Case

A 7-month-old healthy term female presented to the pediatric emergency department for swelling on the left side of her head after a witnessed fall 1 day prior. During a diaper change, she rolled off the bed and fell approximately 2 feet onto the hardwood floor. She cried immediately with no loss of consciousness and no vomiting. She had been acting normally and was observed at home, but on the day of presentation her mother was concerned due to the increased swelling on the left side of her head.

On arrival to the pediatric emergency department, her initial vital signs were: temperature 36.5 °C, heart rate 139 bpm, blood pressure 111/83 mmHg, respiratory rate 38 and oxygen saturation of 97% on room air. On physical examination, she was active and well appearing with a grossly normal neurologic exam. On the left parietal scalp, she had a boggy hematoma approximately 6 cm in diameter. The differential diagnosis for a boggy hematoma after head trauma includes cephalohematoma, skull fracture and underlying intracranial hemorrhage.

Point-of-care ultrasound (POCUS) of the skull was performed in the area of injury and demonstrated a parietal skull fracture with an overlying hematoma (Figure 1). A non-contrast head CT scan was performed which identified a scalp hematoma, a nondisplaced left parietal skull fracture (Figure 2) and an adjacent 3 mm epidural hematoma with no mass effect. She was admitted to the pediatric intensive care unit for frequent neurologic monitoring and underwent a non-accidental trauma evaluation.

Discussion

Head trauma is a common cause of presentation to pediatric emergency departments,¹ especially in younger children, with symptoms that vary widely based on the severity of injury. The vast majority of children with head injuries have minor head trauma, but it is critically important to identify those with clinically important traumatic brain injury (ci-TBI). Much work has been done to identify characteristics that predict risk for ci-TBI and develop clinical decision rules to risk stratify patients.² Since the gold standard imaging test for head trauma is a non-contrast head CT scan, clinical decision rules seek to balance the exposure to ionizing radiation against the risk of ci-TBI, such as those that require neurosurgical intervention, intracranial pressure monitoring, intubation, prolonged hospitalization or that cause death.^3,4 The Pediatric Emergency Care Applied Research Network (PECARN) algorithm for minor head trauma has been validated for identifying children at low risk of ci-TBI, for whom neuroimaging may be omitted.⁵

Point-of-care ultrasound for identifying skull fractures is not currently validated for use within any clinical decision rule for evaluating head trauma, but it may offer some diagnostic utility. A meta-analysis showed a sensitivity of 91% and specificity of 96% for POCUS identification of skull fractures compared to CT scan,⁶ as well as feasibility for the emergency department setting.^7,8 Hematomas can easily be identified with POCUS as hypoechoic areas above the skull in the area of trauma (Figure 1). It is important to scan the skull under and adjacent to the hematoma, as the fracture may not be directly under the hematoma due to shear forces during the injury.⁹ Importantly, skull fractures must be differentiated from cranial sutures in young children. Fractures tend to be sharply demarcated and may be displaced while sutures tend to have a more ragged appearance, are not displaced, have contralateral symmetry and consistently trace back to a fontanelle (Figure 3).¹⁰

While skull fractures are associated with a fourfold increase in relative risk for intracranial injury,¹¹ it is important to note that skull ultrasound does not evaluate for intracranial injury. POCUS through an open anterior fontanelle may allow for evaluation of central pathologies such as substantial intraparenchymal hemorrhage, mass effect and hydrocephalus, as only the central regions of the brain can reliably be seen, especially as the fontanelle shrinks in size (Figure 4). Enlarged ventricles, midline shift and large fluid collections may be visualized scanning through the anterior fontanelle. Subdural and epidural hematomas may be missed, as the periphery is obscured by bone and the acuity of the angle when scanning through the fontanelle. While ultrasound for skull fracture or cranial ultrasound through the anterior fontanelle does not obviate the need for CT imaging if there is concern for ci-TBI, it may add information of clinical utility at the bedside or be of use in resource-limited settings when CT is not readily available.

Case Conclusion

The patient had no deterioration in neurologic status during admission. There were no additional injuries identified on skeletal survey and a repeat head CT scan demonstrated no progression of the skull fracture or epidural hematoma. She was discharged home on the second day of hospitalization with the plan to follow-up with our Physical Medicine and Rehabilitation service.

Indications

• Blunt head trauma
• Concern for ci-TBI
• Scalp hematoma

Technique

• Place the patient in a position of comfort.
• Apply ultrasound gel, a stand-off pad or a water-filled glove over the areas of interest.
• Use a high frequency linear transducer for evaluation of the skull.
• Use a small footprint transducer, such as the phased array or endocavitary transducer, for evaluation through an open fontanelle.
• Scan the area of interest in two dimensions and trace fractures and sutures to determine if they connect to a fontanelle.

Pitfalls and Limitations

• Skull ultrasound does not permit intracranial evaluation due to the high acoustic impedance of bone.
• The field of view for a fontanelle ultrasound is primarily limited to central regions and misses the periphery.
• Skull fractures are often identified directly underneath areas of scalp swelling but can also be found adjacent to hematomas.
• Skull fractures must be differentiated from cranial sutures. Skull fractures tend to be sharp and linear with varying degrees of depression. Sutures tend to be hypoechoic regions with a beveled or end-to-end appearance that separates bony plates, trace back to open fontanelles and demonstrate contralateral symmetry.
• Neither skull nor fontanelle ultrasound are currently incorporated into risk stratifying algorithms for head injury.

Jeffrey Thompson, MD FACEP
Assistant Professor, Emergency Medicine
SUNY at Buffalo

She Still Wants to Look Pretty

We will call her Chloe. We have all seen her. She is about 30, cachectic, disheveled, toothless, covered in tattoos, some artistic, others – purple pocks dotting her arms, legs and neck – seemingly of her own doing. She sleeps soundly in the bed, arousable, but impossible to keep awake for more than a few seconds. She does not wish to be bothered, but her red, swollen, fluctuant thumb demands attention. Her physical appearance matches the preconception I formed based upon a review of her medical record. She certainly matches the description of one who is homeless, addicted to heroin, suffering from endocarditis and unable or unwilling to follow-through with hospital or outpatient treatment. The management for me will be quick and easy – a few labs, Xray, IV (well, that part won’t be easy), antibiotics and admission.

But I was not prepared for where this encounter would take me. After a futile attempt at obtaining a history, I walked across the room in search of a pair of gloves for an exam. As I donned the gloves, I glanced down and scanned the contents of her clear plastic bag sitting on the chair next to her bed – lipstick, a hairbrush, a pink sash, a small bar of soap and a set of pink press-on fingernails. My initial cynicism convinced me that these were her tools of the trade; and perhaps they were. But as I gazed back and forth between the diminutive, pitiable patient curled up sleeping on the bed and the bag of cosmetics on the chair, I realized that beneath this haggard and faded appearance and beyond the grotesque cartoonish thumb, was a young woman who still cares about her appearance. She still wants to look pretty.

In thinking about this recent encounter, I recalled the television commercials from the 80s and 90s with the young, aspirational kids telling us what they want to be when they grow up, reflecting the hopes and dreams of their afterschool audience; and the narrator’s closing line of “nobody ever says, ‘I want to be a junkie when I grow up.’” Say what you will about the so-called war on drugs; these ads were spot on. I have contrasted Chloe’s ED visit with a recent family gathering where my 4-year-old niece danced around showcasing her hair and “make-up” after using her toy cosmetic kit. The contrast between the two is stark, but I wondered if Chloe ever did the same when she was little. When and how did that transformation occur? Who or what happened to her in the years between being an innocent little girl and a woman whose health and life is ever hanging in the balance? And what hope does she cling to that inspires her to keep buying and applying the lipstick, the nails and the sash?

I perfectly predicted Chloe’s hospital course – admitted for 2 days, IV antibiotics through a PICC line and eventual discharge AMA after she was caught injecting through the PICC. We all know someone like Chloe and it can be disheartening to see her story played out on repeat in our EDs across the state and the country. It is easy to become desensitized and cynical after a few of these encounters and each subsequent patient suffers from our depersonalization and the fatalism we adopt when treating this population. No doubt I began my interaction with Chloe with such an attitude. Yet without saying more than a few words, she reminded me that there is much more to these patients than their drug use, their medical complications and their non-compliance. There is a remnant of hope of something different; something better; something pretty.

Up until this point in my medical training, there has always been a set structure and deadlines: there was a deadline to take the MCAT, a deadline to submit applications to medical school, a set medical student curriculum, a deadline to submit audition rotation applications, a deadline to submit the ERAS application and numerous residency requirements. As my second of three years of residency training quickly comes to a close, I find myself reflecting on “what’s next?” I am entering the first phase of my professional career that has fewer rigid deadlines and it is up to me to make my own structure. With that comes many other questions – Do I want submit a fellowship application or do I apply for jobs? How do I find a job? What kinds of things are important to consider in looking at jobs? As I start this process, there are many points that I am starting to consider as I start the job search.

1. Setting. In my training program alone, we rotate through 6 different clinical sites, each with its own “flavor” of emergency medicine. There are large academic centers that are closely aligned with a university or medical school. On the other end of the spectrum, there are more rural emergency departments in resource-scarce areas. If you pursue them, there are fellowships that completely change the nature of your practice such as sports medicine or Emergency Medical Services. There are groups that offer to buy down time for other activities such as administration or other academic pursuits. Combinations of these settings are also possible!
2. Resources. Clinically, it is critical to know what kind of supports are available at your hospital and what time of the day or week they are available. When you find yourself caring for a patient with an acute stroke in the middle of the night, what kind of diagnostic testing is available? What kind of specialty services are available? Does your hospital have an agreement with another hospital for transfer? When you document your patient encounter, what kind of electronic medical record do you use? Do you dictate your own notes or utilize a scribe?
3. Location. Emergency medicine training teaches a skillset that is respected worldwide. As such, do you want to stay “close to home” or practice somewhere else in the country – or even the world? While attending the 2024 ACEP Council, I found it fascinating that there is a Cruise Ship Medicine Section of ACEP. Now, UCLA even offers a Space Medicine fellowship for emergency medicine residency graduates. The possibilities of location to practice emergency medicine are truly endless!
4. Practice Model. Emergency medicine is unique in that there are a number of different practice models. Democratic groups, private groups and corporate groups exist and vary depending on how they are owned and operated. Some emergency medicine physicians are also directly employed by the hospital rather than a group.
5. Compensation. For base salary alone, there is a wide range of compensation for emergency medicine jobs. Salary vs. RVU based incomes vary widely as well. Tax forms (W-2, K1, and 1099) can significantly impact the final dollar amount that you bring home. Some practices offer student loan forgiveness or make you personally eligible for the Public Student Loan Forgiveness (PSLF) Program for those with medical student loans. Additional benefits, such as health insurance, malpractice coverage or even CME funds may tip the scale for some!

Applying for any job can feel overwhelming. When applying for a job as an emergency medicine physician in particular, there are many factors to consider. As I approach the end of my residency career, it is imperative to consider these factors. Regardless of where I end up after residency, I have never been more confident in my choice of specialty and I am absolutely privileged to practice emergency medicine.

Case

A 13-year-old female with past medical history of anxiety who presented to our pediatric emergency department (PED) with complaints of intermittent reflux and chest pain for 3 days. She denied fever, shortness of breath or syncope, but endorsed cough for two days. On her exam, she was alert, interactive, well-appearing and spoke in full sentences. Initial vital signs were temperature 97.5-degree Fahrenheit, blood pressure 110/77, heart rate 139 beats per minute, respiratory rate 18 breaths per minute and oxygen level 100% on room air. Her cardiac exam was significant for tachycardia with no murmurs or gallops with normal capillary refill and chest wall tenderness on palpation. Her lung exam revealed good air entry with no increase work of breathing and the remainder of her exam was within normal limits.

The patient remained tachycardic after pain medication and aggressive oral hydration. At that point, an electrocardiogram (EKG), chest x-ray and labs were drawn.

EKG revealed sinus tachycardia with premature atrial complexes (PACs). Labs showed an elevated troponin of 122 ng/L, BNP of 7472 pg/mL with mildly elevated LFTS and BUN/creatinine. The chest x-ray showed gross cardiomegaly, the heart silhouette being larger than one half of the thoracic cavity.

Disposition Decision:

Patient remained well appearing in no distress and with good perfusion. Outpatient follow up was briefly considered but repeat vitals showed persistent tachycardia and labs showed minor signs of end organ dysfunction. The decision was made to transfer to a tertiary center for further evaluation and admission.

The Inpatient Course:

At the pediatric cardiac intensive care unit (ICU), she rapidly decompensated. Her echocardiogram showed severe biventricular dysfunction, with a left ventricular ejection fraction (LVEF) of 15–20%. She was diagnosed with fulminant myocarditis versus newly diagnosed dilated cardiomyopathy (DCM).

Within 48 hours, she required intubation and mechanical ventilation. She was started on inotropes, antiarrhythmics and broad-spectrum antibiotics while awaiting myocarditis workup. Despite aggressive management, she developed cardiogenic shock and worsening fluid overload. The patient underwent placement of an Impella left ventricular assist device (LVAD) to stabilize her. The patient ultimately required orthotopic heart transplantation (OHT) and slowly recovered back to full function. Our patient is currently thriving back at home with a LVEF of 70% and re-engaged in sports and physical activities.

Discussion:

Pediatric myocarditis is an inflammatory condition of the myocardium often triggered by viral infections such as Coxsackie B, adenovirus, parvovirus B19 and more recently, SARS-CoV-2. It typically presents with vague symptoms like chest pain, fatigue, dyspnea or gastrointestinal discomfort, often mimicking benign illnesses and delaying diagnosis.¹

In severe or fulminant cases, myocarditis can lead to cardiogenic shock, a critical state of reduced cardiac output and end-organ perfusion. Signs include tachycardia, hypotension, cool extremities, oliguria, and altered mental status.² These children may require ICU care, inotropes, mechanical ventilation or mechanical circulatory support such as ECMO or LVAD.^3,4

If inflammation is prolonged or irreversible, it may evolve into DCM characterized by ventricular dilation and systolic dysfunction. Symptoms include poor feeding, respiratory distress or hepatomegaly. While some patients recover with medical therapy, others may require cardiac transplantation.⁵

Diagnostic workups include ECG, troponin, BNP, chest X-ray and echocardiogram. Common findings include arrhythmias, cardiomegaly or global hypokinesis.⁶ Cardiac magnetic resonance imaging (CMR) is now the gold standard for non-invasive diagnosis, offering high sensitivity for detecting myocardial edema, hyperemia and necrosis. The American Heart Association recommends CMR as a first-line modality in stable patients, often replacing biopsy in early or intermediate presentations.⁷ A multicenter 2023 study found that early CMR reduced diagnosis time by 40% and avoided biopsy in over half of pediatric cases.⁸

Endomyocardial biopsy remains the gold standard for diagnosis but is reserved for refractory or fulminant cases due to procedural risk.⁹ In unclear presentations, genetic testing can help identify predispositions to cardiomyopathy.¹⁰

In multisystem inflammatory syndrome in children (MIS-C) secondary to COVID, myocarditis has been reported in up to 17% of patients, often responding well to corticosteroids or IVIG.¹¹ Elevated IL-6 and CRP may predict which patients benefit most from early immunotherapy.¹² For virus-positive myocarditis unresponsive to steroids, interferon-beta is being studied in the MYO-VIR trial.¹³

Lessons in Recognition: When Vitals Don’t Match the Story

This case reinforced a fundamental rule in pediatric emergency medicine:

vital signs are not suggestions, they are critical data points. The patient appeared well, was interactive, afebrile and normotensive. It would have been easy to dismiss her tachycardia as anxiety, pain or other benign causes, but that elevated heart rate was the only suggestion of a brewing cardiac crisis. There were no murmurs, no overt respiratory distress or cyanosis, just a subtle red flag. Recognizing the mismatch between her clinical appearance and vitals led to early cardiology involvement and a timely transfer, ultimately changing her outcome.

Clinical Takeaways

• Persistent or unexplained tachycardia should always prompt further evaluation.
• Myocarditis, though rare, should remain on the differential in pediatric chest pain.
• Early tests like EKG, chest x-ray, troponin and BNP are low-risk and high-yield.
• Vitals are vital for a reason! Do not ignore them and escalate when uncertain.

Can you tell us about the Women’s Health in Emergency Medicine (WHEM) Fellowship and how it is relevant to EM practice?

The Women’s Health in Emergency Medicine (WHEM) Fellowship is a two-year fellowship designed to integrate comprehensive women’s healthcare into emergency medicine practice. This fellowship aims to equip emergency medicine (EM) physicians with the knowledge and skills to address the unique health concerns of female patients, thereby enhancing patient care and outcomes. Further, the fellowship has a strong advocacy and policy component, empowering fellows to become changemakers in the field.

How could WHEM be able to provide for your patient communities?

WHEM works to increase provider awareness of gendered care disparities in the ED and increase the availability of education and resources to eliminate those disparities. While we aim to improve clinical management of female patients, we are also working to improve our warm handoffs to social services such as Public Health Solutions Family Support Program, which provides a comprehensive package of services to pregnant and parenting families in NYC.

Are there certain age groups that could be particularly affected by this Fellowship?

All ages are touched by the fellowship program. However, each fellow will specialize in an area of women’s health in the ED, such as cardiology, neurology or reproductive health. Our inaugural fellow Dr. Alexadra Over, will concentrate on the intersection of social EM and women’s health in the ED.

How did the development of WHEM come about?

WHEM came about in 2024. Jessica Army, MD, had been working for four years to get a miscarriage management protocol approved and Dana Gottlieb, MD, led SANE/SAFE initiatives at Long Island Jewish Medical Center. Army and Gottlieb met T.S. Mendola, PhD, a new faculty hire specializing in reproductive health policy. Together, they decided a Division of Women’s Health in Emergency Medicine would provide an institutional home to leverage their collective goals into action.

When creating successful programming, how important is collaboration with other institutions locally? What specific institutions have you found instrumental?

Collaboration is essential to collective power and policy change. Externally, we partner with Access Bridge, FemInEm and Public Health Solutions. We maintain open communication with our local Planned Parenthood for referrals. Internally, we are proud to be supported by the Katz Institute of Women’s Health and our OBGYN department. We also partner with Zucker Hillside Hospital to strengthen our referrals of women with substance use disorders. However, we want to stress that we are less than one year old! More collaborations are in the works.

How is WHEM presented/taught to other staff/resident in your department?

We publicize our events through newsletters and emails to the department and hold a monthly journal club to address different issues touched by our Division’s mission. We also maintain a public-facing website, womenshealthem.com. In all of our materials, we adhere to WHEM’s mission to provide the highest quality care possible to women and girls in our EDs. We will also be hosting our 4^th annual Women’s Spring Conference this year on April 23, 2025 at the Feinstein Institutes for Medical Research. This year’s annual theme is Reproductive Care in the ED.

What are common challenges encountered with WHEM? How are they overcome?

The biggest challenge we face is sustainable funding. Neither women’s health nor emergency medicine have ever had their own NIH institute, making it a double challenge to secure multi-year research and service grants to support long term clinical and research initiatives at scale. The second biggest challenge is simply navigating the current federal funding landscape, where recent anti-DEI trends make obtaining funding to study gendered disparities challenging.

What advice can you offer to EM physicians interested in initiating a similar program to WHEM but who have no background or training in this field? What are the first steps they can take to pursue this interest?

Start small: choose one thing about women’s health in your ED that you feel could be improved upon. Find the issue in your ED that gets you up in the morning and start asking, why can’t we change this? Ask questions, then ask more questions. Don’t take “no” or “we can’t do that” for an answer. Organize with your fellow physicians and nurses: you are stronger together. Reach out to other institutions doing similar work and ask for mentorship. You would be surprised at how willing people are to help. And then see how far you can go.

Please provide any concluding thoughts on how you see the ER being a conduit for the study of Women’s Health.

The Emergency Department is a unique landscape that becomes a point of refuge for patients who lack care elsewhere or may not feel safe seeking care elsewhere. Like many demographics, women find themselves seeking care in the ED for a myriad of complaints. Until recent decades, they weren’t even represented in the foundational studies to guide that care—and today, the mandate to include women in clinical trials hangs in the balance with uncertain federal guidance. Emergency Medicine, as a newer specialty with a broad patient population, is well positioned to study the needs of our patients and roll out new protocols to expand our access to women’s specific care needs. This includes improved diagnostic testing, protocols, and anticipation of needs for follow-up care.