Category: Pediatrics
Keywords: procedural sedation, procedures, autism (PubMed Search)
Posted: 8/30/2024 by Rachel Wiltjer, DO
(Updated: 12/12/2024)
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Autism Spectrum Disorder (ASD) can often be a diagnosis that complicates usual ED evaluation and management. One of the frequently asked questions is “what medications work well for patients with autism?” It is often said, although with quite variable evidence in the literature, that benzodiazepines should be avoided in patients with ASD due to the risk of paradoxical reaction.
This study was a meta-analysis that included 20 different studies that looked at efficacy and adverse effect of various medications and medication combinations for procedural sedation for a variety of painful and nonpainful procedures. Although the heterogeneity of the indications, medications, and other details of study design of the studies included precludes a definitive recommendation as to the best medication or regimen, it does suggest overall reasonable efficacy of midazolam both as a single agent as well as in combination with dexmedetomidine, especially when balanced against adverse effects noted with some of the more efficacious regimens.
Take Home Point: Medication choice for patients with ASD should be individualized to the patient based on prior experiences, parental or patient input, and prescriber experience given proven efficacy of multiple regimens. Benzodiazepines should be considered within the toolkit.
Zupin L, Sahyoun C, Krauss B, DagriA, Rocco EM, Barbi E, et al. Effectiveness of pharmacologicalprocedural sedation in children with autism spectrumdisorder: A systematic review and meta-analysis. ActaPaediatr. 2024;00:1–15. https://doi.org/10.1111/apa.17364
Category: Pediatrics
Posted: 5/31/2024 by Rachel Wiltjer, DO
(Updated: 12/12/2024)
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Histamine is present in mosquito saliva contributing to itch with bites, however, certain populations – including children – can experience an exaggerated reaction. Skeeter syndrome is a large, localized inflammatory reaction secondary to a mosquito bite that presents with warmth, swelling, and itching. There can occasionally be associated lymphadenopathy and fever as well. The rapid onset is what best differentiates it from cellulitis. Treatment is primarily symptomatic in nature, focused on relieving itch, with antihistamines and topical therapy. There may also be a role for prophylactic antihistamine usage at times when mosquito bites will be unavoidable in a patient known to have developed Skeeter syndrome previously. Other patients who may be affected include those with immunologic and autoimmune phenomena, those with underlying atopy, outdoor workers with frequent exposure, and those with new exposure to indigenous mosquitos.
Take Home: Consider insect (mosquito bite) when evaluating for cellulitis/infection in pediatric patients, with impressive skin findings but otherwise unremarkable exams. They present with rapid onset and itching instead of pain. This can be especially prominent in periorbital and auricular presentations.
Vander Does A, Labib A, Yosipovitch G. Update on mosquito bite reaction: Itch and hypersensitivity, pathophysiology, prevention, and treatment. Front Immunol. 2022 Sep 21;13:1024559
Category: Pediatrics
Posted: 3/29/2024 by Rachel Wiltjer, DO
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Standard practice regarding various pediatric fractures has started to shift over the last several years, often to less restrictive means of treatment. Torus (buckle) fractures of the distal radius are one of the most common pediatric fractures and tend to heal very well with minimal intervention.
The FORCE study (FOrearm fracture Recovery in Children Evaluation), a multicenter study out of the UK, was conducted to compare rigid immobilization (splinting) to a soft bandage used as needed per family discretion for treatment of these fractures. There was no different in outcomes of self-reported pain, function, quality of life, complications, or school absences. UK orthopedic guidelines have been updated to reflect a recommendation against rigid immobilization as well as against any need for specialist follow-up. American guidelines are slower to follow suit, but in recent years have transitioned to an approach of a removable brace.
Take Home: Pediatric torus fractures of the distal radius likely do not require immobilization and can be managed with self-limited activity instead. Practice in the US is in flux, but it is reasonable to manage with a removable brace or soft dressing as well as pediatrician follow up.
Hussain, M, Perry, D, and Messahel, S. Summary of Recent Advances in Management of Torus Fracture of the Distal Radius in Children_. Arch Dis Child_. Epub ahead of print
Knight R, Dritsaki M, Mason J, Perry DC, Dutton SJ. The Forearm Fracture Recovery in Children Evaluation (FORCE) trial: statistical and health economic analysis plan for an equivalence randomized controlled trial of treatment for torus fractures of the distal radius in children. Bone Jt Open. 2020 Jun 9;1(6):205-213.
Category: Pediatrics
Keywords: foreign body ingestion, magnet (PubMed Search)
Posted: 9/29/2023 by Rachel Wiltjer, DO
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Kids eat everything (except perhaps carefully prepared and balanced meals). While button battery ingestions are feared, there is more to worry about. Magnet ingestions – especially rare earth metal magnet ingestions – can lead to high morbidity and mortality.
When more than one magnet (or a magnet and another metallic object) are ingested, they can become stuck together through walls in the GI tract, creating risk for obstruction, erosion, fistula formation, and perforation. Sharp metallic foreign objects can be particularly dangerous as they can do much damage while being moved around by the magnet.
If there is concern for magnet ingestion, care should be taken to try to determine the number ingested (if parents have the magnets, you can compare the size of an object on xray to the size of the magnets as it can otherwise sometimes be difficult to differentiate if it is one magnet or more than one stuck together).
Higher risk features of ingestion include:
Ingestions should prompt consultation with pediatric GI and surgery when isolated as many will require either endoscopic or surgical removal. This may include need for referral and transfer.
Nugud AA, Tzivinikos C, Assa A, et al. Pediatric Magnet Ingestion, Diagnosis, Management, and Prevention: A European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) Position Paper. Journal of pediatric gastroenterology and nutrition. 2023;76(4):523-532.
Category: Pediatrics
Keywords: congenital heart disease (PubMed Search)
Posted: 6/2/2023 by Rachel Wiltjer, DO
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Some things are easy, even reflexive, and one of those things is putting oxygen on cyanotic patients. Usually, this is a great thing. Blue = bad. Occasionally, though, blue = baseline and even in those patients who are too blue, you want to keep them closer to purple than pink.
This issue is commonly encountered in certain types of congenital heart disease and as well as through various phases of their repair. These include ductal dependent lesions, those with significant shunts, and single ventricle physiology. Oxygen functions as a pulmonary vasodilator and can increase or change the direction of shunting, directly impacting physiology by causing pulmonary overcirculation, increased strain on the right ventricle, and decreases in systemic circulation.
Helpful Hints:
1) Find out and shoot for the patient’s goal oxygen saturation range (many lesions will be 75%-85%). This may be available from parents, in the EMR, or by calling the child’s cardiac center if they are an established patient.
2) In an undiagnosed neonate with hypoxia and signs of heart failure (crackles, enlarged liver, edema to the sacrum and/or occiput) or if unresponsive to initial trial of oxygen, decrease FiO2 and titrate support (nasal cannula with blender to set FiO2, HFNC, NIPPV, or intubation if necessary) to address respiratory distress as well as evaluation and treatment for ductal dependent lesions.
3) You may still need to use additional FiO2 to obtain reasonable oxygen saturations, but titrate thoughtfully.
Khalil M, Jux C, Rueblinger L, Behrje J, Esmaeili A, Schranz D. Acute therapy of newborns with critical congenital heart disease. Transl Pediatr. 2019 Apr;8(2):114-126.
McMann, K. T, Schelonka R.L. Editorial: Oxygen for cyanotic neonates: Friend or foe? Pediatric Health. 2010 Feb; 4(1): 1-3.
Category: Pediatrics
Keywords: Pediatrics, infections, neonatal (PubMed Search)
Posted: 5/5/2023 by Rachel Wiltjer, DO
(Updated: 12/12/2024)
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Neonatal rashes are common and, usually, benign. There are some skin findings, however, that require early recognition and treatment for best outcomes. One of these concerning etiologies is omphalitis, infection of the umbilical stump and surrounding tissues.
Features of omphalitis may include erythema and induration around the umbilicus, purulent drainage, and potentially systemic illness.
Risk factors include poor cord hygiene, premature or prolonged rupture of membranes, maternal infection, low birth weight, umbilical catheterization, and home birth.
Evaluation includes surface cultures from the site of infection as well as age-appropriate fever workup if patient is febrile. Consider ultrasound to evaluate for urachal anomalies as these can co-exist.
Management is IV antibiotics to cover S. aureus and gram negatives with surgical consultation if there are signs of necrotizing fasciitis or abscess. Some newer literature suggests that patients with omphalitis seen and treated in high-income countries may not be as sick as previously thought (as most data has been obtained in lower income countries where incidence is higher) and there has been a suggestion that there may be a role for oral antibiotics in well appearing, lower risk infants. This deserves further exploration but cannot yet be considered standard of care.
Other umbilical cord findings to consider (when it isn’t omphalitis): patent urachus, granuloma, local irritation, or partial cord separation
Kaplan RL. Omphalitis: Clinical Presentation and Approach to Evaluation and Management. Pediatr Emerg Care. 2023;39(3):188-189.
Category: Pediatrics
Keywords: sedation, anxiolysis, procedure (PubMed Search)
Posted: 4/7/2023 by Rachel Wiltjer, DO
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Background: Intranasal dexmedetomidine has seen usage in the anesthesia and sedation realms over the past few years, with an increasing interest in usage in the ED setting given its generally favorable safety profile and ease of administration. There has been specific interest and consideration in children with autism and neurodevelopmental disorders.
Study: Single center prospective provider study (compared to a retrospective group of patients under 18 who received oral midazolam for indications of agitation or anxiety via chart review) looking at patients 6 months to 18 years of age with an order for intranasal dexmedetomidine. Following use, a provider survey was completed to evaluate indication/rationale for use, satisfaction, comfort with use, and perceived time to onset as well as duration of effect.
Results: 29% of patients receiving IN dexmedetomidine experienced treatment failure compared with 20.7% of patients receiving oral midazolam (not statistically significant). In subgroup analysis, rates of treatment failure were lower for patients diagnosed with autism spectrum disorder receiving IN dexmedetomidine versus oral versed (21.2% versus 66.7%). Length of stay was longer in the IN dexmedetomidine group (6.0 hours versus 4.4 hours). Indication for use had variability between the two groups.
Bottom Line: IN dexmedetomidine may be a reasonable agent to utilize for anxiolysis in pediatric patients, especially those who have previously had paradoxical reactions or poor efficacy of benzodiazepines. It may be specifically useful when effects are desired for a slightly longer time and for non-painful/minimally painful interventions.
Kenneally A, Cummins M, Bailey A, Yackey K, Jones L, Carter C, Dugan A, Baum RA. Intranasal Dexmedetomidine Use in Pediatric Patients for Anxiolysis in the Emergency Department. Pediatr Emerg Care. 2023 Jan 5. Epub ahead of print.
Category: Pediatrics
Keywords: otitis media, antibiotic (PubMed Search)
Posted: 2/3/2023 by Rachel Wiltjer, DO
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Otitis media is a common pediatric complaint seen in the primary care, urgent care, and ED settings. Recommendations for timing of treatment and deferral of treatment have emerged over the last several years, as have recommendations for regimens for recurrent infections in the age of resistant organisms.
When to consider observation over antibiotics:
Initial treatment
High dose amoxicillin (90 mg/kg/day divided BID)
Recurrent Otitis Media
If less than 30 days from initial treatment, presumed to be persistent
If greater than 30 days from initial treatment can treat as new episode (so amoxicillin unless previous documented resistant infections)
Duration of Antibiotics
Other Considerations
Gaddey HL, Wright MT, Nelson TN. Otitis Media: Rapid Evidence Review. Am Fam Physician. 2019;100(6):350-356.
Rosenfeld RM, Tunkel DE, Schwartz SR, et al. Clinical Practice Guideline: Tympanostomy Tubes in Children (Update). Otolaryngol Head Neck Surg. 2022;166(1_suppl):S1-S55. doi:10.1177/01945998211065662
Category: Misc
Keywords: human rights, DEI (PubMed Search)
Posted: 12/26/2022 by Rachel Wiltjer, DO
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Universal Human Rights
Human rights are rights inherent to all human beings, whether our nationality, place of residency, sex, national or ethnic origin, color, religion, language defines , or any other status
The United Nations Human Rights Council (UNHRC) defines seven substantive rights: the right to life, freedom from torture, freedom from slavery, right to a fair trial, freedom of speech, freedom of thought, conscience and religion, and freedom of movement
The right to life is the essential right that a human being has a right not to be killed by another human being. This has been central in debates on issues of abortion and euthanasia.
Emergency care is an often overlooked, but essential component of the right to life in the highest attainable standard of health and universal health coverage (UHC - a WHO description used to describe access to care). Particularly for vulnerable and disadvantaged populations, emergency care is often the last chance for the health system to save a life.
The focus on vulnerable populations with little access to care and subsequent poor health outcomes has many similarities to the delivery of emergency care. Emergency conditions, such as traumatic injuries, disproportionately affect people in low- and middle-income countries. About 90% of the burden of death and disability from injuries occurs in low- and middle-income countries
COVID-19 emphatically highlighted how far countries (and differences in regulations between states in the US) are from meeting the supreme human rights command of non-discrimination, from achieving the highest attainable standard of health that is equally the right of all people everywhere, and from taking the human rights obligation of international assistance and cooperation seriously.
Implementation of a rights-based framework for emergency care requires countries to enact legislation that ensures access to non-discriminatory emergency care and establish a regulatory body with appropriate oversight and authority to enforce these laws.
Category: Pediatrics
Keywords: unimmunized, pediatric fever (PubMed Search)
Posted: 12/2/2022 by Rachel Wiltjer, DO
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Childhood vaccination has significantly decreased the incidence of bacterial meningitis and bacteremia in infants and young children, specifically vaccines against H. influenzae and S. pneumoniae, shifting broad workups for these disease and empiric antibiosis to younger age groups as rates declined. In recent years the percentage of unvaccinated and under-vaccinated children has been rising due to multiple factors; now over 1% of children in the US under 2 years of age are unvaccinated. The question becomes, should these children be treated more similarly to young infants as they lack to immunity to these organisms?
Literature on this topic is sparse, although, Finkel, Ospina-Jimenez, et al. reviewed the literature available and proposed an algorithm for well appearing children 3-24 months of age without a clear source and a temperature of >39C (102.2F). Recommendations included UA (to determine possible source) in the following patients: fever > 2 days, prior UTI, female or uncircumcised male <12 months, or male <6 months. They also recommended evaluation with viral panel. If no source was determined, they then recommended CBC and procalcitonin with a CXR for WBC > 20,000/mm3. For WBC >15,000/mm3, ANC >10,000/mm3, absolute band count >1,500/mm3, or procalcitonin >0.5ng/mL they recommended blood culture, ceftriaxone 50 mg/kg, and follow up within 24 hours.
Bottom line: Literature is scarce and practice patterns are likely to evolve as ramifications of decrease in vaccination rates become clearer. The above algorithm is proposed, however covers limited situations and may not be practical in all settings. Clinical judgement should be used in the evaluation and management of these patients. A more conservative approach compared to vaccinated infants is reasonable at this time.
Finkel L, Ospina-Jimenez C, Byers M, Eilbert W. Fever Without Source in Unvaccinated Children Aged 3 to 24 Months: What Workup Is Recommended?. Pediatr Emerg Care. 2021;37(12):e882-e885
Category: Misc
Keywords: DEI, transgender, nonbinary (PubMed Search)
Posted: 11/28/2022 by Rachel Wiltjer, DO
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Approximately 1.4 million transgender and gender nonbinary patients live in the United States. Unfortunately, prior research has shown negative experiences with the health system are common after disclosing their trans/NB status. As a result, almost a ¼ report avoiding or delaying needed health care.
This qualitative study interviewed a subset of trans/NB individuals about their experiences visiting emergency departments. Several key themes emerged:
Overall, the study found that clinicians have many opportunities to improve the care of transgender and nonbinary patients, including updating forms, using inclusive language, avoiding medically unnecessary questions, and providing training for staff on trans/NB health.
Allison MK, Marshall SA, Stewart G, Joiner M, Nash C, Stewart MK. Experiences of Transgender and Gender Nonbinary Patients in the Emergency Department and Recommendations for Health Care Policy, Education, and Practice. J Emerg Med. 2021 Oct;61(4):396-405. doi: 10.1016/j.jemermed.2021.04.013. Epub 2021 Jun 25. PMID: 34176685; PMCID: PMC8627922.
Category: Misc
Keywords: DEI, Intimate Partner Violence (PubMed Search)
Posted: 11/7/2022 by Rachel Wiltjer, DO
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IPV can occur once or over years by a current or former romantic partner. Types of IPV include: Physical and/or Sexual violence, Stalking, and Psychological/Financial aggression (the use of verbal and non-verbal communication to harm mentally or emotionally and to exert control over another partner).
IPV is more prevalent that Aortic Dissection and Pulmonary Embolism combined. Think about how risky it is to NOT recognize IPV.
1:4 women and 1:10 men have been victims of IPV during their lifetime.
1:5 homicide victims are killed by an intimate partner.
Over 50% of female homicide victims are killed by a current or former intimate partner. Patients who have been strangled are 4 times more likely to be killed within a year.
Your Spidey Sense should go off when:
Once patient is identified as a victim:
Category: Pediatrics
Keywords: rehydration, fluid management (PubMed Search)
Posted: 11/4/2022 by Rachel Wiltjer, DO
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Subcutaneous Fluid Administration for Rehydration
Caccialanza R, Constans T, et al. Subcutaneous Infusion of Fluids for Hydration or Nutrition: A Review. Journal of Parenteral and Enteral Nutrition. 2018; 42 (2): 296-307
Spandorfer PR. Subcutaneous Rehydration. Pediatric Emergency Care. 2011; 27 (3):230-236.
Category: Pediatrics
Keywords: pediatric cardiology, ALCAPA (anomalous left coronary artery from the pulmonary artery) (PubMed Search)
Posted: 10/7/2022 by Rachel Wiltjer, DO
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Cashen K, Kwiatkowski DM, Riley CM, Buckley J, Sassalos P, Gowda KN, Iliopoulos I, Bakar A, Chiwane S, Badheka A, Moser EAS, Mastropietro CW; Collaborative Research from the Pediatric Cardiac Intensive Care Society (CoRe-PCICS) Investigators. Anomalous Origin of the Left Coronary Artery From the Pulmonary Artery: A Retrospective Multicenter Study. Pediatr Crit Care Med. 2021 Dec 1;22(12):e626-e635.
Hoffman JI. Electrocardiogram of anomalous left coronary artery from the pulmonary artery in infants. Pediatr Cardiol. 2013 Mar;34(3):489-91.
Levitas A1, Krymko H, Ioffe V, Zalzstein E, Broides A. Anomalous Left Coronary Artery From the Pulmonary Artery in Infants and Toddlers Misdiagnosed as Myocarditis. Pediatr Emerg Care. 2016 Apr;32(4):232-4
Category: Misc
Keywords: Migrant Health, DEI (PubMed Search)
Posted: 8/28/2022 by Rachel Wiltjer, DO
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Approximately 284,000 immigrants reside in Baltimore (10% of the total population). In April 2022, Governor Abbott of Texas began sending migrants from the US southern border to Washington, DC, with Arizona joining soon after. It is important for emergency providers to be aware of these changes and how new disparities may arise.
2. Assess acute vs non-acute needs: A study done in pediatric migrant populations suggests that the severity of the reasons for visiting the ED and the hospitalization rates were not higher in the pediatric migrant population than in the general pediatric population. Some common non-urgent diagnoses include scabies, anemia, oral and dental disorders.
3. Create a safe environment: In a study done in 2013, up to 12% of undocumented immigrants that presented to the ED expressed fear of discovery and consequent deportation. On further assessment there was the belief that medical staff are required to report these patients to immigration. It is important to proactively address inaccurate beliefs to promote a safe trusting environment.
Resources in Baltimore/Maryland:
-CASA
-Esperanza Center
-International Rescue Committee
- John's Hopkins Centro Sol
- National Immigration Law Center
National Resources (US):
-Rural Health Information Hub
-National Resource Center for Refugees, Immigrants, and Migrants
Mahmoud I, Eley R, Hou XY. Subjective reasons why immigrant patients attend the emergency department. BMC Emerg Med. 2015 Mar 28;15:4.
Maldonado CZ, Rodriguez RM, Torres JR, Flores YS, Lovato LM. Fear of discovery among Latino immigrants presenting to the emergency department. Acad Emerg Med. 2013 Feb;20(2):155-61.
Tarraf W, Vega W, González HM. Emergency department services use among immigrant and non-immigrant groups in the United States. J Immigr Minor Health. 2014 Aug;16(4):595-606.
Category: Pediatrics
Keywords: pediatric trauma, tranexamic acid (PubMed Search)
Posted: 8/5/2022 by Rachel Wiltjer, DO
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Bottom line: There is not clear evidence for efficacy, but trends are positive and the documented rates of adverse effects in this population are low. It is reasonable to give, especially in patients requiring massive transfusion or who are critically ill.
Eckert MJ, Wertin TM, Tyner SD, et al. Tranexamic acid administration to pediatric trauma patients in a combat setting: the pediatric trauma and tranexamic acid study (PED-TRAX). J Trauma Acute Care Surg. 2014;77(6):852-858.
Hamele M, Aden JK, Borgman MA. Tranexamic acid in pediatric combat trauma requiring massive transfusions and mortality. J Trauma Acute Care Surg. 2020;89(2S Suppl 2):S242-S245.
Nishijima, DK, VanBuren, JM, Linakis, SW, et al. Traumatic injury clinical trial evaluating tranexamic acid in children (TIC-TOC): A pilot randomized trial. Acad Emerg Med. 2022; 29: 862– 873.
Category: Pediatrics
Keywords: pediatric trauma, ultrasound, FAST (PubMed Search)
Posted: 7/1/2022 by Rachel Wiltjer, DO
(Updated: 12/12/2024)
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Bottom line: A positive FAST warrants further workup and may be helpful in the hemodynamically unstable pediatric trauma patient, but a negative FAST does not exclude intraabdominal injury and evidence for performing FAST in hemodynamically stable pediatric patients is limited.
Guyther, J. Advances in Pediatric Abdominal Trauma: What’s New is Assessment and Management. Trauma Reports 2016; 17: 1-15.
Holmes JF, Kelley KM, Wootton-Gorges SL, Utter GH, Abramson LP, Rose JS, Tancredi DJ, Kuppermann N. Effect of Abdominal Ultrasound on Clinical Care, Outcomes, and Resource Use Among Children With Blunt Torso Trauma: A Randomized Clinical Trial. JAMA. 2017 Jun 13;317(22):2290-2296.
Category: Pediatrics
Keywords: autism spectrum disorder, neurodevelopmental disorder (PubMed Search)
Posted: 5/6/2022 by Rachel Wiltjer, DO
(Updated: 12/12/2024)
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Category: Pediatrics
Keywords: inborn error of metabolism (IEM), organic acidemia (PubMed Search)
Posted: 4/1/2022 by Rachel Wiltjer, DO
(Updated: 12/12/2024)
Click here to contact Rachel Wiltjer, DO
Laura L. Guilder, Jonathan B. Kronick; Organic Acidemias. Pediatr Rev March 2022; 43 (3): 123–134.
Category: Pediatrics
Keywords: bell's palsy, pediatric malignancy (PubMed Search)
Posted: 2/4/2022 by Rachel Wiltjer, DO
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Acute facial palsy is common in children and while bell’s palsy is significant proportion, there are other more concerning etiologies that make up a number of cases. A retrospective cohort study of pediatric patients with an ED diagnosis of Bell’s palsy was done using the Pediatric Health Information System and showed an incidence of 0.3% (0.03% in control) for new diagnosis of malignancy within the 60 days following the visit at which bell’s palsy was diagnosed. Younger age increased the risk. There was also a subset of patient’s excluded for diagnosis of bell’s palsy as well as malignancy at the index visit.
These numbers are small but may be clinically significant. They likely do not warrant laboratory or imaging workup as a rule but do make a case for detailed history taking and thorough exam. Consider avoiding steroids which are used commonly but lack high quality data and may undermine later efforts at tissue diagnosis of malignancy or even worsen prognosis.
Walsh PS, Gray JM, Ramgopal S, Lipshaw MJ. Risk of malignancy following emergency department Bell's palsy diagnosis in children. Am J Emerg Med. 2021 Dec 29;53:63-67.