Non-Accidental Trauma

This case is written by Dr. Suzan Schneeweiss. She is a staff physician at Sick Kids Hospital in Toronto and is the Director of Education for the Division of Pediatric Emergency Medicine at the University of Toronto.

Why it Matters

The differential diagnosis for any sick neonate is always broad. This case, in particular, addresses the differential diagnosis and management of a seizing neonate. It highlights the following:

  • The need for anti-epileptics in a neonate with seizures in the context of trauma
  • The importance of including a septic work-up and broad antibiotic/antiviral coverage in the management of a seizing neonate
  • The need to consider non-accidental injury

Clinical Vignette

A 1 month-old male is brought into the ED due to poor feeding and lethargy. The baby was apparently well until this morning, when his mom noticed it was difficult to wake and feed him. There has been no fever. The baby vomited once this morning, and is voiding and stooling normally.

The nurse in triage notices abnormal movements and brings the baby in to your team in the resuscitation room.

Case Summary

The team has been called to help in the ED after a 1 month-old male is brought in seizing. The team is expected to manage the seizure, but then will subsequently realize on examination there are concerning signs for non-accidental trauma, specifically head injury. The team will be expected to establish definitive airway management and consult with PICU and local child protection services.

Download the case here: Non-Accidental Trauma

CXR for the case found here:

neonatal pneumonia

(CXR source: https://radiopaedia.org/articles/neonatal-pneumonia)

 

Pediatric DKA

This case is written by Dr. Donika Orlich. She is an Emergency physician practising in the Greater Toronto Area. She completed her Emergency Medicine training at McMaster University and also obtained a fellowship in simulation and medical education during her training.

Why it Matters

DKA is a reasonably common presentation to the ED. However, it requires several important steps in its management in order to prevent harm. This is especially true in children, where the rates of cerebral edema are higher. This case highlights several important features in the management of Pediatric DKA, including:

  • That there is no role for an insulin bolus.
  • That the precipitant of DKA must always be considered (in this case, it is appendicitis)
  • That cerebral edema is a known complication of DKA and must be managed immediately with a reduction in the insulin and fluid rates as well as with either mannitol or hypertonic saline

We have previously published a case of Pediatric DKA on emsimcases. Today’s case is unique in that it begins with the learners providing advice over the phone to a physician who is less comfortable managing DKA.  We have chosen to publish on this topic a second time as a way to emphasizes how cases on the same topic can be designed with different objectives in mind. The objectives (and therefore the case design) can lead to very different learning experiences. We have no doubt that this new case will also lead to excellent debriefing and evidence review with learners – it certainly does when we run it for our senior residents at McMaster University!

Case Summary

The learners receive a call from a peripheral hospital about transferring an unwell 8-year-old girl with new DKA. She has been incorrectly managed, receiving a 20cc/kg bolus for initial hypotension as well as an insulin bolus of 8 units (adult sliding scale dose for glucose of >20). The learner must perform a telephone consultation and dictate new orders. On arrival, EMS will state that they lost the IV en route, and the patient will become more somnolent in the ED. The learner should begin empiric treatment for likely cerebral edema and concurrently manage the DKA. Physical exam will show a peritonitic abdomen with guarding in the RLQ. Empiric Abx should be started for likely appendicitis. Due to decreasing neurologic status and vomiting, the patient will eventually require an advanced airway. The challenge is to optimize the peri-intubation course and ventilation to allow for compensation of her metabolic acidosis.

Clinical Vignette

Outside Patch: We have an 8-year-old female we want to send for DKA. She presented after feeling generally “unwell” for 3 days, with some accompanying abdominal pain and vomiting. Her blood glucose came back at 24 with a pH of 7.15 and HCO3 of 12, so we made the diagnosis of DKA. She received a 20mL/kg bolus for hypotension (BP 90/60) and Humulin R 8 unit bolus (as per our hospital sliding scale). What do you want for insulin and fluids before we send her?

Download the case here: Pediatric DKA

Post-intubation CXR for the case found here:

normal-intubation2

(CXR source: https://emcow.files.wordpress.com/2012/11/normal-intubation2.jpg)

Acute Chest Syndrome

This case is written by Dr. Carla Angelski. She has completed both a PEM fellowship at Dalhousie and a MEd in Health Sciences Education. She now works in the Pediatric Emergency Department at the Royal University Hospital in Saskatchewan and is intimately involved in the delivery of high-fidelity simulation at the their sim centre. She is currently working on a curriculum to deliver in-situ simulation for ongoing faculty CME within the division and department.

Why it Matters

Patients with sickle cell disease are subject to a host of crises that can be difficult to manage. This case highlights the unique management of acute chest syndrome. In particular:

  • Recognition of acute chest syndrome as a possibility in the sickle cell patient with respiratory distress
  • Judicious use of fluids in patients with possible acute chest syndrome
  • The possible need for exchange transfusion in patients with severe acute chest syndrome

Clinical Vignette

You are working the day shift at a tertiary children’s hospital. A mother brings in her son, James, a four-year old boy with known sickle cell disease (HbSS). She is concerned since he’s had low energy and a cough for two days. Now he’s had a fever since this afternoon.

Case Summary

A 4-year-old boy with known sick cell disease presents with two days of cough and a one afternoon of fever. The patient is initially saturating at 88%, looks unwell and is in moderate-severe distress. During the case, the patient’s oxygenation with drop and the emergency team is expected to provide airway support. They will also need to pick appropriate induction agents for intubation. The case will end with ICU admission. During the case, the mother will also be challenging/questioning the team until a team member is delegated to help keep the mother calm.

Download the case here: Acute Chest Syndrome

CXR for the case found here:

sickle cell CXR

(CXR source: http://reference.medscape.com/features/slideshow/sickle-cell#8)

Post-intubation CXR for the case found here:

Post-intubation R-sided infiltrate

(CXR source: http://www.swjpcc.com/critical-care/?currentPage=4)

CAH with adrenal crisis

This case is written by Dr. Quang Ngo from McMaster University. Dr. Ngo is a pediatric emergency physician in Hamilton, ON and one of the advisory board members at EMSimCases.

Why it Matters

This cases highlights three crucial management steps for a toxic neonate:

  • Maintaining a broad differential diagnosis (including hypoglycemia, sepsis, metabolic/cardiac conditions)
  • Consideration of hypoglycemia as a cause or consequence of a toxic neonate
  • Treatment of hypoglycemia in a neonate

This case also reviews management specific to congenital adrenal hyperplasia:

  • Recognition of laboratory abnormalities associated with adrenal crisis and initiation of steroid treatment

Clinical Vignette

A 1 week old neonate is brought to the emergency department because his parents are worried that he’s been vomiting and not keeping his feeds down. After he vomited his last feed, his parents noted he was quite lethargic and felt cold. His mom states he’s been increasingly sleepy since discharge and she’s been needing to wake him to feed. In between feeding, he sleeps and doesn’t “act like my other 2 kids did at that age.” The team is called to assess this patient urgently after being triaged because the nurse felt the patient looked unwell.

Case Summary

A lethargic 1 week old presents from home after recurrent emesis and progressive sleepiness. He is hypovolemic, hypothermic, and hypoglycemic. If his hypoglycemia is not quickly corrected, he begins to seize and will continue to do so until the team gives glucose. If they do not, the patient will go on to have a VF arrest. If the team identifies and treats the hypoglycemia, orders blood work, and fluid resuscitates the child, they receive blood results demonstrating hyperkalemia and hyponatremia. If they correctly identify and treat the patient as a possible adrenal crisis, the neonate is safely transferred to the PICU. If they fail to treat the hyperkalemia or fail to administer steroids, the patient will have a VF arrest.

Download the case here: CAH Case

ECG for case found here:

Hyperkalemia peaked T waves

(ECG source: http://lifeinthefastlane.com/ecg-library/basics/hyperkalaemia/)