THE EM CASES COURSE 2016 HANDBOOK

Instructions for Getting the Most Out of The EM Cases

Course Handbook

The EM Cases Course has been designed around effective adult learning
theories. The two m ost im portant things that you can do to m axim ize your
learning of the course m aterial are:

1. Reviewing the pre-course m aterial in the handbook

2. Participating in discussions during the course

If you have NO TIM E TO PREPARE prior to the course - At a m inim um

please read the handbook for the m odules that you chose. (10 m inutes
each)

If you want to get M ORE out of the course – Read the handbook AND read
the written sum m ary of the corresponding podcast(s) -Link available in
handbook (20 m inutes each)

If you want to get M OST out of the day – Read the handbook, read the
written sum m ary of the podcast and listen to the relevant podcast(s) (1-2
hours each).

This handbook is divided into 6 m odules:

1. Airway Controversies (pages 2-5)

2. Anticoagulants & Bleeding (pages 6-9)
3. Geriatric Em ergencies (pages 10-12)
4. Low Back Pain Disasters (pages 13-16)
5. Orthopaedic Pitfalls (pages 17-20)
6. Paediatric Em ergencies (pages 21-27)

The handbook is in Word format so that you can easily add your
own notes, and so that the links in it are easily accessed.

  1  
  

EM Cases Course Airway Module

George Kovacs & Brian Wall

Listen to: Airway Controversies Podcast

Listen to: Delayed Sequence Intubation Podcast
Listen to: Management of Obesity Podcast

Objectives
1.To discuss the various approaches to airway management in obese patients, those in shock, burn
patients and head injured patients.
2. To understand the importance of adequate resuscitation prior to airway intubation.
3. To understand the rational and steps involved in apneic oxygenation and delayed sequence intubation.
4. To understand the indications for and steps involved in an awake intubation.
5. To review the best medication options for airway management in a head injured patient.

Case 1: Obese patient in septic shock

66y/o man with history of CHF, diabetes and HTN
• 4-day history of worsening SOB, productive cough with green sputum, and high fever.
• His wife called 911, as he was increasingly confused and having a lot of difficulty
breathing.
• On arrival, he appears to weight approximately 400 lbs in moderate to severe
respiratory distress O2 sat 86% on non-re-breather and ++agitated.
• HR 130; BP 95/40; RR 32; Temp 38.2.

Discussion Questions

Q: Does this Patient need to be intubated? If so how much time do I have?

Q: Do I predict difficulty in a. Physiology? b. Airway?

Q: Can I mitigate some difficulty?

Q: What approach is best for the patient and me?

Q: What is my plan A (primary approach) plan B (can’t intubate/can oxygenate)

plan C (Can’t intubate/Can’t oxygenate)?

  2  
  

Q: What are my drug choices?

Case 2: Burn Patient

A 44y/o woman comes in after house fire with severe facial burns and significant
airway edema. There is no stridor (yet) and oxygen saturation is 93% on 4L by
NP.

Discussion Questions

Q: Does this Patient need to be intubated? If so how much time do I have?

Q: Do I predict difficulty in a. Physiology? b. Airway?

Q: Can I mitigate some difficulty?

Q: What approach is best for the patient and me?

Q: What is my plan A (primary approach) plan B (can’t intubate/can oxygenate)

plan C (Can’t intubate/Can’t oxygenate)?

Q: What are my drug choices?

  3  
  

Case 3: Major Head Injury

A 26y/o man comes in via EMS boarded and collared to your community
hospital after rolling his ATV at a late night party. His vital signs are normal
except for a heart rate of 118. His GCS is 7. He has a huge bruise over his left
temple, an obvious deformity of his right wrist and your FAST exam shows a
sliver of free fluid in Morrison’s pouch.

Discussion Questions

Q: Does this Patient need to be intubated? If so how much time do I have?

Q: Do I predict difficulty in a. Physiology? b. Airway?

Q: Can I mitigate some difficulty?

Q: What approach is best for the patient and me?

Q: What is my plan A (primary approach) plan B (can’t intubate/can oxygenate)

plan C (Can’t intubate/Can’t oxygenate)?

Q: What are my drug choices?

  4  
  

References & Resources

Airway Management in the Obese Patient

1. Heffner AC, Swords DS, Neale MN, Jones AE. Incidence and factors associated with cardiac arrest
complicating emergency airway management. Resuscitation. 2013;84(11):1500-4. Full pdf
2. Dargin J, Medzon R. Emergency department management of the airway in obese adults. Ann
Emerg Med. 2010;56(2):95-104. Full pdf

Delayed Sequence Intubation

1. Weingart, SD & Levitan, RM. 2012. Preoxygenation and prevention of desaturation during
emergency airway management. Ann Emerg Med, 59(3): 165-75. Full article
2. Ramachandran, SK, Cosnowski, A, Shanks, A & Turner, CR. 2010. Apneic oxygenation during
prolonged laryngoscopy in obese patients: A randomized, controlled trial of nasal oxygen
administration. J Clin Anesth, 22(3): 164-8. Full article
3. Christodoulou, C, Mullen, T, Tran, T, Rohald, P, Hiebert, B & Sharma, S. 2013. Apneic oxygenation via
nasal prongs at 10L/min prevents hypoxemia during elective tracheal intubation. Chest, 144(4-
Meeting Abstracts): 890A.
4. Weingart, SD, Trueger, NS, Wong, N, Scofi, J, Singh, N & Rudolph, SS. In Press. Delayed Sequence
Intubation: A prospective observational study. Ann Emerg Med. Full pdf

Awake Intubation

http://emupdates.com/2013/07/07/awake-intubation-a-very-brief-guide/

Airway Management in Trauma Patients

http://www.emdocs.net/management-of-the-trauma-patients-airway-pearls-and-pitfalls/

  5  
  

EM Cases Course Anticoagulants & Bleeding

Walter Himmel & Rick Penciner

Listen to: Tranfusions, Anticoagulants & Bleeding podcast

Listen to: Anticoagulants, PCCs & Platelets podcast
Listen to: Atrial fibrillation podcast
Listen to: Ian Stiell on Atrial Fibrillation 2014 Guidelines
Listen to: Pulmonary Embolism podcast

A shift rarely goes by when we don’t see a patient who is bleeding while on anticoagulants or
requires anticoagulants to treat/prevent thromboembolism. With many newer anticoagulants
now on the market the management of these patients can be challenging, and the reversal of
these agents near impossible. In this module Dr. Himmel and Dr. Penciner will guide you
through discussions around these issues with cases on atrial fibrillation, managing pulmonary
embolism, reversing rivaroxiban in a patient with a massive GI bleed.

Case 1: Atrial Fibrillation

A 66y/o woman with a history of atrial fibrillation and no other medical problems comes
in with 40-hour history of palpitations and no other symtoms. Her HR 130-145, BP is
110/70. She takes a baby aspirin everyday for primary prevention.
Q1: How do you risk stratify your patients with atrial fibrillation in terms of their risk of
stroke and 30 day mortality?

  6  
  

Q2: Would you rate control or rhythm control this patient, and how would this effect
the risk of thromboemobolism?

Risk of stroke and death in paroxysmal vs persistent Afib full pdf

A 30-day mortality clinical decision instrument for patients who present to the ED with
AFib. Abstract

Q3: At what time since the onset of symptoms would you avoid cardioversion?

JACC Finnish study on Thromboembolic Complication After Cardioversion of Acute Atrial

Fibrillation that challenges the 48 hour safety rule Full pdf

Q4: Would you start this patient on an anticoagulant in the ED or arrange follow-up
when the decision can be made? Which anticoagulant?

Study in Annals of Emergency Medicine suggests that patients given a prescription for warfarin
in the ED may have better rates of long-term anti-coagulation. Abstract

Q: W hat is the risk of bleeding in this patient?

HAS BLED mnemonic for bleeding risk: HTN, Abnormal renal or liver function, Stroke, Bleeding
history, Labile INR, Elderly ≥65yo, Drugs that promote bleeding or excess alcohol use – Score ≥3
means higher (3.7%) risk of major bleeding

Case 2: Pulmonary Embolism

A 55y/o m an com es in a few days after a transatlantic flight with SOB and
pleurtitic chest pain. He is tachycardic and O2sat = 93% . A CTA of the
chest shows a large pulm onary em bolism .

Q: W hich anticoagulant is the best choice for treatm ent of non -m assive
pulm onary em bolism ?

Q: Do all patients with subsegm ental pulm onary em bolism need to be

anticoagulated?

Q: W hich patients, if any, with subm assive pulm onary em bolism should be
throm bolysed?

  7  
  

Case 3: Massive GI Bleed on Rivaroxiban

A 46y/o m an on rivaroxiban for recurrent DVTs com es in with near -

continuous hem atem esis for several hours. He adm its to drinking alcohol
regularly. His HR is 140, BP 100/50, GCS 14. Hb = 72 INR = 3.

Q: Does this patient require a red cell transfusion?

Q: Does this patient require reversal of the INR?

Q: W ould you attem pt to reverse the Rivaroxiban? How?

Q: Is there a role for tranexam ic acid in this patient?

Q: W hat is the role of PPIs and octreotide in acute upper GI bleeds?

Management of NOAC-associated Bleeding

(From Thrombosis Canada)

  8  
  

Hemostatic agents and their role in NOAC -asociated bleeding

References

Canadian Atrial Fibrillation Guidelines 2014 Full PDF

American Heart Association Atrial Fibrillation Guidelines 2014 Full PDF

Airaksinen, J et al. Thrombolembolic Complications After Cardioversion of Acute Atrial Fibrillation. The FinCV
(Finnish CardioVersion) Study. J Am Coll Cardiol. 2013;62(13):1187-1192

Meyer G, Vicaut E, Danays T, et al. Fibrinolysis for patients with intermediate-risk pulmonary embolism. N
Engl J Med. 2014;370(15):1402-11. Abstract

Villanueva C, Colomo A, Bosch A, et al. Transfusion strategies for acute upper gastrointestinal bleeding. N
Engl J Med. 2013;368(1):11-21. Full PDF

Lee FM, et al. Reversal of new, factor-specific oral anticoagulants by rFVIIa, prothrombin complex
concentrate and activated prothrombin complex concentrate: a review of animal and human studies..
Thromb Res 2014;133(5):705-713.

Siegal DM, et al. How I treat target-specific oral anticoagulant-associated bleeding. Blood.
2014;123(8):1152-1158.

CRASH-2 Trial collaborators. Effects of tranexamic acid on death, vascular occlusive events, and blood
transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebocontrolled
trial. Lancet 2010;376(9734):23-32.

  9  
  

EM Cases Course Geriatrics Module

Don Melady & Andrew Petrosoniak

Listen to:  Link to Geriatrics Podcast  

Listen to:  Geri-EM website  

Patients over the age of 65 represent 50% of emergency department visits, 1/3 of
hospital admissions and 50% ICU admissions. They have higher rates of bounce backs
from missed life threatening diagnoses, which results in 2x the mortality rate.

Objectives
1. Define and discuss the clinical approach to an elderly patient with Delirium in the ED
2. Outline evidence based strategies to prevent the onset of Delirium in patient while in the ED
3. List the risk factors for falls and develop a management plan for older patients who suffer from
frequent falls
4. Identify the most common drug interactions and toxicities in older patients

Case 1: Delirium & Dementia

A 79 y/o woman who has come to your ED on Thursday evening for unclear reasons, seemingly
related to voiding frequently but she has a long list of minor complaints too. Vital signs are
normal. She hasn’t been in your ED for several years. She lists a family doctor in your
community as hers.

She is triaged to the Ambulatory area where she waits happily for two hours to see the Emerg
doc. The doc elicits no acute findings but notices 4+ WBCs in her urine. He prescribes TMP-
SMZ, tells her to drink lots of water, and discharges her home.

She is found wandering on a highway three hours later by the police who were called by her
desperate family. The family subsequently lodges a complaint with the hospital administration
and with the physician’s regulatory body.

1. How can we identify delirium in the ED and why is it important to identify?

2. What are the risk factors for developing delirium?

3. What are the major causes of delirium that we need to think about in the ED?

  10  
  

4. What are the indications for a CT head in patients who present to the ED with delirium
NYD?
5. How do you manage agitation in the ED patient with delirium?

6. What is the best strategy for managing severe constipation as a cause for delirium in the
ED?

“DIMES” for Differential Diagnosis of Delerium

Drugs and drug withdrawal - largest category!

Infection - most common are PUS: Pneumonia, UTI and Skin

Metabolic - order and review BW carefully for metabolic causes

Environmental - too hot/ too cold

Structural - CNS events (spontaneous or traumatic subdural bleeding, stroke, etc.)

Case 2: Frequent Falls

An 82y/o man is brought to the ED by his daughter with whom he lives. He has fallen today and
has a sore hip but walked in. His daughter says she cannot manage with him at home anymore
and that “he needs to stay in hospital”: “I’m not taking him home.”

PMH: dementia, hypertension, BPH,

Meds: donepezil, metoprolol, hydrocholothiazide, ASA, tamsulosin,

On examination, he is settled, not agitated, but difficult to get to participate in a physical exam.
VS normal.

A more thorough history (if it’s taken) will reveal that he has fallen five times in past four days
(not normal for him); that he has been up all night every night for the past week (not normal for
him); that he and his daughter get no assistance at home and that she normally manages quite
well.

1. What are the risk factors for falls and why is this important in formulating a safe
discharge plan?

2. What can we do as ED providers to minimize the chance of frequent falls in our

older patients?

  11  
  

Case 3: The Weak & Dizzy Patient

Drug interactions, toxicity & withdrawal

An 89 y/o female who lives independently in senior’s residence comes in complaining of vauge
weakness and dizziness for the past few days. She states that she does not feel sick, and denies
fever, chest pain, belly pain, back pain, dyspnea, melena, focal neurological symptoms or
headache, but complains of no appetite or energy.
PMHx: Afib, CHF
Meds: Furosemide, HCTZ, Warfarin, Digoxin, Tylenol #3
OE: HR: 42, all other vitals are stable, Normal mental status
Labs: elevated BUN, Cr

Q: What are some of the common drug toxicities and interactions that we need to be on the
lookout for in any older patient presenting to the ED?

Review drugs with high-risk and low benefit

Review drugs with high-risk and high benefit

References

Inouye SK, Bogardus ST, Charpentier PA, et al. A multicomponent intervention to prevent delirium in
hospitalized older patients. N Engl J Med. 1999;340(9):669-76.

Geriatric Emergency Department Guidelines. American College of Emergency Physicians. 2014.

http://www.acep.org/geriEDguidelines/

Gandell D, Straus SE, Bundookwala M, Tsui V, Alibhai SM. Treatment of constipation in older people. CMAJ.
2013;185(8):663-70. http://www.cmaj.ca/content/early/2013/01/28/cmaj.120819

  12  
  

EM Cases Course Low Back Pain Module

Walter Himmel & Rick Penciner

Listen to: Low Back Pain Disasters Podcast

Listen to: EM Cases Digest ebook with chapter on Low Back Pain  

Back pain is the most common MSK complaint that results in visits to the ED. When we pick up a chart in
the ED and see that the chief complaint is low back pain, most of us have a similar reaction – not another
lumbosacral sprain; or, not another drug seeker; or not another patient I can’t do anything for.

Upwards of 90% of low back pain presentation in the ED turn out to be benign etiologies like lumbosacral
sprain, and ED docs have been shown to be poor at providing good education and evidenced based
treatments for lumbosacral sprain even though there’s a huge, often long-term, morbidity associated with
it.

There are several very important life or limb threatening diagnoses that we must consider in every patient
who presents with low back pain from Cauda Equina Syndrome to AAA, that we’ll be giving you all the key
pearls about in this module. Some of these serious causes of low back pain are easy to miss, and more
nd rd th
often than not are only diagnosed on the 2 or 3 or even 4 visit to the ED. So we need to approach all of
these low back pain patients with a high degree of scrutiny.

Objectives

5. Discuss the clinical pearls and pitfalls in the diagnosis of spinal epidural abscess
6. Define cauda equina syndrome precisely so as to understand when a thorough work up and timely
surgical referal is required
7. Understand when to suspect, how to work up and how to treat metastases to the spine
8. Discuss the various treatments for mechanical low back pain

Case 1: Spinal Epidural Abscess

A 63 year old woman arrives in your ED with the chief complaint of abdominal pain. This is her
rd
3 visit for the same complaint in the last 10 days. Her illness started about 2 weeks ago when
she developed back pain and then a few days ago developed lower abdominal pain, bilateral leg
weakness and difficulty urinating. She complains that she’s been sweating a lot and getting
flushed in the face. On her previous visit she was discharged after a Foley in and & out. On
further questioning about her back pain she described a mostly right low back pain with burning
pain to both thighs that’s not relieved by acetominophen or any change in position. She’s unable
to sleep adequately because of the pain.

  13  
  

Her past medical history includes Diabetes and a 40pk/yr smoking history. She denies alcohol
or drug abuse.

On exam she appears to be in a significant amount of pain, writhing in the stretcher.

Her vitals include a BP of 173/103, HR 96, RR 20, Temp of 37.2 and O2sat of 99% on rm air. She’s
tender over the lower-midback and right para-spinal muscles. Her abdominal exam reveals
suprapubic fullness, no mass and no peritoneal signs. She has brisk reflexes in the lower
extremities with proximal right leg weakness and decreased sensation in the right leg. A digital
rectal examination was not done.

Q: What are some of the more important risk factors for spinal epidural abscess?

Q: What is the usual natural history of spinal epidural infection and why is this
important?

Q: In patients with a low pre-test probability of spinal epidural abscess, but you are
considering the diagnosis, how do you work them up?

CASE CONTINUED:
A foley was again placed and blood and urine was sent as well as an X-ray of the lumbar spine.
The serum WBC came back at 28 and urinalysis showed positive leuks and nitrates. The X-ray
was read as normal by the ED doc and later, the radiology report read ‘endplate erosion’ L3/L4.

Normal ESR = (Age + 10)/2

Q: How do you work up a patient with a high pretest probability for spinal epidural
abscess? What is the role of CT and how can CT be misleading?

Case 2: Disc Herniation & Cauda Equina Syndrome

A 49 year old man presents to your ED with the chief complaint of several hours of severe
crampy abdominal pain. He has had difficulty urinating for the past 12hrs. Four days prior, he
fell off his bicycle and has been suffering from low back pain ever since. There was no head or
extremity injury. In terms of neurologic symptoms, he does complain of decreased sensation to
the lateral foot.

He has a PMHx of chronic low back pain which he takes ibuprophen for occasionally and goes to
physiotherapy reguarly but no other medical problems. He denies any change in bladder or
bowel function.

On exam he’s pacing around the room in obvious distress in a stooped, bent forward posture,
resting his hands on his thighs for support. His vitals are normal. His abdominal exam reveals a
diffusely tender protruberant abdomen with no palpable mass, normal bowel sounds and no
peritoneal signs. He has no spinal process tenderness, paraspinal muscle tenderness or CVA

  14  
  

tenderness. He has an abnormal straight leg raise on the left, and a positive crossed-straight leg
raise on the right. He has no saddle anesthesia. He has decreased sensation and strength in the
L5-S1 distribution and his ankle tendon reflexes are absent.

Q: How do you define cauda equina syndrome?

 

BMJ DEFINITION OF CAUDA EQUINA

Must have both of these:

1. Either urinary retention or rectal dysfunction or sexual dysfunction or all
2. One of saddle anesthesia/hypoesthesia or rectal hypoesthesia

Q: How do you perform a physical exam in a patient suspected of cauda equina

syndrome?

Q: How do you work up a patient with a low pre-test probability of cauda equina
syndrome compared to a high pre-test probability?

Case 3: Mets to the Spine

A 43y/o woman presents to your ED with a 3-week history of progressive low back pain. She decided to
come to the ED today because the pain is so severe that she was unable to sleep the night prior. There
has no radiation of the pain, no alleviating factors and no aggravating factors. She has been having difficulty
walking because of numbness in the right leg, but denies saddle paresthesias. She has normal bowel and
bladder function and denies fever, chills and night sweats. She says that she has never had pain like this
before and denies any back trauma or previous back problems. She also complains of general weakness
and vague muscle aches, mild headache as well as nausea and constipation.

Her PMHx includes hypothyroidism, diabetes which are well controlled with medication as well as breast
cancer. She had a mastectomy 2 years prior, and is in remission according to her oncologist.

On exam she appears a bit drowsy but unable to find a comfortable position. Her vitals are unremarkable
except for a heart rate of 110.
She has spinous process and paraspinal muscle tenderness around the high L-spine. Her lower extremity
exam reveals scattered decreased sensation that doesn’t seem to fit a dermatomal distribution, global 3/5
power in the lower extremities with normal patellar but absent ankle reflexes.

Q: In which patients do you suspect mets to the spine?

Q: How do you work up a patient that you suspect might have mets to the spine?

  15  
  

Case continued: the patient went on to have an L-spine X-ray and routine blood work. The X-ray showed a
compression fracture of L1. The blood work was unremarkable except for a slightly low Hb and platelet
count.
 
Pearl: any finding on x-ray consistent with malignancy portends a 60% of cord compression

Q: Which patients with suspected mets to the spine require an MRI? How urgently do
they require it?

Q: What is the role of steroids and bisphosphonates in the management of met to the
spine?
 
CASE OUTOME: The patient went on to have an MRI of the entire spine which showed moderate cord
compression at L1 as well as multiple bony mets at multiple vertebral levels. Neruosurgery and medicine
were consulted. The internist ordered a TSH, T4, Ca, Mg, Phos and ESR. The patient was found to be
severely hypercalcemic, accounting for her generalized weakness, drowsiness, nausea and constipation
and had an ESR of 110. The patient received a NS bolus, IV pamidronate and IV Dexamethasone 100mg
and went to the O.R. She walked out the hospital 3 weeks later with normal lower extremity function and a
corrected calcium on an oral bisphphonate and follow-up with the oncologist.

Case 4: Management of Mechanical Low Back Pain

rd
A 32 y/o man comes in after lifting a heavy couch complaining of low back pain. This is his 3
such episode. He has no red flags for serious causes of low back pain and is otherwise healthy.
His physical exam is unremarkable except for paraspinal muscle tenderness and increased pain
on flexion of the L-spine.

Q: What are the best treatments available for mechanical low back pain?

Q: What discharge instructions would you give to this patient?

References

Management of Chronic Low Back Pain. 2004

Full pdf

Downie A, Williams CM, Henschke N, et al. Red flags to screen for malignancy and fracture in patients with
low back pain: systematic review. BMJ. 2013;347:f7095.

  16  
  

EM Cases Course Orthopaedic Module

Arun Sayal & Teresa Chan

Prior to The Course please review the wrist and ankle injuries in the following EM Cases
resources:
Listen to: Commonly Missed Uncommon Orthopaedic Injuries Part 1
Listen to: Commonly Missed Uncommon Orthopaedic Injuries Part 2
Listen to: Occult Fractures and Dislocations
Listen to: EM Cases Digest Volume 1: MSK and Trauma PDF Download

We often see orthopaedic patients near the end of a busy emergency shift when we are
fatigued and perhaps not a thorough as we’d like to be. This is a high-risk time.
Sometimes we make the mistake of assuming a benign injury after a seeing a normal
set of standard x-rays. Some of these missed diagnoses can result in long- term
morbidity.

Objectives
1. Discuss the differential diagnosis for patients presenting with wrist and ankle injuries
that have a normal set of standard view x-rays.
2. Discuss the key history and physical pearls for some important occult injuries of the
wrist and ankle.
3. Know the indications for additional x-ray views required to identify these ‘easy to miss’
injuries that have significant sequelae.
4.

Case 1

A 19-year-old woman fell on her left wrist. She complains of pain in her left
wrist. On physical examination, she is tender at the dorsal wrist. There may
be some mild swelling. Head-to toe exam is otherwise normal. You take a
quick look at the x-ray of the wrist and it looks normal to you.

  17  
  

Discussion Questions

Q1: What injuries are on your differential diagnosis for a FOOSH besides a
Colles’ fracture and scaphoid fracture?

Q2: What are the key history and physical exam clues to help you sort out this
differential diagnosis?

Q3: What additional x-ray view(s) might be required?

  18  
  

Case 2:

A 22-year-old comes in to your ED after injuring his ankle while being

tackled during a football game. His friend says he has not and cannot
weight bear since the injury. He complains of pain at the anterolateral
ankle. There is minimal swelling or tenderness noted at the medial or lateral
malleoli. He has no pain over the various locations of the Ottawa Ankle and
Foot Rules.

Discussion Questions

Q1: What is the differential diagnosis you need to think about for ankle injuries
such as this?

Q2: What are the key history and physical exam clues to help you sort out this
differential diagnosis?

Q3: What additional x-ray view(s) might be required?

  19  
  

Q4: What if this patient was a CFL player, would that change your management?
What if he was the son of the hospital CEO? Would you X-ray this patient? Why
or why not? (Check out paper on practice variations on this exact topic in the
reference section #6)

References

1. Anderson RB, Hunt KJ, McCormick JJ. Management of common sports-related injuries about the
foot and ankle. The Journal of the American Academy of Orthopaedic Surgeons. 18(9):546-56.
2010

2. Lin C, Gross M, Weinhold P. Ankle Syndesmosis Injuries: Anatomy, Biomechanics, Mechanism of

Injury, and Clinical Guidelines for Diagnosis and Intervention. J Orthop Sports Phys Ther.
2006;36(6):372-384.

3. Stanbury S, Elfar J. Perilunate dislocation and perilunate fracture-dislocation. Journal of the

American Academy of Orthopaedic Surgeons. 2015;19(9):554.

4. Unay K, Gokchen B, Ozkan, et al. Examination tests predictive of bone injury in patients with
clinically suspected occult scaphoid fracture. Injury. 2009;40:1265-1268.

5. Van Heest T, Lafferty P. Injuries to the Ankle Syndesmosis. The Journal of Bone & Joint Surgery.
2014;96(7):603-613.

6. Mercuri M, Sherbino J, Sedran RJ, Frank JR, Gafni A, Norman G. When guidelines don’t guide: the
effect of patient context on management decisions based on clinical practice guidelines. Academic
Medicine. 2015 Feb 1;90(2):191-6.

  20  
  

EM Cases Course Paediatric Module

Sarah Reid & Teresa Chan

Listen to: Paediatric DKA on EM Cases
Listen to: Paediatric Sepsis on EM Cases
Listen to: Bronchiolitis on EM Cases
Listen to: Amy Plint on the Management of Bronchiolitis
Listen to: Paediatric POCUS Appendicitis & Intussusception
Read: TREKK summary of DKA

Objectives

5. Discuss the key historical and physical examination pearls for select pediatric
presentations to the emergency department: DKA, Sepsis, intussesception and
bronchiolitis.
6. Understand the subtleties and controversies in the management of DKA when it comes to
fluid management, correcting serum potassium and acidosis, preventing cerebral edema,
as well as airway management
7. Review of diagnostic modalities – essential vs non-essential – for confirming diagnosis
and avoiding potential pitfalls in DKA, sepsis, bronchiolitis and intussesception
8. Review the most up-to-date evidence based management strategies for DKA, Sepsis,
Bronchiolitis and Intussusception.

Case 1: DKA

A 4 year old boy presents to ED with his parents complaining of abdominal

pain, SOB, since waking that morning. He reports no fever, no vomiting and
normal BM. He has no cough and no chest pain. He has been going to the
bathroom more often than usual to urinate. His PMH is unremarkable. On
exam he appears fatigued, but alert and oriented with GCS of 15.
Tachypnea with deep respirations, but no indrawing. Chest is clear, Cap
refill is 2 secs. Mucous membranes are dry, abdominal exam is benign, and
neuro exam is grossly normal.

Diabetes: Random serum glucose >11.1 mmol/L

Acidosis: pH<7.3 OR HCO3<15
Ketosis: Ketones on urine dipstick or urinalysis
(usually mod/large)

  21  
  

Mild DKA Moderate Severe DKA

DKA
pH < 7.3 pH < 7.2 pH < 7.1
HCO3< 15 HCO3< 10 HCO3<5

Kids who present to the ED in DKA without a known history of diabetes, can
sometimes be tricky to diagnose, as they often present with vague symptoms.
When a child does have a known history of diabetes, and the diagnosis of DKA is
obvious, the challenge turns to managing severe, life-threatening DKA, so that
we avoid the many potential complications of the DKA itself as well as the
complications of treatment - cerebral edema being the big bad one. The
approach to these patients has evolved over the years, from bolusing insulin and
super aggressive fluid resuscitation to more gentle fluid management and
delayed insulin drips, as examples. There are subtleties and controversies in the
management of DKA when it comes to fluid management, correcting serum
potassium and acidosis, preventing cerebral edema, as well as airway
management for the really sick kids.

Discussion Questions

Q1: What key historical and physical exam features make you think of DKA? Why
does this case prominently feature abdominal pain?

Q2: How do you manage pediatric patients with mild to moderate DKA? How can
we prevent and manage cerebral edema in severe DKA?

Q3: Do you have an institutional protocol for pediatric DKA? Why or why not?
(Please bring yours to the course if you have one!)

Case 2: Pediatric Sepsis

A 7-month girl with a 3 day history of chicken pox, goes to an after-hours

clinic with an area of redness around a lesion on her abdomen. She has
fever of 38.7 degrees Celcius. She is crying constantly. At the after hours
clinic, she is given antibiotics and is sent home. Mom gives you the history
that on arrival at home, the child becomes limp, unresponsive, and 911 is
called. When she gets to your ED, her vital signs are: T 39.4, HR 168, RR of
44 BP 70/35, saturation 94%. She looks ill, and she is difficult to rouse. Her
skin is mottled. Her cap refill is 5s.

  22  
  

Kids aren’t little adults. Pediatric sepsis and septic shock usually presents as
‘cold shock’ where as adult septic shock usually presents as ‘warm shock’.
Sepsis in children is a relatively rare emergency department presentation.
Although only about 0.35% of pediatric emergency department visits are for
sepsis, the mortality rate is as high as 2 to 10%. Having a sepsis protocol in the
emergency department can decrease mortality from 5% to as low as 1%.

WARM Shock COLD Shock

Peripheries Warm, flushed Cold, clammy,
cyanotic
Capillary refill <2 sec >2 sec
Pulse Bounding Weak, thready
Heart rate Tachycardia Tachycardia or
bradycardia*
(*fulmimant sepsis
Blood pressure +/-Hypotensio +/- Hypotension
Pulse pressure Widened Narrowed

Discussion Questions

Q1: What are the red flags that help us recognize paediatric sepsis and septic
shock?

Q2: What is the best approach to acute management of paediatric sepsis/septic

shock in terms of fluid resuscitation, intubation, antibiotics and inotropes?

  23  
  

Case 3: Bronchiolitis

You are working in a busy community ER when a 5-month old girl is

brought in by her parents for difficulty breathing. She has had a cough,
runny nose for the past 4 days, gradually increasing SOB since previous
evening. This is her second visit. On the first visit, she was treated with
nebulized salbutamol, given ibuprofen and sent home. Her PMH reveals she
had a normal delivery with no NICU admission, no history of reactive
airways. She is otherwise healthy and there is no family history of asthma
or atopy. On exam, Her vitals HR 160, RR60, O2 sat of 95% on RA, T38.4.
Patient is alert and does not appear toxic. She is in moderate respiratory
distress with tracheal tugging and intercostal indrawing. Auscultation
reveals bilateral diffuse biphasic wheeze. Normal heart sounds are heard
without murmurs; abdominal exam appears unremarkable, mucous
membranes are moist. Fontanels are flat. Cap refill is 1 sec.

Bronchiolitis is one of the most common diagnoses we make in the ED. There is
a wide spectrum of severity of illness as well as a huge variation in practice in
treating these children. Bronchiolitis rarely requires any work up yet a lot of
resources are used unnecessarily. We need to know when to worry about these
kids, as most of them will improve with simple interventions and can be
discharged home, while a few will require complex care. Not only is it difficult to
predict the course of illness in some of these children, but the evidence for
different treatment modalities for bronchiolitis is all over the place. We need to
sort through what the best evidence-based management of bronchiolitis is.
Finally, we need to be confident in managing the kid in severe respiratory
distress who’s tiring with altered LOC.

The Canadian Paediatric Society Guidelines for Bronchiolitis, 2014  

 
Recommended Evidence Not
equivocal recommended
Oxygen Epinephrine Salbutamol
nebulization (Ventolin)
Hydration Nasal suctioning Corticosteroids
3% hypertonic Antibiotics
saline
nebulization
Combined Antivirals
epinephrine and
dexamethasone
Cool mist therapies
or therapy with
saline aerosol

  24  
  

Discussion Questions

Q1: How do you differentiate bronchiolitis from a child with asthma, pneumonia,
or concurrent serious bacterial infection?

Q2: How would you treat the patient in this case?

Case 3: Abdominal Pain & Vomiting

A 2-year old boy presents during your night shift with several hours of
crying and possible abdominal pain. He has no history of vomiting or
urinary symptoms. His last BM was normal 2 days ago. One week ago he
had mild URTI which resolved spontaneously. He has no relavent PMH, no
past surgical history, and is on no medications. His vital signs are normal
except for a slightly elevated HR, T38.0. His abdomen is soft and non-
tender with bowel sounds present. Abdo x-ray shows that the patient was
FOS (full of stool) with no obvious sign of obstruction. He was diagnosed
with constipation and discharged home with a perscription for PEG 3350
and dietary instructions. The following day returned to ER with lethargy,
looking pale, tachypneic, and a distended abdomen. He was placed on
monitor, and an IV was started in resus. 20cc per kg saline bolus was
given, as well as IV antibiotics to cover for possible sepsis. X-ray showed
prominent loops of bowel. VBG showed metabolic acidosis with pH 7.1.
Rectal exam was positive for fecal occult blood.

It can sometimes be difficult to decide in which patients with abdominal pain you
need to proceed to advanced imaging. This is especially the case in pediatrics,
because often imaging for children may require transfer to a dedicated site that
has ultrasound or low-dose CT for imaging (e.g. Children’s hospital). The infant,
toddler, and other non-verbal patients (e.g. those with special needs) are
especially challenging. In the sea of patients with abdominal pain and vomiting,
how does one decide who can be safely discharged with viral illness precautions,
and who needs to stay for further testing? Intussusception is the most common
surgical emergency of the abdomen in children from 6 months to 6 years old. The
classic triad of intermittent crying, bloody stools and sausage-shaped mass in the
abdomen is seen in less than 40 % of cases. The classic currant jelly stool is a
late finding and only present in about 10 % of cases. Therefore it is very
important for emergency physicians to be aware of the variety of ways children
with intussusception could present and rapidly diagnose the disease by ordering
the appropriate diagnostic imaging.

  25  
  

Discussion Questions

Q1: Discuss the differential diagnosis that you typically consider when faced with
a child with abdominal pain and vomiting. What are the key clinical pearls to help
pick up a “can’t miss” diagnosis (e.g. intussusception)?

Q2: How do you typically work up a pediatric patient with abdominal pain and
vomiting in your ED? How useful are laboratory and imaging tests in making your
diagnosis?

References
DKA
1. Wherrett D, Huot C, Mitchell B, Pacaud D. Type 1 diabetes in children and adolescents. Can J
Diabetes. 2013;37 Suppl 1:S153-62. Full PDF
2. Wolfsdorf JI, Allgrove J, Craig ME, et al. Diabetic ketoacidosis and hyperglycemic hyperosmolar
state. Pediatr Diabetes. 2014;15 Suppl 20:154-79. Full PDF
3. TREKK. (2014). Bottom Line Recommendations: Diabetic Ketoacidosis. Full PDF

Sepsis

1. Singhal S, Allen MW, Mcannally JR, Smith KS, Donnelly JP, Wang HE. National estimates of
emergency department visits for pediatric severe sepsis in the United States. PeerJ.
2013;1:e79. Full Text
2. Dellinger RP, Levy MM, Rhodes A, et al. Surviving sepsis campaign: international guidelines for
management of severe sepsis and septic shock: 2012. Crit Care Med. 2013;41(2):580-637. Full
text
3. Kleinman ME, Chameides L, Schexnayder SM, et al. Pediatric advanced life support: 2010
American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency
Cardiovascular Care. Pediatrics. 2010;126(5):e1361-99. Full Text

Bronchiolitis

1. Ecochard-Dugelay E. et al. Clinical predictors of radiographic abnormalities among infants with

bronchiolitis in a paediatric emergency department. BMC Pediatr 2014. Abstract

  26  
  

2. Fernandes, RM et al. Glucocorticoids for acute viral bronchiolitis in infants and young children.
2013. The Cochrane Database of Systematic Reviews, Issue 6. Abstract

3. Friedman, JN et al. Bronchiolitis: Recommendations for diagnosis, monitoring and management of

children one to 24 months of age 2014. Pediatr Child Health, 19(9):485-491. Full PDF

4. Hartling, L, et al. Epinephrine for Bronchiolitis (Review). 2011. The Cochrane Database of Systematic
Reviews, Issue 6. Abstract

5. Plint, AC et al. Epinephrine and dexamethasone in children with bronchiolitis. 2009. NEJM,
360(20):2079-2089.Abstract

6. Clinical practice guideline: The diagnosis, management and prevention of bronchiolitis. 2014.
Pediatrics. 2014;134:e1474–e1502. Full PDF

7. Systematic Review Snapshot. Do glucocorticoids provide benefit to children with bronchiolitis? Ann
Emerg Med. 2014. Vol. 64, No. 4, Oct 2014. Full PDF

  27