All posts with tag: "gi"

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Parents bring in a 3 year old child that drank a few sips of household bleach which had been stored by grandparents in an empty coke bottle. 

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You are seeing a 19 year old male who has had several ED visits for abdominal pain, nausea and vomiting. He insists that he does not use cannabis at all.

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A 6 year old boy presents with 2 days of nontender palpable purpura of bilateral lower extremities, accompanied by arthralgia of the left ankle. Vital signs are temperature 37.6, HR 90, RR 20, BP 105/60. He has no nuchal rigidity. He has no significant past medical history. His CBC shows normal platelet count and PT/PTT are normal. 

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(Click the link to comment and to vote - voting not working through email, sorry!) You are seeing a 4 week old infant with non-bilious forceful vomiting x 3 days. [yop_poll id="176"]

(Click the link to comment and to vote - voting not working through email, sorry!) You are seeing a 5 day old infant born term without complications brought to the ED because the parent noted a streak of bright red blood in the diaper. The baby is formula feeding well, not lethargic, has no fever, and has had a few non-bilious spit-up episodes. Physical exam shows mild abdominal distension; no anal fissure seen. [yop_poll id="175"]

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(Click the link to comment and to vote - voting not working through email, sorry!) You are seeing a 3 year old child adopted from another country 6 months ago for abdominal pain. Since then, the child has had chronic nasal congestion and cough as well as failure to thrive which was expected to improve with improved nutrition provided by the adoptive family but has not. The child is afebrile and there are no ill contacts. On exam, there are scant wheezes and O2 sat is 95% on room air. CXR shows hyperinflation. Chart review shows prior visits for respiratory illness, and an episode of rectal prolapse. When asked about the presence of constipation, the parents describe frequent smelly oily stools. [yop_poll id="167"]

(Click the link to comment and to vote - voting not working through email, sorry!) You are seeing a 2 year old who is slowly improving from a bout of acute gastroenteritis manifested by fever, vomiting, diarrhea, and abdominal pain that started 5 days ago. The parent is concerned that he remains less active and appears pale. Vital signs are temperature 37.7, HR 135, RR 24, BP 110/60, O2 sat 99% on room air. Point of care hemoglobin is 6.5 g/dL. [yop_poll id="155"]

(Click the link to comment and to vote - voting not working through email, sorry!) You are seeing a 2yo patient with 6 hours of intermittent episodes of apparent abdominal pain happening every 15-20 minutes, and non-bloody non-bilious vomiting. In between episodes, the child appears well and is playful. There is no fever, diarrhea, or concern for toxic ingestion. The child has a history of constipation with hard stools and occasional skipped days with no stooling. There is no other significant past medical history. [yop_poll id="152"]

(Click the link to comment and to vote - voting not working through email, sorry!) You are seeing a 10 year old boy with abdominal pain. He was seen last night with a few hours of periumbilical abdominal pain. Work-up at that time showed a CBC with WBC 10.2, 55% neutrophils, UA negative, RLQ ultrasound appendix not visualized. He was discharged home with return precautions and instructions to follow-up with his pediatrician. He returns 15 hours later with continued constant right mid-abdomen pain, anorexia, nausea, a few episodes of non-bilious vomiting, and temperature of 37.8. [yop_poll id="123"]

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(Click the link to comment and to vote - voting not working through email, sorry!) A full term infant with no birth complications and no known risk factors for hyperbilirubinemia complications, discharged early at 36 hours of life, presents to the ED on day of life #4 with jaundice that just started on the day of presentation. Serum bilirubin is 15, all unconjugated. The baby is exclusively breastfed and having 4 wet diapers per day. [yop_poll id="110"]  

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(Click the link to comment and to vote - voting not working through email, sorry!) What is the most common cause of lower GI tract bleeding in young infants after anal fissure? [yop_poll id="80"]

(Click the link to comment and to vote - voting not working through email, sorry!) A 1 week old presents with multiple bouts of hematemesis. The baby was born full-term, no complication, has been breast-feeding normally, and is afebrile. The baby is nontoxic, has normal vital signs and perfusion, and has a normal physical examination. Point of care hemoglobin is 15 g/dL. [yop_poll id="76"]

(Click the link to comment and to vote - voting not working through email, sorry!) 14yo boy presents with LLQ abdominal pain and left hip pain for 5 days. He has not had any fever. He is an active baseball player and skinned his right knee the week before. On exam, he prefers to keep his left hip flexed at 90 degrees, walks with a limp and lordosis, and is most comfortable laying on his right side with his hips flexed. He has LLQ abdominal tenderness and has maximal pain with any attempt to extend or internally rotate his left hip. Genitourinary exam is normal. [yop_poll id="61"]

(Click the link to comment and to vote - voting not working through email, sorry!) A 5 month old comes in with diarrhea x 3 days, 5 times per day initially now 3 times per day, non-bloody, no fever, no vomiting. The patient was seen in the ED the day before, and had stool culture sent which was negative, C. difficile toxin which was positive, and stool WBC negative. [yop_poll id="51"]

(Click the link to comment and to vote - voting not working through email, sorry!) An 11 year old girl was sitting with lap belt only in the back seat of a minivan involved in a motor vehicle accident where her car was rear-ended. She has a “seat belt sign,” or ecchymosis over her lower abdomen. Her CT abdomen with contrast is normal, but she continues to have tenderness to palpation. However, she states she is hungry. [yop_poll id="48"]

(Click the link to comment and to vote - voting not working through email, sorry!) A 10 month old infant with history of constipation comes in with a 1cm dark red (but not dusky) painless mass extruding from the anus. The patient is afebrile, well appearing and playful, and the remainder of the exam is unremarkable.  Wikimedia Commons, user BellaVuk [yop_poll id="42"]

(Click the link to comment and to vote - voting not working through email, sorry!) Several members of a family present to the cruise ship infirmary of an Alaskan cruise. They just ate a lunch consisting of tuna salad sandwiches. For breakfast they had a buffet of pancakes and waffles, and last night they ate a shellfish feast dinner which included raw oysters, crab, clams, scallops, and fish. For dessert they had ice cream. They have also been visiting the bar onboard. They are all experiencing abdominal cramping, nausea, vomiting, and frequent watery diarrhea. Some have low-grade fever and chills. Which meal most likely caused their symptoms? [yop_poll id="16"]

A family obtained tuna from the local farmer’s market and prepared it for dinner. The children thought the fish tasted weird, peppery or metallic, but the parents did not, and told the children to stop complaining and eat dinner. Within 20 minutes of consumption, the children complain of headache, dizziness, pruritis, abdominal cramping, and nausea. They appear somewhat flushed in the face, neck, and chest. (Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="12"]

A 19yo man presents with his 3^rd bout of unremitting nausea and vomiting. He has been admitted twice before and treated with ondansetron and IV fluids. He was noted to take frequent long showers while admitted. (Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="8"]

All of the following preclude expectant outpatient management in the case of an ingested button battery found by imaging to be in the stomach except: A. Co-ingestion of a magnet B. Child complains of abdominal pain C. Child has history of constipation D. Battery is > 15mm diameter and has been present > 4 days in a child < 6 years old E. N/A; ingested batteries should always be endoscopically removed

A 6yo boy is in the ED with his third episode of intussusception over the past year. Previous episodes presented with colicky abdominal pain and stool guaiac positive, and were successfully managed using barium enemas. He has been completely well between episodes. What imaging study is indicated to assess for the most common cause of a pathologic lead point? A. Complete ultrasound of the abdomen B. Computed tomography of the abdomen with oral and IV contrast C. Upper gastrointestinal study with small bowel follow-through D. Technetium-99m-pertechnetate scintigraphy E. Magnetic resonance imaging of the abdomen

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Note: controversies are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also regarding your thought processes and the evidence behind your decisions. We can learn from each other!

You are seeing a child who has been passing infrequent stools, and when the child does stool, the stools are hard.

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(Click the link to comment and to vote - voting not working through email, sorry!) Note: controversies are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also regarding your thought processes and the evidence behind your decisions. We can learn from each other! [poll id="52"]

What do you include in your GI cocktail for adolescents? [poll id="15"]

You are seeing a 5 year old with intermittent LLQ abdominal pain for a month. She is well appearing and has a benign abdominal exam. She is eating normally, not vomiting, and has no fever or diarrhea. The parents deny constipation or hard stools, but you suspect constipation is the diagnosis. [poll id="13"]

You are seeing a 6 week old ex-full term infant who is breastfeeding exclusively, having 6 wet diapers per day, 4 or more soft seedy stools per day, growing well, and no fever. Baby has been jaundiced since 1^st week of life, and while it is not worse, parents come in because it is prolonged. Jaundice is to the level of the chest, and transcutaneous bili is 10. [poll id="12"]

With the rise in legality of cannabis products, ED (and even PED) clinicians are seeing a big rise in cannabis hyperemesis syndrome. Topical capsaicin 0.025-0.075% is a known reliever of symptoms, as outlined on AliEM here. But who stocks topical capsaicin cream in their ED? Turns out hot sauces can be used as outlined here. Hot sauces are graded in Scoville units, and the equivalent to capsaicin cream is a hot sauce with 4,000-12,000 Scoville units. Avoid hot sauces that go higher than that - they can burn the skin. Tabasco original red sauce has a Scoville rating of 2,500-5,000 units.

Hyperemesis due to cannabis use is on the rise, particularly in areas with marijuana legalization. While classically it is seen in chronic, daily users, affected patients sometimes have been using cannabis for less than a year, and may be using it as infrequently as once a week. Patients present with bouts of severe nausea, vomiting, and abdominal pain. A classic symptom is relief with hot showers (due to activation of the TRPV1 receptors). Symptom relief in the ED involves fluid rehydration and ondansetron (although this often no longer works for the patient after multiple bouts). There are also many reports of successful resolution of acute symptoms with benzodiazepines, haloperidol, and topical capsaicin. Curative treatment involves convincing the patient to stop cannabis use. Therein lies the tip, which I just learned from a colleague – a good way to help the patient understand is to tell them they suffer from an “allergy” to marijuana– while some people may be able to use marijuana chronically, they cannot, as it will cause these symptoms. Cessation of cannabis use can result in symptom relief as soon as 12-24 hours but sometimes not for as long as 3 weeks. So let them know how long that “allergic reaction” can continue!

Your local hospital cafeteria can be a useful resource in managing your PED patients:

1. Sugar liberally applied to the edema of a paraphimosis or rectal prolapse may help decrease swelling and improve reduction efforts
2. A mayonnaise packet provides useful lubricant for removing a tight ring
3. Tannins from a tea bag (particularly black tea) can help clotting with post dental extraction bleeding (place a moistened tea bag in the socket and have the patient apply pressure by biting down)
4. A packet of sugar + 10 mL sterile water = make your own sucrose solution for treatment of pain associated with procedures in infants

Know of any more? Comment below!

What can you do if your patient is maxed out on ondansetron but still feels nauseated? A recent study in Annals EM found a positive treatment effect of deeply inhaling from a standard isopropyl alcohol pad held 2.5 cm from the patient's nose. Patients inhaled for 60 seconds at 0, 2, and 4 minutes (stopping if nausea resolved), and nausea was rated up to time 10 minutes. (Caveat: this study enrolled only adults). A 2012 Cochrane review also found isopropyl alcohol inhalation beneficial, although less so than standard antiemetic medications. Also, anecdotally, for dehydrated patients, rehydration and resolution of ketosis is thought to improve nausea and vomiting. For the grammar police out there, clarification of nauseated vs nauseous can be found here