​Differential Diagnosis	​Clinical Findings	​Management
​Balanoposthitis (cellulitis of glans or foreskin)	​Glans, foreskin, or both are erythematous, tender, or edematous	​Warm soaks +/- oral antibiotic or antifungal cream depending on etiology
​Phimosis	​Stenosis of distal foreskin preventing retraction of foreskin over the glans	​Most uncircumcised infants have normal, physiologic phimosis that will spontaneously resolve by 5 years of age. Rarely requires treatment other than daily hygiene. Monitor for if foreskin completely seals off causing acute urinary retention – true emergency.
​Paraphimosis	Entrapped ring of foreskin retracted proximal to glans of penis causing pain, erythema, and swelling	​Consult pediatric urology emergently! In cases when urology is not immediately available or necrosis of penis is imminent, ED physician may attempt reduction.

References:
– Liu DR. Pediatric Urologic and Gynecologic Disorders. In: Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw Hill; 2020
– https://www.uptodate.com/contents/balanitis-and-balanoposthitis-in-children-and-adolescents-management

References:

Walker, R.A. Adhikari, S. Eye Emergencies. In Tintinalli’s Emergency Medicine: A Comprehensive Study Guide (9th ed.). 

https://www.google.com/imgres?q=perilimbal%20flush%20uveitis&imgurl=https%3A%2F%2Fs3.ap-southeast-2.amazonaws.com%2Fwikem.cf.bucket%2Fimages%2Fthumb%2FAnterior-uveitis.jpg%2F300px-Anterior-uveitis.jpg&imgrefurl=https%3A%2F%2Fwikem.org%2Fwiki%2FUveitis&docid=i16sTpseqXcUeM&tbnid=LV7HE_b44e_8WM&vet=12ahUKEwiSn4-v1LqFAxUdD1kFHd29DxAQM3oECGoQAA..i&w=300&h=198&hcb=2&ved=2ahUKEwiSn4-v1LqFAxUdD1kFHd29DxAQM3oECGoQAAhttps://www.google.com/url?sa=i&url=https%3A%2F%2Faneskey.com%2Firitis-acute-anterior-uveitis%2F&psig=AOvVaw1g_mAok7XanZ3d_OYcUcbF&ust=1712942893847000&source=images&cd=vfe&opi=89978449&ved=0CBIQjRxqFwoTCPiil9fXuoUDFQAAAAAdAAAAABAE

Today’s Essential Teaching Image: Traumatic Iritis

Review Part 1 here!

The last two weeks, Dr. Cash taught us about bradycardia and transcutaneous pacing. This week, we dug back years into the archives and pulled out Dr. Pelletier-Bui’s famous post on transvenous pacing.

A timeless classic! Just be sure to know what supplies are available in your department, where to find them, and alternate options if your supplies differ.

References:

Bessman, E. (2019). Emergency cardiac pacing. In Roberts et al (Eds.), Roberts and Hedges’ clinical procedures in emergency medicine and acute care (pp. 288-308).  Elsevier, Inc.

Bohanske. (2013, November 4). Transvenous pacemaker placement – Part I: The walkthrough.  Taming the Sru.  https://www.tamingthesru.com/blog/procedural-education/transvenous-pacemaker-placement-part-1-the-walkthrough 

Mason, J. [EM:RAP Productions] (2018, October 11).  Placing a transvenous pacemaker [Video]. YouTube. https://www.youtube.com/watch?time_continue=24&v=00-T8PcbStE&feature=emb_title

1. Treat possible underlying cause if known 

2. Atropine
   •  Class 2a treatment
   • Dose 0.5 mg IV every 3-5 minutes, up to total dose 3 mg 
   • Can produce paradoxical worsening bradycardia 
   • Less effective in patients with cardiac transplant 
   • Skip if unstable, move directly to pacing 

3. Transcutaneous pacing  
   • Class 1a recommendation
   • Place pads in anterior lateral or anterior posterior position 
   • Consider sedation or pain control  
   • Set monitor to “Pacer” 
   • Set rate, usually around 60 bpm 
   • Start current at 0 mA and slowly increase until capture is obtained. Consider different placement of pads if capture not achieved by 130 mA 
   • Confirm capture by feeling pulse or cardiac ultrasound 
   • Transcutaneous pacing is ultimately a bridge to transvenous pacing or permanent pacemaker – discuss with cardiology or transfer to center with these capabilities  
   • Capture (pictured below) shows pacer spike followed by a wide QRS and then ST and/or T wave  

References: 

1. Judith E. Tintinall, et al. (2020). Tintinalli’s Emergency Medicine : A Comprehensive Study Guide (Ninth Edition). New York: McGraw-Hill. 

2. Doukky R, Bargout R, Kelly RF, Calvin JE. Using transcutaneous cardiac pacing to best advantage: How to ensure successful capture and avoid complications. J Crit Illn. 2003 May;18(5):219-225. PMID: 30774278; PMCID: PMC6376978. 

3. Holger J S, Lamon R P, and Minnigan H J et al.: Use of ultrasound to determine ventricular capture in transcutaneous pacing. Am J Emerg Med.  2003; 21: 227 

A	ACS	Myocardial infarction, also consider cardiomyopathies, myocarditis
T	Thyroid	Hypothyroidism
R	Rhythms	Second degree AV block (type I & II), complete AV block
O	Overdose	Digoxin, beta blockers, calcium channel blockers, amiodarone, clonidine, organophosphates, naturally occurring cardiac glycosides (e.g. foxglove), opioids
P	Pressure	Increased intracranial pressure (Cushing’s response)
I	Infection	Lyme disease, diphtheria, typhoid fever, aortic root abscess
N	Nippy	Hypothermia
E	Electrolytes	Glucose, potassium, calcium, and magnesium

Other Considerations:

• Hypoxia
• Infiltrative Disorders (Amyloidosis, Sarcoidosis, Hemochromatosis)
• Autoimmune disorders (SLE)
  

References: 

1. Judith E. Tintinall, et al. (2020). Tintinalli’s Emergency Medicine : A Comprehensive Study Guide (Ninth Edition). New York: McGraw-Hill. 

2. Briggs, Blake & Husain, Iltifat. (2024, Jan 16) Bradycardia: “But my Apple Watch…?” (208). Emergency Medicine Board Bombs.