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 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 July 16, 2025.
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

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