UMEM Educational Pearls - By Rachel Wiltjer

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.

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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.

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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.

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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

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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.  

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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:

• If symptoms <48 hours, no severe pain, and fever < 39C and child is 2 years or older (either unilateral or bilateral AOM) OR unilateral AOM with symptoms <48 hours, no severe pain, and fever < 39C and child is 6 months to 2 years
• If observing, consider either a prescription that parents can fill if symptoms persist or ensure prompt primary care follow up

Initial treatment

High dose amoxicillin (90 mg/kg/day divided BID)

• If true penicillin allergy, can use cefdinir or cefpodoxime if tolerated or trimethoprim-sulfamethoxazole or a macrolide (e.g. azithromycin) but rates of resistance are higher
• Cefdinir and azithromycin are the most commonly used  
• Levofloxacin is also an option for age >8 years

Recurrent Otitis Media

If less than 30 days from initial treatment, presumed to be persistent

• If previously on amoxicillin, start amoxicillin-clavulanate (extra strength suspension has highest amoxicillin to clavulanate ratio and should be used)
• If previously on amoxicillin-clavulanate, ceftriaxone either for 3 days or 2 doses 36 hours apart

If greater than 30 days from initial treatment can treat as new episode (so amoxicillin unless previous documented resistant infections)

Duration of Antibiotics

• Less than 2 years, 10 days
• 2 years and up, 5-7 days

Other Considerations

• Amoxicillin-clavulanate should be used as an initial agent if there is concurrent purulent conjunctivitis
• Children with tympanostomy tubes and purulent otorrhea may be treated with otic fluoroquinolones (with or without dexamethasone), as long as debris does not obstruct entry of antibiotic drops
• Remember that the otic canal and TM can become red with fever and non-purulent effusion is common with URI
• Remember to treat pain and fever!

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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.

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.

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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:

• ED intake forms are commonly unequipped to reflect patients’ pronouns and chosen names. This leads to downstream misgendering and the use of deadnames.
• Patients often fielded inappropriate questions and comments unrelated to their medical care
• Many patients felt they had to educate clinicians regarding issues of trans health, rather than the other way around
•  These negative experiences decreased the likelihood patients would return for needed medical care

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.

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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:

1. Stories Change
2. History doesn’t match up with injuries
3. Injuries in areas that are concealed, multiple injuries of varying ages, defensive wounds
4. Major delays in seeking care
5. Non-specific complaints - headache, gastric issues
6. Multiple ED visits at odd hours
7. Refusing the use of an interpreter by partner (why we always use an official interpreter)

Once patient is identified as a victim:

1. Place victim in a safe, inaccessible by visitors, and hidden area
2. Treat all medical issues
3. Contact Social Work/SAFE/SANE examiner (some institutions will have IPV specific resources)
4. Contact police if patient is willing to report
5. Safe disposition
6. If unable to ensure a safe disposition, be very careful about documentation provided in discharge paperwork and language used

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Subcutaneous Fluid Administration for Rehydration

• An old school technique (described in the 1800’s) that fell out of favor but still has applicability - primarily in pediatrics although it has been explored for use in geriatrics and mass casualty events (due to ease and speed of use)
• Most appropriate for stable but mildly to moderately dehydrated patients who need rehydration, are not tolerating PO, and in whom an PIV is difficult to establish (this should not replace an IO in a critically ill child)
• Either a small gauge angiocath or butterfly can be used for access
• Most common area to access in younger children is between the shoulder blades, although the lateral abdomen, thighs, or outer upper arms can be used as well; the site must have adequate subcutaneous tissue (can test by pinching between the fingers)
• Subcutaneous catheter placement is generally quite easy, however care should be taken with securing the catheter as there will be expected swelling at the area which can cause dislodgement or discomfort
• Mild erythema may also occur at the site of administration
• Injection of hyaluronidase (150 U) at the site being used increases the volume that can be administered as well as speed of absorption (hospitals may carry this product for treatment of severe PIV infiltration events)
• It is not necessary to have hyaluronidase to utilize subcutaneous fluid administration, but improves efficiency and efficacy
• Fluids administered should be isotonic and can be administered at 20 mL/kg over an hour – this can be repeated as necessary

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• Anomalous left coronary artery from the pulmonary artery (ALCAPA) is a rare congenital defect in which there is an altered origin of the left coronary artery (also known as Bland-White-Garland syndrome)
• Generally asymptomatic at birth, but can present in late infancy, toddlerhood, or later with signs of congestive heart failure, a myocarditis picture, or sudden cardiac death
• Flow through the left coronary artery is normal at birth due to high pulmonary pressures, but as those pressures drop the blood flow drops as well and may become reversed due to the pressure gradient
• This can cause chronic myocardial ischemia, the severity of which, is dependent on collateral flow
• Most patients will also develop mitral regurgitation
• Cardiomegaly may be seen on CXR (and some patients will present with respiratory symptoms/wheezing)
• EKG findings include: findings consistent with ischemia (ST changes, q waves – specifically in the anterolateral leads), leftward axis (for age), abnormal R wave progression (loss of R wave amplitude in affected leads)
• Diagnosis can generally be made with echocardiogram (although not 100% sensitive) and the disease is generally treated with surgical repair

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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.

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• TXA has been used for pediatric non-traumatic (surgical) bleeding with good evidence
• Currently used in around 1/3 of pediatric trauma centers based on survey data
• PED-TRAX (retrospective review of pediatric trauma admissions in a combat zone) showed an association between use of TXA and decreased mortality, with no increase in thromboembolic events
• Dosing strategies in the literature and in practice have been variable (bolus at variable dosing versus bolus + infusion)
• The TIC TOC trial was recently completed - a multicenter randomized pilot study looking at 2 dosing strategies of TXA versus placebo which demonstrated feasibility of a larger study and will hopefully serve as a model for further research to determine efficacy as well as ideal dosing

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.

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• Use of FAST is less common in pediatric trauma than in adult trauma
• FAST in pediatric trauma has a lower negative predictive value than in adults
  • 1/3 of pediatric patients with hemoperitoneum on CT will have a negative FAST
  • Lowest sensitivity and specificity is in the under 2 years age group
• A 2017 randomized clinical trial of ~900 patients showed no difference in clinical care, use of resources, or length of stay in hemodynamically stable children who received FAST + standard trauma evaluation versus standard trauma evaluation alone
• There may be a role for FAST as a screening in patients with low suspicion for intraabdominal injury in conjunction with labs and physical exam, but this has not been fully explored

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.

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• Autism spectrum disorder and other neurodevelopmental disorders can predispose to challenging ED encounters secondary to difficulties with sensory processing and communication
• Small changes to the environment can help to reduce stress, generally by decreasing stimulation
• Use quieter areas of the ED when possible, decrease volume of alarms, and consider noise cancelling headphones or white noise if available
• Consider dimming the lights, turning the monitor/computer screen away from the patient
• Allow the patient to remain in their own clothing and consider whether restrictive items such as the monitor, pulse oximeter, and blood pressure cuff are necessary (but continue to use them when they are medically appropriate)
• Offering distraction via electronics, fidget toys, or weighted blanket (or lead apron) may help with managing stress
• Ask the patient or family which modifications would be helpful for the patient and ask child life for assistance where available

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• 2/3’s present in the neonatal period and can mimic conditions such as sepsis, gastroenteritis, and meningitis requiring careful consideration to prompt testing
• Common symptoms are poor feeding, lethargy, irritability, vomiting, and encephalopathy
• May be referred in if detected on newborn screen, but not all are tested on the newborn screen
• Should look on labs for acidosis, elevated anion gap, hyperammonemia, lactic acidosis, ketosis/ketonuria, and hyper/hypoglycemia  
• Emergent treatment includes: identification and treatment of any underlying triggers (such as infection), stopping any protein intake until situation can be clarified, providing fluids with glucose (requirements of 8-10 mg/kg/min of glucose in neonates), and genetics consultation

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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.

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