UMEM Educational Pearls - By Adam Friedlander

Category: Pediatrics

Title: Magnets in noses...

Keywords: Magnet, Foreign body, pediatric, nose, nasal, perforation (PubMed Search)

Posted: 6/10/2011 by Adam Friedlander, MD (Emailed: 6/11/2011) (Updated: 6/11/2011)
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If there is a single truth of pediatric emergency medicine, it is that kids love to stuff things into their noses.  A particular danger (aside from batteries, covered in a previous pearl) is the magnet.  

Specifically, two magnets (as seen with magnet ear and nose rings, frequently worn by children and teens whose pesky parents won't allow piercings), attracted across the nasal septum can cause necrosis and perforation within hours.

Here's how to save yourself (and some noses):

  1.  Place a strong magnet such a mechanic's pocket magnet (<$10), or a pacer inhibition magnet within 1.5cm of the magnets.  Be careful not to apply pressure to the septum.
  2. Watch for the opposite side magnet to fall out of the nose.
  3. Easily remove the second magnet, which is no longer stuck to anything...you can use the strong magnet from step 1 at the nare opening to assist.
  4. Though this method is generally non-traumatic, you should pre-treat the nares with 4% lidocaine and 1:1,000 epinephrine spray to minimize potential bleeding.

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Category: Pediatrics

Title: Positioning in Pediatric Intubation

Keywords: Airway, Intubation, Pediatric, Positioning (PubMed Search)

Posted: 5/13/2011 by Adam Friedlander, MD (Updated: 8/28/2014)
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"Ear to sternal notch" positioning has gained wide acceptance in the emergency medicine and anesthesia literature.  Most often, this teaching is brought up with respect to obese adult patients whose large body habitus requires the raising of the neck and head to achieve airway alignment.

However, the correct anatomic positioning principle applies to all ages.  Specifically, with regard to neonates, a shoulder roll is often placed indiscriminately to put the patient into the now out-dated "sniffing position," usually worsening the view of the airway.  

Though this positioning is frequently misused, it can be easily adapted to apply ear to sternal notch positioning to neonates, whose misaligned airway is the result of a large occiput rather than a large torso.  In all ages, if you follow these positioning principles, you will improve your view of the airway:

1. Align the ear to the sternal notch

2. Keep the face parallel to the ceiling (do NOT hyperextend the neck, as in the sniffing position)

3. In adults, the head usually needs to be raised (Image 1), while in infants, the torso usually needs to be raised (image 3).

 

 

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Category: Pediatrics

Title: Neonatal hypermagnesemia and respiratory depression

Keywords: magnesium toxicity, neonatal hypotonia, neonate, intubation, neonatal resuscitation (PubMed Search)

Posted: 4/8/2011 by Adam Friedlander, MD
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So the magnesium didn't work, and the baby is on the way!  You're prepared with everything you need for the delivery from bulb suction to a tripod for Dad's camera...  But what is going to special about this baby?  

Babies born to mothers who received magnesium therapy for any reason are at risk for hypotonia and severe respiratory depression.

  • DO provide respiratory support as needed, as respiratory depression is the only dangerous side effect of hypermagnesemia in the neonate (be prepared to provide supplemental oxygen, positive pressure ventilation (PPV), and possibly intubation)
  • DO recognize that generalized hypotonia may be a clue as to how significantly affected the neonate may be, however, don't let the hypotonia itself scare you - it will go away, and is not dangerous in and of itself
  • DO follow neonatal resus guidelines (PPV for HR<100, CPR for HR<60), but remember that supportive measures will resolve all problems related to hypermagnesemia in the neonate...if there are other issues, don't blame the mag
  • DO NOT give calcium as, in contrast to their mothers, these patients are not hypocalcemic (and the hypermagnesemia will spontaneously resolve in 48 hours)
  • DO remember that these infants frequently require a brief NICU stay until they no longer require respiratory support

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Category: Pediatrics

Title: To CT or not to CT, Part II

Keywords: head CT, trauma, pediatrics, head injury (PubMed Search)

Posted: 2/11/2011 by Adam Friedlander, MD (Updated: 6/24/2024)
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Head injuries in children over 2yo are stress provoking as well.  Here are the rules for that age group, piggy-backing on last week's pearl, based on a large (42,412 children, 31,694 >2yo) multi-center trial conducted by PECARN.
 
In children >2yo, if all of the following criteria are met, there is 99.95% chance that no clinically important traumatic brain injury exists (defined as an injury requiring intervention):
  • normal mental status
  • no loss of consciousness 
  • no vomiting
  • non-severe injury mechanism
  • no signs of basilar skull fracture
  • no severe headache
No children in either low risk group required neurosurgical intervention.
 

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Category: Pediatrics

Title: To CT or not to CT, Part I

Keywords: head CT, trauma, pediatrics, head injury (PubMed Search)

Posted: 2/4/2011 by Adam Friedlander, MD
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Head injuries in children under 2yo are stress provoking, particularly with regard to when you should be getting a head CT.  Luckily, a large (42,412 children, 10,718 <2yo) multi-center trial exists to guide your behavior.

 
In children <2yo, if the following criteria are met, there is a near 0% (95% CI) chance of a clinically important traumatic brain injury (defined as an injury requiring intervention):
  • normal mental status
  • no non-frontal scalp hematoma
  • no loss of consciousness, or LOC <5s
  • non-severe injury mechanism
  • no palpable skull fracture
  • acting normally according to the parents
Approximately 25% of the patients who had CTs, fit the low risk criteria above, and none had clinically significant brain injuries.  
 
In other words, just follow these simple rules to cut down the number of head CTs done on children <2yo by 25%.

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Category: Pediatrics

Title: Hypertonic Saline for the treatment of hyponatremic seizures in children

Keywords: hypertonic saline, seizures, hyponatremia, hyponatremic, encephalopathy, pediatric, children (PubMed Search)

Posted: 1/6/2011 by Adam Friedlander, MD (Emailed: 1/7/2011) (Updated: 1/7/2011)
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Hyponatremic seizures are a frightening entity.  Anticonvulsants don't work well, and will likely cause apnea well before they halt the seizure.  Hypertonic saline carries with it the fear of inducing central pontine myelinolysis (CPM) with overly rapid correction of the hyponatremia.  

However:

  • CPM usually occurs at sodium level corrections of >8 mEq/L/day
  • Hyponatremic seizures are usually stopped with a correction of only 3-5 mEq/L

So, you can safely correct hyponatremia rapidly in the setting of seizures. Do it like this:

Give 2-3 mL/kg of 3% NaCl in rapid sequential boluses, until seizures stop.  A theoretical maximum dose is 100mL/kg, but recall that only a relatively small correction is required to stop the seizure.  
 
After you've stopped the seizure, correct the hyponatremia slowly, as you would otherwise.
 
 

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Category: Pediatrics

Title: Cuff Pressure in Pediatric Intubations

Keywords: Pediatric Intubation, Airway Control, Cuff Pressure (PubMed Search)

Posted: 12/10/2010 by Adam Friedlander, MD
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In the past several years it has become common practice to use cuffed tubes for pediatric intubations.  However, a recent study suggests that cuff pressures are not as well regulated in pediatric patients, particularly when the patients are quickly intubated prior to aeromedical transport. Cuff pressures >30 cm H2O are associated with tracheal damage, however, up to 41% of pediatric patients transferred had cuff pressures >30 cm H2O, and 30% of those had pressures >60 cm H2O!  

So:

  • Check your cuff pressures in all patients, particularly prior to transport

  • Cuff pressures must be <30cm H2O

  • Recall that for years uncuffed tubes were the standard, so as long as effective ventilation is achieved, it is best to err on the low side...

If you work at a facility that routinely transfers out the sickest pediatric patients, you will save their life by securing an airway in this most stressful of circumstances, but careful attention to this seemingly small detail can save your patient from long term complications.

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Category: Pediatrics

Title: Do not flex the neck in pediatric LP positioning

Keywords: pediatric, lumbar puncture, positioning, interspinous space (PubMed Search)

Posted: 12/3/2010 by Adam Friedlander, MD
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We've all been there.  It's 2am, and a 4 week old with a temperature of 38.1 rolls in the door.  You grab the LP kit and your "best holder."  This person then holds the baby's head and neck flexed with one hand, while the other brings the bottom and legs up to the chest as much as possible...all, usually, without pulse oximetry monitoring.

 
Well, it's time for a change.  Here's why:
  • By ultrasound, the largest interspinous space is achieved in the upright, hips flexed position (ie. leaning forward).
  • In the lateral decubitus position (often preferred in young infants), neck flexion DOES NOT increase the interspinous space.
  • Furthermore, neck flexion increases the incidence of respiratory compromise and hypoxia. 
In other words,  NECK FLEXION SHOULD BE ABANDONED in the positioning for pediatric LP.

 

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Category: Pediatrics

Title: Ondansetron and Oral Rehydration Therapy

Keywords: Ondansetron, Oral Rehydration, Therapy, vomiting, pediatrics (PubMed Search)

Posted: 10/15/2010 by Adam Friedlander, MD (Updated: 10/16/2010)
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You may already love ondansetron, but consider using it ORALLY followed by PO hydration in children with vomiting.

  • Improve ORT success
  • Decrease IV placements
  • Decrease admission rates
  • NOT cause any significant difference in the number of missed serious alternate diagnoses 

The size of the study that showed this: N of just under 35,000.

But don't skimp on dosing.  The dose is 0.1 - 0.15mg/kg, and you don't reach a max until 8mg.  To put this in perspective, a scrawny 115lb (about 53kg) middle school tennis player would get 8mg, an initial dose often reserved for chemo patients in the adult ED.

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Category: Pediatrics

Title: Subtle SCFE

Keywords: SCFE, slipped capitofemoral epiphysis (PubMed Search)

Posted: 10/1/2010 by Adam Friedlander, MD
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Slipped capito-femoral epiphysis (SCFE) is a favorite board exam topic, and typically involves a young early or pre-adolescent obese girl with hip pain and the classic "ice cream falling off the cone" appearance on hip radiographs. However, keep these three pearls in mind when thinking about SCFE:

  1. Girls > Boys, but boys may be older at presentation - don't forget 15 year old boys and SCFE.
  2. An early radiographic finding may only be physis widening, so consider comparison films - the ice cream may only be levitating, but not falling off.
  3. 23% of these children present with knee pain - think before diagnosing an obese 15 year old boy with a knee sprain from football. *bonus* Recall that this injury is non weight-bearing.

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Category: Pediatrics

Title: Bronchiolitis

Keywords: Bronchiolitis, RSV (PubMed Search)

Posted: 9/10/2010 by Adam Friedlander, MD
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As RSV season approaches, remember these key points in managing bronchiolitis:

  • Diagnosis is clinical - labs and XRays will not help you, unless you want to rule out a specific alternate diagnosis.  It's all about the H&P.
  • Supportive care, including bulb suction of secretions, placing the child in a position of comfort, and possibly providing humidified air, is the mainstay of treatment.
    • Ribavirin, corticosteroids, and antibiotics are not indicated.  Don't use them.
    • Bronchodilators have no benefit in bronchiolitis alone, and non-response to bronchodilators supports the diagnosis of bronchiolitis.  If a trial does work, know what you are treating - some children with bronchiolitis may have an underlying component of reactive airway disease, and should be treated accordingly.
  • Before disposition be sure that the child can tolerate PO.  A fussy, tachypneic child may require admission for IV hydration if they are unable to tolerate feeds - recall that infants are obligate nose breathers.
  • Finally, beware the RSV bronchiolitis bounceback - the peak incidence of respiratory failure in RSV bronchiolitis is after 3-4 days of illness, when most children should be improving.

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Category: Pediatrics

Title: Pediatric Burns, Part II

Posted: 8/13/2010 by Adam Friedlander, MD (Updated: 6/24/2024)
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A common debate on the topic of pediatric burns is whether or not blisters should be debrided.  ALL PEDIATRIC BURN BLISTERS SHOULD BE DEBRIDED.  There are two reasons for this:

1. Without debridement of burn blisters, the depth of a burn cannot be assessed, and such an assessment will certainly affect treatment and disposition.
2. There is conflicting (poor) evidence that blister fluid provides both protective and damaging properties, however, there is excellent evidence that ruptured blisters, or large blisters which are likely to rupture, carry a higher risk of infection if not debrided. Therefore, all blisters should be debrided. 

The best method for debriding blisters uses sterile gauze soaked in saline, and it is important to note that pain is almost universally decreased after debridement. 

The "1, 2, 3 Ouch!" technique is exactly what it sounds like (count to three with the child, and then wipe quickly, like tearing off a bandage), and works well in older children with smaller burn areas.  Sedation may be necessary for extensive debridements, and these children may need to be taken to the OR for debridement under anesthesia.  Some burn centers utilize non-operating room anesthesia (NORA) areas for such debridements that may be prolonged or painful, but do not require the full resources of an operating room.

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Category: Pediatrics

Title: Pediatric Ethanol Ingestion

Keywords: Ethanol, Pediatric, Ingestion (PubMed Search)

Posted: 8/7/2010 by Adam Friedlander, MD
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Pediatric Ethanol Ingestion

A young child is brought to you after accidentally drinking a shot of alcohol at a wedding party. Here is what you need to consider:

  • Infants and young children who have ingested enough ethanol to cause a peak serum level ≥50 mg/dL (11 mmol/L) are at risk for profound hypoglycemia, in addition to the other effects of alcohol seen in adults The key is that the dangerous serum level is MUCH lower in children than in adults, and children require FAR smaller volume than what may be considered dangerous by adults.
  • Supportive care is the key to good outcomes, with particular focus on treating hypoglycemia - check your D-sticks early and often.
  • Consider child protective services involvement in every case of pediatric intoxication, and consider measurement of serum acetaminophen levels as well as other possible toxic ingestion candidates.
  • Activated charcoal cannot adsorb ethanol and should only be used if other substances are being considered.
  • Children who are asymptomatic for six hours, and have a safe home environment, may be discharged.

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Category: Pediatrics

Title: Pediatric Burns, Part I

Keywords: Pediatric Burns, Fire, Injury, Burn Injuries, Sage Diagram, TBSA (PubMed Search)

Posted: 6/11/2010 by Adam Friedlander, MD (Updated: 6/24/2024)
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Current American Burn Association guidelines state that any child with a greater than 10% total body surface area (TBSA) burn should be admitted to a center capable of caring for pediatric burns, rather than being discharged after wound management.  However, physician use of TBSA% estimation techniques is variable.  An excellent free tool for estimating TBSA is available online, allows for automatic weight based calculation, and allows printing of your diagram.  The diagram is available at http://www.sagediagram.com/.  More to come...

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Category: Pediatrics

Title: Cerebral Edema in Pediatric DKA, Part 2

Keywords: DKA, diabetic ketoacidosis, Pediatric, Children, Mental Status Change (PubMed Search)

Posted: 5/14/2010 by Adam Friedlander, MD (Updated: 6/24/2024)
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Once you've made the presumptive diagnosis of cerebral edema in Pediatric DKA (refer to part 1), here's what's next:

  • DO NOT GET A HEAD CT - this will only waste your time, recall that most children with DKA have subclinical cerebral edema
  • Reduce the fluid rate by at least half
  • Start mannitol at 0.25-1g/kg IV over 20 minutes (may repeat in 2 hours)
  • OR (not and) 3% saline at 5-10mL/kg over 30 minutes (slightly less used and supported)
  • If you intubate, DO NOT HYPERVENTILATE.  A pCO2 < 22 mmHg is associated with poorer outcomes, presumably secondary to ischemia from reduced bloodflow...

Mortality from cerebral edema in DKA is 20-25%, and 15-35% of survivors have permanent disability. 

The best strategy is to do your best to avoid cerebral edema in the first place, but if you do recognize it, this is a clinical diagnosis, and you should not delay treatment for radiographic studies.

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Category: Pediatrics

Title: Cerebral Edema in Pediatric DKA, Part 1

Keywords: DKA, diabetic ketoacidosis, Pediatric, Children, Mental Status Change (PubMed Search)

Posted: 4/13/2010 by Adam Friedlander, MD (Emailed: 4/16/2010) (Updated: 4/16/2010)
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  • Cerebral edema develops in 20-90% of children with DKA, and mortality ranges from 20-90%
  • Children younger than 5, and with newly diagnosed diabetes are at higher risk, and the risk in children in general is MUCH higher than the risk in adults
  • Cerebral edema usually results from osmolarity changes during treatment, but may precede treatment
  • Limit fluid repletion to isotonic fluids (Normal Saline), at a rate of no faster than 10-20 mL/kg/hr (In shock, resuscitate as usual)
  • Head CT Is of limited value as the majority of children in DKA may show signs of subclinical cerebral edema, TREAT BASED ON CLINICAL SIGNS, and do not delay treatment for head CT which is likely to be abnormal in ALL kids
  • Bicarb is implicated in increasing the risk of cerebral edema - focus on correction of acidosis with insulin and appropriate fluids, NOT bicarb

...more to come.

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Category: Pediatrics

Title: Congenital Hypothyroidism - Don't Street Until You Treat

Keywords: Newborn screen, pediatrics, hypothyroidism, neonatal, congenital (PubMed Search)

Posted: 3/18/2010 by Adam Friedlander, MD (Emailed: 3/19/2010) (Updated: 3/20/2010)
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Congenital hypothyroidism (CH) is almost uniformly identified before symptoms develop because of newborn screening.  Though this problem will rarely present to the Emergency Department, it is not uncommon for parents with poor access to care to present to EDs after being notified of an abnormal screen.  Here is what you need to know:

  • CH affects 1 / 3,000 live births
  • When left untreated, there are many sequelae, but the most important by far is almost certain profound mental retardation
  • Children treated within two weeks of birth have NORMAL intellect when followed into adolescence (compared to sibs, age matched controls)
  • Children treated after two weeks have measurable declines in cognitive ability and motor skills - even though they may not develop MR, they are at VERY HIGH risk

So:

  • Start treatment on ALL infants you encounter with CH, IMMEDIATELY if they are approaching 14 days of age
  • Consider admission if there is any chance of a parent having poor access to prescription coverage or close followup
  • Goal levels of T4 are >10 mcg/dL; infants with very low levels need IMMEDIATE TREATMENT with high dose-range levothyroxine - any delay can lead to drops of up to 20 IQ points
  • Initial dose of Levothyroxine is at least 10-15 mcg/kg/day
  • Tablets must be crushed and mixed with breast milk or formula, and NOT with soy, calcium or iron-containing substances which decrease levothyroxine absorption.  Liquid preparations are unreliable.

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Category: Pediatrics

Title: Hyperleukocytosis / Blast Crisis

Keywords: hyperleukocytosis, leukemia, blast crisis (PubMed Search)

Posted: 1/8/2010 by Adam Friedlander, MD (Updated: 6/24/2024)
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Hyperleukocytosis is often seen in acute presentations childhood leukemias, and is defined as a WBC count of greater than 30-50K.  Complications usually arise at counts greater than 300, however, keep in mind that automated cell counters may underestimate very high white counts.

Complications include:

  • Hyperviscosity Syndrome / Leukostasis
    • Risk of CVA, PE, Mesenteric Ischemia, etc.
  • Tumor Lysis Syndrome (TLS)
    • Risk of fatal arrhythmia, may monitor with K, LDH, Uric Acid
  • Disseminated Intravascular Coagultion (DIC)

Treatment:

  • EMERGENT LEUKOREDUCTION APHERESIS, aka Leukopheresis
  • This is a true emergency - if you are at a facility without leukopheresis capability, the fastest transport mode possible is indicated - fly, don't drive
  • Temporizing measures include fluids, fluids, and fluids
  • Allopurinol / Rasburicase may be considered, but not if this will delay transport, especially if there is no evidence of TLS - this decision may be made in consultation with the pediatric heme/onc specialist who is helping to arrange for leukopheresis


Category: Pediatrics

Title: Sexual Assauit in Children

Keywords: Sexual Assault, Children, Herpes, Gonorrhea, Chlamydia (PubMed Search)

Posted: 12/14/2009 by Adam Friedlander, MD
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The Emergency Department is often the first line in detecting the sexual abuse of a child.  Unfortunately, what you do or don't say/ask/test can significantly affect the legal protection of the abused child.


1. Know your region's dedicated sexual abuse center, if one exists.  These centers have personnel trained in interviewing and forensic evidence collection.  There may be different centers for children of different ages.

2. Know your state laws regarding what is and is not admissible as evidence of sexual abuse.  GC/CT urine testing (NAAT), though more sensitive than swab cultures, is not currently admissible as evidence in many states.

3. Withhold prophylactic antibiotic treatment when possible - antibiotics work well, and often eliminate evidence.  Withholding antibiotics is acceptable if the child is asymptomatic or only has very mild symptoms.

4. Any sexually transmitted disease in a child warrants further workup and investigation.  Primary genital HSV in a young child warrants testing for Gonorrhea and Chlamydia, and appropriate referral as well as police involvement.

5. Finally, if trained personnel is available to conduct the interview of a child, limit the questions you ask the child directly.  Any evidence in your note that you may have suggested something to the child in your line of questioning could negate the validity of their testimony.



Category: Pediatrics

Title: Tungsten: The New Problem Jewelry

Keywords: Tungsten, ring, removal, hand injury, finger injury (PubMed Search)

Posted: 11/22/2009 by Adam Friedlander, MD
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Ring-removal is a dreaded problem in pediatric hand and finger injuries.  Removal can be difficult and time consuming.  The relatively recent introduction of Tungsten into the jewelry market has further complicated this problem:

  • The hardest metal used in jewelry - cannot be scratched, much less cut, by common tools
  • Cheap, easy to buy online, attractive to adolescents

However, it is:

  • Extremely brittle
  • May be safely and quickly broken with locking pliers (also cheap), by sequentially, gradually tightening the locking plier grip

This video explains how.  Of course, this works on adults as well.

http://www.youtube.com/watch?v=poM423pewRE

I have no relationship with the copany which made this video - it was simply chosen for its clear explanation of the solution described in this pearl.