PEMDoc Pearls

Hi everyone,

Here is just a list of teaching points from our conference on January 10th.

Cardiology;  Supraventricular tachycardia and Wolff-Parkinson-White Syndrome 

When trying to differentiate between sinus tachycardia and a tachyarrhythmia on an ECG – one of the things to look for is a biphasic P wave in V1 which is indicative of sinus tachycardia 

Pediatric atrial flutter tends to run at a rate of 240

Re-entrant Supraventricular tachycardia usually has an abrupt, acute onset

For Wolff –Parkinson-White (WPW) look out for delta waves and short PR intervals

Atrial fibrillation in the setting of WPW is a medical emergency when there is rapid antegrade conduction over a fast accessory pathway . 

 You should never see a large Q wave in leads 1 or AVL – this may be the only sign of ALCAPA (Anomalous left coronary artery from the pulmonary artery)

Radiology: Obstructed Pediatric Airway

A swallowed foreign body may tend to present with air proximal to it or surrounding it in the retropharynx on a lateral neck film

Epiglottitis – a resurgence due to lack of vaccinations or poor vaccination response. Three signs on lateral neck radiograph (apart from clinical suspicion which takes precedence); 1) thumb print epiglottis (epiglottis usually see above the hyoid bone or at the base of the tongue 2) Lumpy aryepiglottic folds. 3) Obliteration of the vallecula

Anterior bowing of the thoracic trachea on a lateral chest film may occur as a result of a vascular ring oresophageal foreign body

On a lateral neck radiograph, normally there is a “step-off” between the posterior wall of the pharynx and the posterior wall of the trachea at the level of  the larynx ( around C4). The retropharyngeal space is normally around twice as thick below this level compared to above it. If the area above C4 is more than twice as thick compared to the area below this level; this may be associated with a retropharyngeal abscess (with clinical correlation).

Follow-up rounds

If you have a patient who is not able to abduct his/her arm for an axillary film to rule out a dislocation other options include performing a transcapular y or a Velpeau (superior to inferior view) of the shoulder.

Posterior dislocation of the clavicle is commonly not seen on an A/P chest film unless via the serendipity view which is an A/P view of the clavicles with the tube angled at 40⁰ while the patient is supine; CT or CT angiogram is the modality of choice.

Patients who are on a low protein diet e.g. if they have a metabolic condition may be more prone to hypocalcemia.

DiGeorge syndrome is a potential cause of neonatal seizures due to hypocalcemia