Keywords: congenital heart disease (PubMed Search)
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.
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.
Keywords: Pediatrics, infections, neonatal (PubMed Search)
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.
Keywords: sedation, anxiolysis, procedure (PubMed Search)
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.
Keywords: otitis media, antibiotic (PubMed Search)
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:
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
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
Keywords: human rights, DEI (PubMed Search)
Keywords: unimmunized, pediatric fever (PubMed Search)
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
Keywords: DEI, transgender, nonbinary (PubMed Search)
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.
Keywords: DEI, Intimate Partner Violence (PubMed Search)
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:
Keywords: rehydration, fluid management (PubMed Search)
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.
Keywords: pediatric cardiology, ALCAPA (anomalous left coronary artery from the pulmonary artery) (PubMed Search)
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
Keywords: Migrant Health, DEI (PubMed Search)
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.
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.
Keywords: pediatric trauma, tranexamic acid (PubMed Search)
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.
Keywords: pediatric trauma, ultrasound, FAST (PubMed Search)
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.
Keywords: autism spectrum disorder, neurodevelopmental disorder (PubMed Search)
Keywords: inborn error of metabolism (IEM), organic acidemia (PubMed Search)
Laura L. Guilder, Jonathan B. Kronick; Organic Acidemias. Pediatr Rev March 2022; 43 (3): 123–134.
Keywords: bell's palsy, pediatric malignancy (PubMed Search)
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.
Keywords: peds ortho, calcaneus, stress injury (PubMed Search)
Smith JM, Varacallo M. Sever Disease. [Updated 2021 Jul 18]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK441928/
Keywords: febrile infant, neonatal fever (PubMed Search)
What they are: Clinical practice guidelines put together by an AAP subcommittee over a span of several years based on changing bacteriology and incidence of illness, advances in testing, and evidence that has accumulated
Includes: Healthy infants 8 to 60 days of life with an episode of temperature greater than or equal to 38.0 C who at now at home after being born at home or after discharge from the newborn nursery, born between 37 and 42 weeks, without focal infection on exam (cellulitis, vesicles, etc)
For the well appearing 8-21 day old:
For well appearing 22- 28 day olds:
For well appearing 29-60 day olds:
Pantell, R., Roberts, K., et al. Evaluation and Managment of Well-Appearing Febrile Infants 8 to 60 Days Old. Pediatrics. Aug 2021, 148(2) e2021052228
Keywords: RSV, bronchiolitis (PubMed Search)
CDC. Increased Interseasonal Respiratory Syncytial Virus (RSV) Activity in Parts of the Southern United States. Health Alert Network. Published online June 10, 2021.
Ralston, S., Lieberthal, A., et al. Clinical Practice Guideline: The Diagnosis, Management, and Prevention of Bronchiolitis. Pediatrics. Nov 2014. 134(5) e1474-1502.