EM Quick Hits 66 Pediatric Torticollis, Stable Wide Complex Tachydysrhythmias, Post-intubation Neurocritical Care, Hyponatremia Correction Rates, Paronychia Management, Women in EM Leader Series with Judith Tintinalli

Topics in this EM Quick Hits podcast

Deborah Schonfeld on pediatric torticollis (02:33)

Anand Swaminathan on stable wide-complex tachycardia (28:24)

Andrew Petrosoniak on post-intubation neurocritical care considerations (33:45)

Justin Morgenstern on correcting hyponatremia (42:39)

Andrew Tagg on paronychia management (53:09)

Victoria Myers and Judith Tintinalli on Women in EM leaders series (1:00:00)

Podcast: Play in new window | Download (Duration: 1:31:24 — 83.7MB)

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Podcast production, editing and sound design by Anton Helman

Podcast content, written summary & blog post by Brandon Ng, edited by Anton Helman, July, 2025

Cite this podcast as: Helman, A. Schonfeld, D. Swaminathan, A. Petrosoniak, A. Morgenstern, J. Tagg, A. Myers, V. Tintinalli, J. EM Quick Hits 66 – Pediatric Torticollis, Stable Stable Wide Complex Tachydysrhythmias, Post-intubation Neurocritical Care, Hyponatremia Correction Rates, Paronychia Management, Women in EM Leader Series with Judith Tintinalli  https://emergencymedicinecases.com/em-quick-hits-july-2025/. Accessed June 23, 2026.

Pediatric torticollis: Not just muscular injury

Broad Categories in the differential diagnosis of pediatric torticollis

• Muscular (SCM/trapezius): Most common; typically resolves within a week.

• Atlantoaxial Subluxation: C1/2 instability due to ligamentous or osseous abnormalities.

• Infectious:

  • Viral URTI/Pharyngitis → Referred pain, muscle spasm
  • Retropharyngeal Abscess (typically ages 2–4): Limited neck extension, fever, dysphagia, drooling, stridor
  • Osteomyelitis/Discitis: Cervical spine tenderness
  • Lemierre Syndrome: IJ thrombophlebitis post-oropharyngeal infection → SCM or jugular tenderness/swelling

• CNS Lesion (typically painless):

  • Up to 20% of posterior fossa tumors present with torticollis
  • 50% of pediatric malignant brain tumors are located in the posterior fossa
  • Clinical red flags: headache, vomiting, gait changes, ataxia, focal neuro deficits

Atlantoaxial Subluxation

Risk Factors for Atlantoaxial Subluxation

• Ligamentous injury (more common than fracture in children)
• Congenital hypermobility: Trisomy 21/Down syndrome, Marfan’s Syndrome, Juvenile Idiopathic Arthritis
• Grisel Syndrome: Post head/neck surgery with local inflammation → ligament laxity

Physical exam pearl to distinguish atlatoaxial subluxation from muscular torticollis

• Muscular torticollis: Head tilts toward spastic SCM
• Subluxation: Tilts away from affected side

Imaging for suspected atlantoaxial subluxation

• XR: Odontoid and lateral views; assess Atlantodental Interval (≤5 mm if <8 years) – use as screening in low pretest probability patients; be aware than sensitivity is poor

Source: Radiopaedia under the Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported licence

• CT: Gold standard when high suspicion or red flags present

Bottom Line

• Most cases of torticollis self-limiting, due to SCM muscle spasm
• Torticollis >1 week or with neurological findings → Image to rule out subluxation, infection, or CNS lesion

Approach to Stable Wide-Complex Tachydysrhthmias

Regular, Wide, Fast Tachycardia? Assume VT.

Rhythms >120 bpm that are regular, wide, and fast are usually Ventricular Tachycardia (VT)—rarely SVT with aberrancy.

In unstable patients, decision making is typically straighforward with immediate electrical cardioversion.

When stable, we may be tempted to reach for diagnostic algorithms to distinguish VT vs. SVT—but:

• Algorithms are ≤80% accurate
• They waste precious time
• Patients may decompensate rapidly

Rapid approach:
Assume regular wide-complex tachycardia (>110–120 bpm) is VT.

• VT treatment works for SVT with aberrancy—not the reverse.
• Consider hyperkalemia if rate <110 bpm.

Management:

• Treat with electrical cardioversion in all cases unless contraindicated.
• ACLS suggests chemical cardioversion, but efficacy is variable.
• Procainamide is more effective than amiodarone (67% vs. 38% success, Ortiz et al. 2017).
• 200 J biphasic is safe and most effective.
• Use light sedation (e.g., propofol or etomidate) if patient is alert.

Bottom Line
In any hemodynamically stable patient with regular, wide, fast tachycardia, skip the guessing—electrical cardioversion is your safest and fastest option.

ECG Cases 19 – Tachycardias: Approach, WIDER mnemonic for Wide SVT DDx, VT vs SVT

Episode 112 Tachydysrhthmias with Amal Mattu & Paul Dorian

Post-intubation Neurocritical Care: 5 Non-pharmacologic and 4 pharmacologic best practices

Securing the airway in head-injured patients is only the beginning; meticulous post-intubation care optimizes neurologic outcomes.

Non-pharmacologic best practices:

1. Head elevation (≈ 30°) or reverse Trendelenburg to lower ICP by ~ 5 mm Hg and reduce aspiration risk
2. Loosen C-spine collar or switch to an aspen collar to prevent pressure sores and ICP elevation
3. Gastric decompression using OG tube to reduce discomfort/pain
4. Bladder decompression using foley catheter to reduce discomfort/pain
5. Early arterial line placement for continuous BP monitoring (BP variability worsens outcomes)

Pharmacologic best practices:

1. Propofol infusion is preferred over benzodiazepines (allows rapid on/off of sedation for neuro exams)
2. Have boluses of sedatives (e.g. propofol) ready immediately post intubation, as infusion pumps are not always adequate
3. Consider norepinephrine to maintain BP targets if propofol causes mild hypotension
   • Alternatives include switching sedatives to ketamine or IV fluid boluses
4. Use opioid boluses rather than continuous infusions for analgesia to avoid accumulation, delirium, hyperalgesia
   • Fentanyl 25–50 µg, then hydromorphone 1–2 mg IV after obtaining CT

Bottom line => After securing the airway, focus on 5 pharmacologic and 4 non-pharmacologic best practices to deliver optimal post-intubation neurocritical care.

Hyponatremia correction rates: Has the slow correction rate dogma been debunked?

The Paper: Correction Rates and Clinical Outcomes in Hospitalized Adults With Severe Hyponatremia: A Systematic Review and Meta-Analysis by Ayus et al. JAMA Intern Med 2025.

Traditional caution against rapid sodium correction (due to osmotic demyelination syndrome, ODS) may inadvertently increase mortality.

• P: 16 studies, n = 11811 with severe hyponatremia (Na < 120 or < 125 + severe symptoms)
• I/C: hyponatremia correction at rates of rapid (> 8–10 mEq/L/24 h); slow (< 8); very slow (< 4–6)
• O: slow and very slow correction was associated with 32 (3.2% absolute increase) and 221 (22% absolute increase) additional in-hospital deaths per 1000 patients, respectively, compared to rapid correction. There were no statistically significant differences in risk of ODS between groups with different correction rates (< 1% across all correction speeds).

Additional considerations:

• The paper does not have access to underlying patient data that informs potential confounding factors (e.g. reason for hyponatremia, reason for treatment at different rates)
  • Slower treatment groups may have higher rates of cirrhosis, heart failure, metastatic cancer, which may act as confounding factors, amongst many others
• Limited quality evidence warrants further data from studies including RCTs
• Other studies suggest that there is a strong correlation between baseline health conditions and demyelination

Bottom line => While awaiting RCTs, don’t let fear of ODS (rare) drive overly slow correction that may increase mortality; prioritize life-threatening symptoms and consider faster correction.

Paronychia Management

Acute or chronic nail-fold infections are common in children and often overtreated with antibiotics.

Acute paronychia:

• Usually bacterial (Staph aureus, Strep pyogenes) after minor trauma (nail biting, splinters)
• Presents as painful, red, swollen lateral nail fold ± fluctuant abscess
• Complications include cellulitis, osteomyelitis, chronic nail changes, and systemic infections (particularly if immunocompromised)
• Management: warm soaks × 10 min, then drain the pus by lifting the lateral nail fold with a fine needle
  • Consider oral antibiotics (e.g., cephalexin, clindamycin) only if surrounding cellulitis, lymphangitis and/or immunocompromise

Chronic paronychia:

• From repeated moisture or irritant exposure (e.g. hand washing, eczema)
• Management: trigger avoidance (e.g. keep hands dry, barrier creams), manage underlying dermatological conditions, treat secondary infections.
• Refer to dermatology if persistent

Mimics of paronychia:

• Herpetic whitlow (HSV blister) → antivirals

Herpetic Whitlow. Source – Wikipedia

• Felon (deep fingertip abscess) → I&D

Felon. Source: Northwestern Medicine

• Acrodermatitis continua of Hallopeau (pustular psoriasis) → dermatology referral

Source: huidarts.com

Bottom line => Drain acute paronychia promptly and reserve antibiotics for cellulitis/secondary infections. Prevent chronic cases with trigger avoidance and education. Consider mimics of paronychia.

Women in EM Leaders Series: Dr Judith Tintinalli

None of the authors have any conflicts of interest to declare