PEM Source

Your source for all things Pediatric Emergency Medicine

All posts with tag: "surgery"

PEM Questions

(Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="113"]
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(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 13 year old girl presents with sudden onset sharp RLQ pain radiating toward her groin, along with nausea and vomiting once, non-bloody, non-bilious. [yop_poll id="40"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 17 year old boy comes is brought in to the ED at 2am for severe retrosternal chest pain that awoke him from sleep. He was well prior to going to bed at 11:30pm, and denies fever, cough, radiation of the pain, vomiting, trauma, foreign body ingestion. He has a past medical history of appendectomy 8 months prior, acne for which he takes an oral antibiotic and uses a topical cream daily, and mild intermittent asthma for which he uses an inhaler once or twice a year "when the weather changes." He is a straight A student applying to colleges currently. His physical examination is normal, as is a CXR and ECG. What is the probable cause of his chest pain? [yop_poll id="28"]
A 12yo boy with ALL, recent induction chemotherapy 2 weeks ago, presents to the ED with fever, RLQ abdominal pain, 2 episodes of watery diarrhea with streaks of blood, nausea but no vomiting. Denies ill contacts. On exam, temperature 38.4, HR 110, RR 24, BP 95/60. Alert, no nuchal rigidity, lungs clear to auscultation, heart RRR, abdomen mildly distended, RLQ tenderness, no rebound, decreased bowel sounds. Labs show an absolute neutrophil count of 100. KUB findings are similar to as shown here: pneumatosis The most appropriate next step would be: A. Consult surgeon for appendectomy B. Admit for IV antibiotics directed at treating infectious diarrhea C. Admit for empiric IV antibiotics to cover for fever and neutropenia D. Admit for broad spectrum antibiotics, make NPO, consult with surgeon, consider GCSF, for neutropenic enterocolitis E. Consult gastroenterologist for endoscopy to confirm pseudomembranous colitis

Tips and Tricks

Hairtourniquet Wikimedia James Heilman Hair_Tourniquet_after Photos before & after release from Wikimedia Commons Hair tourniquets (and sometimes thread tourniquets) can occur on toes (most common), fingers, and more rarely the penis, clitoris, or uvula. Peak occurrence is at age 2-6 months, corresponding with maternal postpartum hair loss. Edema may progress to vascular compromise; ischemia and autoamputation have occurred. Tips for removal:
  • Magnifying loupes can be helpful
  • Consider topical anesthesia with EMLA or viscous lidocaine (avoid LET w/epinephrine so as to not confuse discoloration due to the tourniquet vs due to temporary epinephrine effect)
  • If definitely a hair, depilatory cream (eg Nair) can be applied for 3-10 minutes on unbroken skin; repeat once if not successful (the product can irritate skin, however)
  • AliEM describes use of a cutting needle to get under the hair and cut it https://www.aliem.com/2012/06/trick-of-trade-hair-tourniquet-release/
  • If the hair is too deep / not visualized, the cutting needle can still be used to lift the tissue and constricting band, and a scalpel then used to cut the hair and superficial layer of tissue
  • Severe tourniquets may require perpendicular cuts to the bone, best done at 3:00 and 9:00 positions
  • Look for improvement in swelling and color with release. If the hair cut deeply, it may be difficult to see if release is complete. At least one author has studied ultrasound for identification https://www.ncbi.nlm.nih.gov/pubmed/29341258.
  • Consult a urologist for deep penile tourniquets
  • Consider child abuse, particularly with genitalia involvement

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