UMEM Educational Pearls - By Jenny Guyther

Category: Pediatrics

Title: Development of an algorithm for battery ingestion

Keywords: Button batteries, removal (PubMed Search)

Posted: 5/18/2018 by Jenny Guyther, MD (Updated: 4/13/2024)
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Question

There were 180 battery ingestions over a 5 year period at two tertiary care children’s hospital.  The median age was 3.8 years (0.7 to 18 years).  The most common symptoms were abdominal pain (17%), and nausea and vomiting (14%).  X-rays detected the location in 94% of patients.

Based on these patients, a treatment algorithm was developed (See attached).  Prospective validation is needed.

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Attachments

1805180920_battery_algorithm.docx (123 Kb)



Category: Pediatrics

Title: Epidural hematoma formation after pediatric lumbar puncture

Keywords: Infant fever, lumbar puncture, risks, ultrasound (PubMed Search)

Posted: 4/20/2018 by Jenny Guyther, MD (Updated: 4/13/2024)
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Unsuccessful lumbar punctures (LP) may lead to epidural hematoma (EH) formation at the site of needle insertion which may affect subsequent attempts and lead to no success or a grossly bloody sample.  There is no standard definition of a traumatic LP based on CSF red blood cell counts.  Gross blood may also be obtained by interrupting the vascular structures outside the spinal canal which would not result in EH formation.

This was a prospective study of children younger than 6 months who had an LP at a single children’s hospital.  Post LP ultrasounds were completed by the investigating team and interpreted by a pediatric radiologist. 74  patients were included in the study.  31% of the patients had evidence of a post LP EH.  17% fully effaced the thecal sac which would likely preclude future success at that anatomic site.  25% of patients where the clinician did not feel there was a traumatic attempt had evidence of an EH.The study was not powered to determine the risk factors for EH formation.  The study also did not look at any other consequences to EH.

Key points: Point of care ultrasound to evaluate EH and bleeding at the failed LP site my provide useful information for a location of subsequent attempts.  Also US to evaluate for bleeding in the spinal canal may help with interpretation of the CSF when a large number of red blood cells are present.  

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Question

Fluid overload (defined in this study as (fluid input-output)/weight)) is associated with longer hospital stays, longer treatment duration and oxygen use.

Bottom line: Treat dehydration appropriately but try not to over resuscitate the asthmatic.  Further studies are needed before definitive recommendations are made.

 

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Category: Pediatrics

Title: What is the diagnosis?

Keywords: foreign body, choking (PubMed Search)

Posted: 2/16/2018 by Jenny Guyther, MD
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Question

Patient: 11 month old with trouble breathing and color change after a family member sprayed air freshener.  Symptoms have since resolved.

What are you concerned about in the attached xrays?

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Attachments

1802161333_11_mo_lung_FB_word.docx (408 Kb)



Category: Pediatrics

Title: Oral morphine versus ibuprofen in postoperative orthopedic pain in children

Keywords: Pain control in children, opiates, NSAIDS, motrin, orthopedic (PubMed Search)

Posted: 1/19/2018 by Jenny Guyther, MD
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This was a randomized superiority trial of 0.5mg/kg of oral morphine every 6 hours to 10 mg/kg of ibuprofen every 6 hours in children 5-17 years old who had minor outpatient orthopedic surgeries.  There were 77 patients in each group.  Primary outcome was pain as rated on the Faces pain scale.  Secondary outcomes were additional analgesic requirements, adverse events, and unplanned visits to the doctor.

Bottom line: Oral morphine was not superior to ibuprofen and both drugs decreased pain with no difference in efficacy.  Morphine was associated with more adverse events.

 

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Category: Pediatrics

Title: What is the ideal observation time for a patient with croup who has received racemic epinephrine?

Keywords: Croup, epinephrine, discharge, observation (PubMed Search)

Posted: 12/15/2017 by Jenny Guyther, MD (Updated: 4/13/2024)
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The peak age for croup is 6 months to 3 years.  The cornerstone of treatment is corticosteroids, traditionally dexamethasone.  With oral administration, the peak onset is 1-2 hours. Steroids shorten the duration of symptoms, reduce the need for nebulized epinephrine and decrease the need for intubation.

Racemic epinephrine has been used for moderate to severe croup and can show an improvement in patient symptoms for up to 120 minutes.  There is little evidence to suggest how long to observe the patient for recurrence of symptoms after racemic epinephrine was given.  Previous studies have suggested both 2 and 4 hour observation.

299 patients were included in this study.  136 patients were observed for 3.1 to 4 hours.  In the 3.1 to 4 hour group, 21 (7%) failed treatment, 19 of those patients required admission and 2 returned within 24 hours.  No patients who were discharged home after 4 hours returned to the emergency department within 24 hours.

Bottom Line: Consider a 4 hour period of observation after giving racemic epinephrine in order to decrease bounce backs.

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Category: Pediatrics

Title: Pediatric marijuana ingestion

Keywords: Marijuana, symptoms, overdose (PubMed Search)

Posted: 11/17/2017 by Jenny Guyther, MD (Updated: 4/13/2024)
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In the US, there are an estimated 22.2 million users of cannabis based on the 2015 National Survey on Drug Use and Health.  The incidence of unintentional cannabis ingestion has increased in states that have legalized medical and recreational marijuana.  The cited article reviewed of 44 articles involving unintentional cannabis ingestion in children younger than 12 years.

The majority of intoxications were through cannabis resins followed by cookies and joints.

Lethargy was the most common presenting sign followed by ataxia.  Tachycardia, mydriasis and hypotonia were also noted.  Rarer but more serious presentations included respiratory depression and seizures.

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Question

Within the first hour after administration, ondosterone, metoclopramide and bromopride were equally efficacious.  At the 6 hour and 24 hour period after receiving the initial dose of medication, ondansetron was statistically superior to bromopride (not available in the US) and metoclopramide.  There were no reported side effects in the ondansetron group (including diarrhea or sedation).

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Question

Elective surgeries with general anesthesia are often cancelled when the child has an upper respiratory tract infection.  What are the adverse events when procedural sedation is used when the child has an upper respiratory tract infection?

Recent and current URIs were associated with an increased frequency of airway adverse events (AAE).  The frequency of AAEs increased from recent URIs, to current URIs with thin secretions to current URIs with thick secretions.   Adverse events not related to the airway were less likely to have a statistically significant difference between the URI and non-URI groups

AAEs for children with no URI was 6.3%.  Children with URI with thick/green secretions had AAEs in 22.2% of cases.  Children with URIs did NOT have a significant increase in the risk of apnea or need for emergent airway intervention.  The rates of AAEs, however, still remains low regardless of URI status.

 

 

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Category: Pediatrics

Title: Bacterial Meningitis in Pediatric Complex Febrile Seizures

Keywords: Febrile seizure, meningitis (PubMed Search)

Posted: 8/18/2017 by Jenny Guyther, MD (Updated: 4/13/2024)
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Question

Febrile seizures occur in children 6 months through 5 year olds.  A complex febrile seizure occurs when the seizure is focal, prolonged (> 15 min), or occurs more than once in 24 hours.

The prevalence of bacterial meningitis in children with fever and seizure after the H flu and Strep pneumomoniae vaccine was introduced is 0.6% to 0.8%.  The prevalence of bacterial meningitis is 5x higher after a complex than simple seizure.

From the study referenced, those children with complex febrile seizures who had meningitis all had clinical exam findings suggestive of meningitis.  More studies are needed to provide definitive guidelines about when lumbar punctures are needed in these patients.

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Category: Pediatrics

Title: Reducing radiation exposure in evaluation of ventricular shunt malfunctions in children

Keywords: CT scans, radiation exposure, pediatrics (PubMed Search)

Posted: 7/21/2017 by Jenny Guyther, MD (Updated: 4/13/2024)
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Ventricular shunt (VP) malfunction can be severe and life-threatening and evaluation has typically included a dry CT brain and a shunt series which includes multiple x-rays of the skull, neck, chest and abdomen.  The goal of this study was to decrease the amount of radiation used in the evaluation of these patients since these patients will likely present many times over their lifetime.  Several institutions have more towards a rapid cranial MRI, however, this modality may not be readily available.

This multidisciplinary team decreased the CT scan radiation dose from 250mA (the reference mA in the pediatric protocol at this institution) to 150 mA which allows for a balance between reducing radiation exposure and adequate visualization of the ventricular system.  They also added single view chest and abdominal x-rays.

The authors found that after implementing this new protocol, there was a reduction in CT radiation doses and number of x-rays ordered with no change in the return rate.

 

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Category: Pediatrics

Title: Pediatric blunt trauma and the need for chest xray

Keywords: Blunt thoracic trauma, pediatric trauma, chest xray (PubMed Search)

Posted: 6/16/2017 by Jenny Guyther, MD
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Question

Chest injuries represent the second most common cause of pediatric trauma related death.  ATLS guidelines recommend CXR in all blunt trauma patients.  Previous studies have suggested a low risk of occult intrathoracic trauma; however, these studies included many children who were sent home.

Predictors of thoracic injury include: abdominal signs or symptoms (OR 7.7), thoracic signs of symptoms (OR 6), abnormal chest auscultation (OR 3.5), oxygen saturation < 95% (OR 3.1), BP < 5% for age (OR 3.7), and femur fracture (OR 2.5).

4.3 % of those found to have thoracic injuries did not have any of the above predictors, but their injuries were diagnosed on CXR.  These children did not require trauma related interventions.

Bottom line: There were still a number of children without these predictors that had thoracic injuries, so the authors suggest that chest xray should remain a part of pediatric trauma resuscitation.

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Question

IM ziprasidone (Geodon) has a relatively quick onset of action with a half-life of 2-5 hours.  Although commonly used in adults, there has not been a study looking at an effective dose in pediatrics. Based on the study referenced, the suggested pediatric dose of ziprasidone is 0.2 mg/kg (max 20mg).

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Question

Predictive factors of asthma development in patients diagnosed with bronchiolitis include:

- Male sex (OR 1.3)

- Family history of asthma (OR 1.6)

- Age greater than 5 months at the time of bronchiolitis diagnosis (OR 1.4)

- More than 2 episodes of bronchiolitis (OR 2.4)

- Allergies (OR 1.6)

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Category: Pediatrics

Title: Does urine concentration effect the diagnosis of urinary tract infection?

Keywords: Pediatrics, urinary tract infection, urine concentration (PubMed Search)

Posted: 4/14/2017 by Jenny Guyther, MD (Updated: 4/13/2024)
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Question

A recent study suggests that using a lower cut off value of white blood cells in dilute urine, may have a higher likelihood of detecting a urinary tract infection in children.

In dilute urine (specific gravity < 1.015), the optimal white blood cell cut off point was 3 WBC/hpf (Positive LR 9.9).  With higher specific gravities, the optimal cut off was 6 WBC/hpf (Positive LR 10).  Positive leukocyte esterase has a high likelihood ratio regardless of the urine concentration. 

 

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Question

A 12 year old with arm pain after doing push ups during gym class.  What is the diagnosis?

 

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Attachments

1702180240_peds_pearl.jpg (504 Kb)



Category: Pediatrics

Title: Can you glue a pediatric nail bed laceration?

Keywords: Nail bed injuries, wound closure (PubMed Search)

Posted: 1/20/2017 by Jenny Guyther, MD (Updated: 4/13/2024)
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Question

More studies are needed, but the existing data shows that medical adhesives may be quicker without impacting cosmetic and functional outcome.

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Category: Pediatrics

Title: Do older infants with fever and diarrhea need a UA and culture?

Keywords: fever, diarrhea, urinary tract infection (PubMed Search)

Posted: 12/16/2016 by Jenny Guyther, MD (Updated: 4/13/2024)
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Question

After 4 months old, the answer MAY be no.

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Category: Pediatrics

Title: What is the optimal dosing for IV ketamine for moderate sedation in children?

Keywords: Ketamine, conscience sedation, pharmacology, pediatrics (PubMed Search)

Posted: 11/18/2016 by Jenny Guyther, MD
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Question

Using 1.5 mg/kg or 2 mg/kg of IV ketamine led to less redosing compared to using 1 mg/kg IV.

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Category: Pediatrics

Title: Plasma-Lyte A versus 0.9% NaCl for rehydration in the pediatric patient

Keywords: Fluid resuscitation, gastroenteritis, dehydration (PubMed Search)

Posted: 10/21/2016 by Jenny Guyther, MD
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Question

Plasma-Lyte A outperformed 0.9% NaCl for rehydration in children with acute gastroenteritis showing a more rapid improvement in serum bicarbonate levels and dehydration scores.

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