UMEM Educational Pearls - By Jenny Guyther

Category: Pediatrics

Title: Amusement park safety

Keywords: roller coasters, summer, death (PubMed Search)

Posted: 9/17/2021 by Jenny Guyther, MD
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Over a one year study period, 182 accident events at amusement parks were reported in the news from 38 countries.  51 events involved a fatality. Mechanical rides and roller coasters were involved in 87 events. 
The risk of injury associated with spending a day at an amusement park is very low, but not non-existent.
The high g forces of certain thrill rides (ie roller coasters) can predispose to injury in some children and adolescents with preexisting medical conditions.
Among the conditions that are considered contraindications to exposure to high g force or other thrill rides are Marfan syndrome, Down syndrome, hypermobility-related disorders, coagulation disorders, and many cardiac disorders, particularly ones with rhythm abnormalities.

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Category: Pediatrics

Title: Pediatric heat related car deaths

Keywords: hyperthermia, pediatrics, car (PubMed Search)

Posted: 8/20/2021 by Jenny Guyther, MD (Updated: 9/23/2021)
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- A higher metabolic rate, reduced capacity for sweating, greater thermolability, and a larger body surface-to-volume ratio make infants and young children more susceptible to hyperthermia.

- Temperatures can rise rapidly within enclosed vehicles, reaching maximum temperatures within 5 minutes. In an open area with an ambient temp of 98 F (36.8 C), interior temperatures reach 124-152 F (51 to 67 C) within 15 minutes of closing the car doors.

- Texas leads the country in the numbers of pediatric heatstroke fatalities due to unattended children left in cars, followed by Florida and California.

- Most heatstroke victims (78.2%) were unknowingly left in vehicles by their caregivers.

- Most organizations interested in child safety issues recommend placing a phone, briefcase, or handbag in the back seat when traveling with a child as one way to prevent heatstroke fatalities.

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Category: Pediatrics

Title: Does atropine prevent bradycardia during rapid sequence intubation in pediatric patients?

Keywords: Bradycardia, intubation, RSI, atropine (PubMed Search)

Posted: 7/16/2021 by Jenny Guyther, MD (Updated: 9/23/2021)
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Atropine has historically been used in the pediatric population as a premedication for rapid sequence intubation (RSI) in order to prevent bradycardia.   Recent research indicates that bradycardia that occurs during intubation may be driven by hypoxia as opposed to a vagal response. In 2002, the American Heart Association guidelines recommended pretreatment with atropine for all children younger than 1 year, children receiving succinylcholine, adolescents receiving a second dose of succinylcholine and anyone with bradycardia at the time of induction. The 2015 AHA Pediatric Advanced Life Support guidelines revised the statement on atropine to say that "it may be reasonable for practitioners to use atropine as a premedication in specific emergency intubations when there is higher risk of bradycardia." 
This study retrospectively looked at 62 patients who underwent rapid sequence intubation.  3 patients experienced a bradycardic event during intubation, 1 of which received atropine.  15 patients received atropine for pretreatment. The incidence of bradycardia was similar between those received atropine and those who did not.
Bottom line: Although atropine is generally considered safe, larger studies are needed to determine if there are any specific indications for atropine as a premedication in RSI or if atropine is needed at all for the prevention of bradycardia.

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Category: Pediatrics

Title: Treatment of fingernail avulsion injuries

Keywords: finger injuries, nail bed (PubMed Search)

Posted: 6/18/2021 by Jenny Guyther, MD (Updated: 9/23/2021)
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Traditional management (referred to as "operative management") of a nail avulsion is to replace the nail in the epicanthal fold and suture this in place.  A study was done to see if wound cleaning and placement of a non-adhesive dressing was non inferior to this traditional management.  The primary outcome was the appearance of the new nail at 6 months as determined by 2 separate physicians using a Nail Appearance Score (NAS) and who were blinded to the treatment groups.  The secondary outcomes were patient and parental satisfaction and infection rate.  There were no statistically significant differences in the NAS or patient and parental satisfaction scores between the 2 groups.
Parents were informed of both options and allowed to choose between the treatments.  Patients between 1-16 years with proximal or complete nail bed avulsion injuries were included.
Conclusions: In this small study, non-operative management for fingernail avulsions was not inferior to operative management.

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Category: Pediatrics

Title: Sodium bicarbonate in pediatric cardiac arrests

Keywords: pediatric, cardiac arrest, metabolic acidosis, sodium bicarbonate (PubMed Search)

Posted: 5/21/2021 by Jenny Guyther, MD (Updated: 9/23/2021)
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During cardiac arrest, metabolic acidosis develops because of hypoxia-induced anaerobic metabolism and decreased acid excretion caused by inadequate renal perfusion.  Sodium bicarbonate (SB) administration was considered as a buffer therapy to correct metabolic acidosis.  However,  SB has several side effects such as hypernatremia, metabolic alkalosis, hypocalcemia, hypercapnia, impairment of tissue oxygenation, intracellular acidosis, hyperosmolarity, and increased lactate production.  The 2010 Pediatric Advanced Life Support (PALS) guideline stated that routine administration of SB was not recommended for cardiac arrest except in special resuscitation situations, such as hyperkalemia or certain toxidromes.  An evidence update was conducted in the 2020 Pediatric Life Support (PLS) guideline and the recommendations of 2010 remain valid.  This article was a systematic review and meta-analysis of observational studies of pediatric in hospital cardiac arrests.  The primary outcome was the rate of survival to hospital discharge after in hospital cardiac arrests. The secondary outcomes were the 24-hour survival rate and neurological outcomes.   

 
Bottom line: The result of this study supports current PLS guidelines that “routine administration of SB  is not recommended in pediatric cardiac arrest in the absence of hyperkalemia or sodium channel blocker (eg. tricyclic antidepressant) toxicity”.

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Category: Pediatrics

Title: Pediatric stroke

Keywords: stroke, altered mental status, TPA (PubMed Search)

Posted: 4/16/2021 by Jenny Guyther, MD (Updated: 9/23/2021)
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Stroke diagnosis is often delayed in pediatric patients due to delay in seeking care, misdiagnosis and lack of stroke being included in the initial differential diagnosis. 
Perinatal strokes (occurring between 20 weeks gestation and 28 days of life) are more common than strokes in ages 29 days to 18 years.  The incidence of perinatal stroke is 37/100,000 births and 2.3/100,000 children after 29 days.  Infants age 29 days to < 1 year had the highest rate of stroke outside of perinatal strokes, followed by 15-19 year olds.
The most common risk factors for pediatric strokes include: arteriopathies (such as arterial dissection, moyamoya and vasculitis), cardiac disorders (single ventricle physiology have the highest risk) and infections.  Sickle cell disease and cerebral venous thrombosis are other risk factors for acute ischemic stroke.
Children younger than 6 years were more likely to present with altered mental status or seizures.  Other presentations included facial weakness, speech disturbances, hemiparesis, headache, nausea and vomiting.
There is a pediatric NIH stroke scale that can be used in children at least 2 years old that accounts for developmental differences.
Differential Diagnosis includes (most to least common): migraines, seizures, Bell's palsy, conversion disorder and syncope. Once study found that up to 63% of patients that were suspected of having a stroke, but did not, had another significant disease process that required further evaluation. These other processes included vascular anomalies, seizures, inflammatory disease, metabolic anomalies and drug ingestions.
MRI brain and MRA of the head and neck are gold standard for diagnosis.  If this is not obtainable or would be delayed, then head CT followed by CTA of the head and neck should be obtained.
The treatment of acute ischemic stroke is still not fully researched and much is adopted from adult protocols.   TPA and endovascular thrombectomy are not well established.  There has been a small study of patients treated with TPA, but a subsequent NIH funded trial could not recruit enough patients.  Adult dosing guidelines for TPA have been adopted if TPA is going to be used and should be given within 4.5 hours of symptom onset.  Endovascular therapy should be considered only in patients with persistent, disabling neurological defects and a confirmed large vessel occlusion.  Patient selection is limited by the side of the catheter used.  Patients with confirmed ischemic stroke who do not receive TPA or endovascular therapy should receive antiplatelet therapy.
Cerebral venous thrombosis is treated with anticoagulation.  Hemorrhagic strokes in children are treated similar to adults.
Exchange transfusion is the mainstay of treatment for sickle cell patients with a goal to decrease HbS to < 30%.

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Category: Pediatrics

Title: When should troponin be ordered in a pediatric patient?

Keywords: Chest pain, ischemia, pediatrics, myocarditis (PubMed Search)

Posted: 3/19/2021 by Jenny Guyther, MD (Updated: 9/23/2021)
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Even though acute myocardial ischemia (AMI) does not present as commonly in the pediatric patient as in the adult and the literature is limited, it is reasonable to obtain a troponin when acute cardiac ischemia is suspected based on the history and physical exam. 

Recreational drugs including cocaine, amphetamine, cannabis, Spice, and K2 (cannabis derivatives) have been shown to result in myocardial injury including AMI. Coronary vasospasm secondary to drug use is well documented in the pediatric population. While cocaine use is a known risk factor for coronary vasospasm, the same condition has been reported in pediatric patients after marijuana use.

In a study of pediatric patients with blunt chest trauma, 3 of 4 patients with electrocardiographic or echocardiographic evidence of cardiac injury had elevations in troponin I above 2.0 ng/mL. Cardiac troponins are an accurate tool for screening for cardiac contusion after blunt chest trauma in pediatric patients even with limited data.

Cardiac troponins are also useful in the evaluation for myocarditis. In one study, myocarditis was the most common diagnosis (27%) in pediatric ED patients presenting with chest pain and an increased troponin. Eisenberg et al showed a 100% sensitivity and an 85% specificity for myocarditis using a troponin of 0.01 ng/mL or greater as a cut off.  A normal troponin using this cutoff can be used to exclude myocarditis. Abnormal troponin in the first 72 hours of hospitalization in pediatric patients with viral myocarditis is associated with subsequent need for extracorporeal membrane oxygenation and IVIg.

Bottom line: Troponin can be used in pediatric patients with clinical concern for cardiac ischemia, cardiac contusion and myocarditis

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Category: Pediatrics

Title: Is there utility in measuring BNP in pediatric patients in the emergency room?

Keywords: Congestive heart failure, trouble breathing, basic natriuretic peptide (PubMed Search)

Posted: 2/19/2021 by Jenny Guyther, MD (Updated: 9/23/2021)
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In children with known congenital heart disease, BNP measurements are higher in those patients with heart failure compared to those without heart failure.

The utility of BNP in differentiating a cardiac from pulmonary pathology in patients with respiratory distress has been studied in pediatrics. In one study involving 49 infants with respiratory distress, the patients with a final diagnosis of heart failure had a higher mean BNP concentration than those patients with other causes.  Also, there is a suggestion that the relative change in NT proBNP levels may be useful in patients with underlying pulmonary hypertension.  However, currently there is not enough literature to support the routine use of BNP or NT proBNP in acute management.

Bottom line: BNP can be useful in your patient with congenital heart disease who is decompensating and may be used in a patient where there is difficulty in differentiating a primary respiratory from cardiac etiology.

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Category: Pediatrics

Title: Lactate use in pediatric sepsis

Keywords: Infection, sepsis, lactic acid (PubMed Search)

Posted: 1/15/2021 by Jenny Guyther, MD (Updated: 9/23/2021)
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Despite a lack of formal guidelines and evidence, lactate measurement has become a component of many pediatric emergency sepsis quality programs, with one survey showing that up to 68% of responding pediatric emergency medicine providers routinely measured it.

The Surviving Sepsis Campaign, last updated in February 2020, could not make a recommendation on the use of lactate in pediatric patients with suspected shock. The authors did state that lactate levels are often measured during the evaluation of septic shock if the lab can be obtained rapidly. However, lactate levels alone would not be an appropriate screening test.

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Category: Pediatrics

Title: Can procalcitonin be used to risk stratify the febrile infant?

Keywords: Procalcitonin, febrile infants, sepsis (PubMed Search)

Posted: 12/18/2020 by Jenny Guyther, MD (Updated: 9/23/2021)
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Young infants (0-90 days) have immature immune systems and are at higher risk for serious bacterial infections, particularly urinary tract infections, bacterial meningitis, and bacteremia. Infants less than 90 days old have an incidence of bacterial infections between 8 to 12.5%, while infants less than or equal to 28 days old have almost a 20% incidence.

Risk-stratification of this group has been a huge focus of research over the past couple of decades to help identify which patients require a full sepsis work-up, particularly in well-appearing infants if a source of fever is identified early. Recent studies have explored the utility of biomarkers in risk stratification in this population. A better ability to discriminate would hopefully decrease unnecessary lumbar punctures, antibiotic use, and hospital admission. Multiple studies have shown procalcitonin is able to outperform CRP for prediction of serious bacterial infections. Kuppermann et al developed a tool to identify low risk febrile infants < 60 days using procalcitonin and ANC. Their prediction rule gave a 97.7% sensitivity, 60% specificity, and 99.6% NPV for serious bacterial infection.  There have been several other studies that have looked harder to detect infections such as osteomyelitis or septic arthritis across all pediatric patients and the data has not been as promising.

Bottom line: Procalcitonin shows promise as part of a risk stratification tool in infants younger than 60 days.  Other studies have failed to show its relevance as a screening tool for osteomyelitis, septic arthritis, renal abscess or community acquired pneumonia.

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Category: Pediatrics

Title: Helpful hints for the pediatric prepubescent genitourinary exam

Keywords: vaginitis, vaginal discharge (PubMed Search)

Posted: 11/20/2020 by Jenny Guyther, MD (Updated: 9/23/2021)
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To determine if the child is prepubescent, look for the lack of pubic hair, clitoral size, configuration of the hymen, breast development, and axillary hair growth. A Tanner stage of 1 would be consistent with prepuberty.

The proper positioning for the physical exam will allow the child to be comfortable and the examiner to obtain an adequate view including up to one-third of the vagina.

If the child is small enough, they can lay in the parent’s lap. For a larger child, you can have the parent sit in the bed with the patient or stand near the child’s head. Engage child life if available.

The frog leg position with gentle downward and outward traction of the labia at the 5- and 7-o’clock positions provides the optimal view.

The knee to chest position is helpful when further evaluation is needed.

A rectovaginal exam is useful for evaluation of masses or foreign body only and is not routinely needed. Place the examiner’s little finger in the rectum and the other hand on the abdomen and palpate.

The use of a vaginal speculum is rarely needed in prepubertal children; if it is needed, perform the exam under anesthesia.

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Category: Pediatrics

Title: Labial adhesions

Keywords: GU anomaly, prepubescent (PubMed Search)

Posted: 10/16/2020 by Jenny Guyther, MD
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A labial adhesion is defined as a thin avascular clear plane, a raphe, between the labia minora. These adhesions which can be caused by minor trauma or infection in the absence of estrogen  can cause varying degrees of obstruction.  

The prevalence is between 0.6% and 5% of females and occurs between 3 months and 3 years of age with a peak between 13 and 23 months.  At least 50% are asymptomatic and found incidentally.  Patient may also have a UTI (20%), postvoid dripping (13%), urinary frequency (7%), or vaginitis (9%).  First-line treatment: estradiol cream 0.01% 1-2x/day for 2-6 weeks. Gentle traction during application of the cream increases the success of separation.  The success rate is between 50% and 89%.  Apply an emollient to reduce recurrence rate.  If there are severe symptoms or medical therapy fails, surgical separation is recommended.

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Category: Pediatrics

Title: Prepubertal Urethral Prolapse

Keywords: prepubertal vaginal bleeding, mass (PubMed Search)

Posted: 9/18/2020 by Jenny Guyther, MD (Updated: 9/23/2021)
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- Urethral prolapse will appear as a protrusion of the distal urethra through the urinary meatus causing a “doughnut” sign.

- Risk factors include trauma, UTI, anatomical differences, and increased intraabdoiminal pressure from cough or constipation.  There is a higher incidence in people of African descent.

- The chief complaint may include urethral mass and vaginal bleeding.

- There is a bimodal age distribution (prepuberty and postmetapause) due to a relative estrogen deficiency.

-Treatment is with estrogen cream and sitz baths for 4- 6 weeks.

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Category: Pediatrics

Title: Imperforate hymen

Keywords: Female GU, abdominal pain, missed period (PubMed Search)

Posted: 8/21/2020 by Jenny Guyther, MD
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Definition: Congenital anomaly where the hymen is completely obstructing the vaginal opening

Demographic: Incidence 0.05-0.1% of females

History:  Most are asymptomatic and diagnosed on physical exam or incidentally when there is lack of menarche. Symptoms in adolescents can include: Abdominal pain (50%), urinary retention (20%), abnormal menstruation (14%), dysuria (10%), frequency, renal failure, UTI and back pain.

Physical exam: bulging, blueish hymenal membrane

Complications: Late detection can lead to infections, fertility problems, endometriosis, hydronephrosis, and rarely renal failure

ED treatment: If abdominal pain is significant or there is urinary obstruction, a urinary foley can be placed.  GYN should be consulted.

Definitive treatment: Hymenectomy, hymenotomy, carbon dioxide laser treatments or foley insertion through the hymen (done by a specialist).

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Category: Pediatrics

Title: Risk factors for pediatric cervical spine injuries

Keywords: MVC, neck injury, neurological injury (PubMed Search)

Posted: 7/24/2020 by Jenny Guyther, MD (Updated: 9/23/2021)
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There is no well validated clinical decision rule similar to NEXUS or the Canadian Cervical Spine rule in children for clearing the cervical spine.  Clinical clearance versus imaging first is a complicated decision.  Certain risk factors may predispose children to injury and should be taken into account when deciding about clinical clearance versus imaging (XR).

High Risk Criteria for Cervical Spine Injury in Pediatrics

Mechanism

 

High risk MVC

              Intrusion > 12 inches at the occupant site

              Intrusion > 18 inches at any site

              Partial or complete ejection

              Death in the same passenger compartment

              Vehicle telemetry consistent with high speed

Fall > 10 feet

Nonaccidental trauma

Diving injury

History

 

Down’s Syndrome

22.q11.2 deletion

Klippel-Fiel syndrome

Physical Exam

 

Altered mental status

Intoxication

Hypotension

Focal neurological exam

Neck pain

Torticollis

             

 

 

 

 

 

 

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Category: Pediatrics

Title: Failure to thrive in children in the ED

Keywords: weight loss, not eating, small, FTT (PubMed Search)

Posted: 6/19/2020 by Jenny Guyther, MD
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Children will often present to the ED with concern for poor feeding or weight loss.  Be concerned about failure to thrive when: 2 or more growth percentile lines are crossed or weight or length is less than the 5th percentile for the patients chronological age.
Make sure to ask about feeding technique, type of formula, frequency of feeds and problems with feeding.
Keep a broad differential in the ED in children with weight concerns including non accidental trauma, congenital heart disease, genetic abnormalities, hyperthyroidism, and gastrointestinal abnormalities.  GI problems include cow's milk protein intolerance, celiac disease, pyloric stenosis and reflux.

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Category: Pediatrics

Title: When does a car seat need to be replaced?

Keywords: seat belt, car seats (PubMed Search)

Posted: 5/15/2020 by Jenny Guyther, MD (Updated: 9/23/2021)
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NHTSA recommends that car seats be replaced following a moderate or severe crash. Car seats do not automatically need to be replaced following a minor crash.

A minor crash is one in which ALL of the following apply:

-The vehicle was able to be driven away from the crash site.
-The vehicle door nearest the car seat was not damaged.
-None of the passengers in the vehicle sustained any injuries in the crash.
-If the vehicle has air bags, the air bags did not deploy during the crash
-There is no visible damage to the car seat.

NEVER use a car seat that has been involved in a moderate to severe crash. Always follow manufacturer's instructions.

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Category: Pediatrics

Title: Teen Driving Education in the Pediatric Emergency Department

Keywords: MVC, anticipatory guidance, seatbelts. (PubMed Search)

Posted: 4/17/2020 by Jenny Guyther, MD (Updated: 9/23/2021)
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The leading cause of death in the US for those aged 16 to 24 years is motor vehicle collisions (MVCs).  Teen drivers are more likely than any other age group to be involved in an MVC that result in injury or fatality.  Texting while driving, nighttime driving, inexperienced driving, and driving under the influence of alcohol or drugs may play a role in these collisions.

Can anticipatory guidance related to safe driving be done in the ED?  YES!

This study implemented a toolkit that contained a copy of the driving law, a sample parent-teen driving contract and statistics on teen driving injuries. Post toolkit questionnaires showed that both teens and their guardians learned new information.

Bottom line: Engage in anticipatory guidance in the ED with teens and their parents about seatbelt use, the dangers of driving under the influence and local driving laws.

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Category: Pediatrics

Title: SARS-CoV-2 Infection in Children

Keywords: pandemic, coronavirus, pediatric (PubMed Search)

Posted: 3/20/2020 by Jenny Guyther, MD (Updated: 9/23/2021)
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New information is coming out each day.  Below is just a sample of some of the recent data in children.
 
SARS-CoV2 Infection in Children - Lu et al
- 1391 Children in China were tested between 1/28-2/26/20. 171 were positive. 
- Fever was present in 41.5 % of infected children at some time during their illness course
- 3 patients required ICU care
- 27 patients did not have any symptoms or pneumonia on chest xray
 
Infant COVID Study - Wei et al
-2 month retrospective review
-9 infants under 1 year tested positive for COVID during this time period
-3/9 asymptomatic, 4/9 fever only, 2/9 mild URI symptoms
 
Children COVID Study - Xai et al
-2 week retrospective review
-20 children, all inpatients 
-12/20 fever (60%), 13/20 cough (65%)
-Coinfection pathogens: influenza A, B, mycoplasma, CMV, RSV 
 
Bottom line: Children appear to be less severely affected than adults and with a different symptom pattern.  Coinfection with other respiratory viral pathogens can occur.

 

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Category: Pediatrics

Title: Epinephrine administration in pediatric prehospital cardiac arrest

Keywords: cardiac arrest, prehospital, epinephrine (PubMed Search)

Posted: 2/21/2020 by Jenny Guyther, MD (Updated: 9/23/2021)
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This was a population based observational study in Japan that enrolled pediatric patients age 8-17 years with out-of-hospital cardiac arrests (OHCA).  The primary end point was 1 month survival and secondary end points were favorable 1 month neurological outcomes and pre-hospital return of spontaneous circulation (ROSC).  In Japan, prehospital administration of epinephrine is allowed in children 8 years and older with appropriate training.
3961 pediatric OHCA were eligible (306 received epinephrine and 3655 patients did not).
There were no differences between the epinephrine and no epinephrine groups in regards to 1 month survival or favorable neurological outcome.  The epinephrine group had a slightly higher likelihood of achieving pre-hospital ROSC.

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