Rasha Sawaya, Children's National

"Given pain meds as Rasha suggested, review chart and make decision around given antibiotics (probably not) and acyclovir (possibly). Labs already done. Order MRI of the head with contrast. Admit to PICU if his vital signs remain abnormal; to the floor only if he is mentating better than at admission." -Jennifer Chapman, Children's National

From the Hot Seat

by Nazreen Jamal, Children's National

Great case, certainly one that would give me some pause in the ED. My initial focus, as Jennifer and Rasha highlighted, were the elevated BP and low HR that are concerning for increased ICP. The history of T#3 use with pinpoint pupils and slow (not irregular) respirations make me think that opioid use is potentially confounding the picture, as it can certainly cause somnolence, bradycardia, and respiratory depression, but I would expect relative hypo, not hypertension, so it doesn't explain the whole picture. My approach would likely be to draw up 3% at the bedside (but not give it at this point) while getting access and bedside VBG/lytes/glucose, putting the patient on an ETCO2 monitor. I would likely give a dose of Narcan to see if the opioid use was affecting the patient’s mental status and improve my ability to get a more complete neurologic exam. I would think about giving incremental low dose Narcan (0.4 mg) as recommend for therapeutic opioid toxicity, as giving the full reversal dose of 2 mg for someone on opioid therapy may precipitate severe pain .

At this point, if he is more awake but still altered with abnormal vital signs, I would feel obliged to re-image (but not intubate). As Jennifer noted, I would be worried about meningo-encephalitis and would order a CT with contrast. Brain abscess also crossed my mind, but the lack of persistent fever without antimicrobials and non-focal exam goes against this. Though an MRI would be ideal, with hypertension and bradycardia, I think more urgent imaging is indicated, and a CT with contrast would be the fastest substitute.

This is a patient I would accompany to the scanner on full monitors, 3% in hand in case of any change in pupillary or respiratory exam. Along the way, I would be trying to figure out where the original presentation of abdominal pain fits into his diagnosis and make sure I’m not missing anything, but not many things pop into my mind. Mycoplasma encephalitis can be accompanied by GI symptoms, so would add it to the myriad list of diseases to test for with a working diagnosis of encephalitis. I would admit the patient to the PICU, defer LP at this time with the thought that that this is progression of the same etiology that caused the meningitis, and discuss with Neuro/ID for tests to send from the ED while awaiting the PICU bed. Of course, if he becomes increasingly somnolent unresponsive to narcan, has increasing ETCO2s, loses his gag, etc, would have to intubate, but otherwise would watch him very closely until he goes to the PICU.. and would then stalk the progress notes to find out what his diagnosis turns out to be…

Denouement

by Marina Gore, INOVA Fairfax

The patient was admitted. He had an MRI and repeat LP. The MRI showed no acute intracranial abnormality. The repeat LP showed WBC 70 (88% lymphs) , RBC 0, protein 82.5, HSV negative. The patient was started on steroids, which improved his headache. He had improved but persistent gait abnormalities at discharge.

The altered mental status was likely due to narcotics while the headache and persistent neck rigidity was secondary to the resolving viral meningitis.

He is scheduled for neurology and neuro-ophthalmology outpatient follow-up. When called at home, the family said that the patient is doing well, has gone back to school, and is his independent self again.

Editor's Note
by Sonny Tat, Children's National

This patient's somnolence confused an already challenging clinical situation and was likely caused by the codeine in Tylenol #3, which was prescribed earlier. Not everyone who has been on Tylenol #3 for a few days becomes obtunded or difficult to arouse. Recent data has reported deaths in children post-tonsillectomy who have received codeine-based pain medications. Authors suggest these deaths are related to children who are ultra-rapid metabolizers of codeine, which leads to higher levels of conversion of codeine to morphine. The data and variable pharmacokinetics has led the FDA to place a black box warning on using codeine for post-tonsillectomy patients and other authors to suggest that codeine is on it's way out as a drug of choice for pediatric pain control.

The Hot Seat is a recurrent online case series aimed at facilitating asynchronous sharing of PEM knowledge and experience. Faculty are placed on The Hot Seat and publish their opinions without knowing the case or its outcomes. Cases are based on real cases and written by PEM fellows at Children's National in DC, Johns Hopkins in MD, and INOVA Fairfax in VA to highlight teaching points. Emily Willner is the faculty advisor for the Hot Seat.