UMEM Educational Pearls - By Jenny Guyther

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.   

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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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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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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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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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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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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.  

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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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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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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

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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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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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Tonsillectomy and adenoidectomy (T&A) is the second most common ambulatory surgery performed in the US.  Children younger than 3 years, children with craniofacial disorders or sleep apnea are typically admitted overnight as studies have shown an increase rate of airway or respiratory complications in this population.

The most common late complications include bleeding and dehydration.  Other complications include nausea, respiratory issues and pain.

Post-operatively, the overall 30-day emergency department return rate is up to 13.3%.  Children ages 2 and younger were more likely to present to the ED.  There is significantly higher risk of dehydration for children under 4 years.  Children over the age of 6 had significantly higher bleeding risk and need for reoperation for hemorrhage control.

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Urinary retention in pediatrics is defined as the inability to void for more than 12 hours in the presence of a palpable bladder or a urine volume greater than expected for age.

Maximum urine volume calculation for age:  (age in years + 2) x 30ml.

Causes of urinary retention include mechanical obstruction, infection, fecal impaction, neurological disorders, gynecological disorders and behavioral problems.

The distribution is bimodal occurring between 3 and 5 years and 10 to 13 years.

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Streptococcal pharyngitis is common in the pediatric population however in children younger than 3 years, group A streptococcus (GAS) is a rare cause of sore throat and sequela including acute rheumatic fever are very rare.  Inappropriate testing leads to increased healthcare and unnecessary exposure to antibiotics.

The national guidelines published by the Infectious Diseases Society of America do NOT recommend GAS testing in children less than the age of 3 years unless the patient meets clinical criteria and has a home contact with documented GAS.

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