- Tibial tubercle avulsion fractures are rare and pediatrics, accounting for less than 3% of all epiphyseal injuries in children ages 11-17 years.
- The typical mechanism is a sudden forceful quadriceps contraction. Patients present with sudden pain after sprinting or jumping with pain, bruising, deformity or swelling over the tibial tubercle and with a decrease ability to extend the leg.
- 10 to 20% of cases result in anterior compartment syndrome related to the rupture of the anterior tibial recurrent artery.
- Although directly measured intra-compartmental pressures can facilitate the diagnosis of compartment syndrome, interpretation of these values can be challenging with healthy children having higher average lower leg compartment pressures than adults. Treatment of subsequent compartment syndrome is often based on a high index of suspicion.
Gunshot injuries are a leading cause of morbidity and mortality in the pediatric population. The Pediatric Trauma Society supports the use of tourniquets in severe extremity trauma. The Combat Application Tourniquet (CAT) that is commonly used in adults has not been prospectively tested in children. This study used 60 children ages 6 through 16 years and applied a CAT to the upper arm and thigh while monitoring the peripheral pulse pressure by Doppler. The CAT was successful in occluding arterial blood flow in all of the upper extremities and in 93% of the lower extremities.
Bottom line: The combat application tourniquet can stop arterial bleeding in the school aged child.
-Benzodiazepines alone are effective in terminating status epilepticus in 40 to 60% of pediatric patients
-The guidelines for second line agents are based on observational studies and expert opinion
-Adverse effects of phenytoin include hepatotoxicity, pancytopenia, Stevens-Johnson syndrome, extravasation injuries, hypotension and arrhythmias
- Levetiracetam has a reduced risk of serious adverse events, greater compatibility with IV fluids and can be given in 5 minutes versus 20 minutes for phenytoin.
Bottom line: In a recent randomized control trial they found that levetiracetam was not superior to phenytoin as a second line agent for management of convulsive status epilepticus in children. There was no difference between efficacy or safety outcomes between the two groups.
Washington state was one of the first states to legalize recreational marijuana use. Toxicology call center data was collected on patient's 9 years old and younger with marijuana exposure between July 2010 and July 2016. There were 161 cases during that time frame and of those 130 occurred after the legalization of recreational marijuana (over a 2.5 year period). The median age range was 2 years old. There were increasing cases noted after recreational marijuana was legalized and again after marijuana shops became legal.
Measles outbreaks have been reported all over the globe, with the incidence increasing due to low immunization rates. Italy experienced 5000 cases in 2017. This study was a retrospective multicenter observational study of children less than 18 years hospitalized for clinically and laboratory confirmed measles over a year and a half period from 2016-2017.
There were 263 cases of measles that required hospitalization during this time and 82% developed a complication with 7% having a severe clinical outcome defined by a permanent organ damage need for ICU care or death. A CRP value of greater than 2 mg/dL was associated with a 2-4 fold increased risk of developing complications. 23% developed pneumonia and 9.6% developed respiratory failure. Hematologic involvement was seen in 48% of patients. 1.2% of hospitalized patients died.
Bottom line: Consider CRP, lipase and CBC at a minimum in your patients with suspected measles who require hospitalization.
Hyponatremia is the most common electrolyte abnormality in hospitalized patients, affecting approximately 15-30% of patients. Children have historically been given hypotonic maintenance IV fluids based off of theoretical calculations from the 1950s. Multiple studies have shown complications related to iatrogenic hyponatremia, including increased length of hospital stay, seizures and death.
The American Academy of pediatrics completed a systematic review and developed an updated clinical practice guideline:
Patient's age 28 days to 18 years requiring maintenance IV fluids should receive isotonic solutions with the appropriate amount KCl and dextrose.
Post tonsillectomy hemorrhage occurs and 0.1-3% of post tonsillectomy patient's. It occurs typically greater than 24 hours after surgery and up to 4-10 days postoperatively. A survey of otolaryngologists showed that ED management strategies for active bleeding have included direct pressure, clot suction, silver nitrate, topical epinephrine, and thrombin powder.
This article was a case study demonstrating the use of nebulized tranexamic acid (TXA) for post tonsillectomy hemorrhage in a 3-year-old patient. The patient had a copious amount of oral bleeding and had failed treatment with nebulized racemic epinephrine and direct pressure was not an option due to the patient's cooperation and small mouth. 250 mg of IV TXA was given via nebulizer with a flow rate of 8 L. Bleeding stopped 5-7 minutes after completion of the nebulizer. The patient was then taken to the OR for definitive management. No adverse effects were noticed.
TXA in the pediatric population has been shown to decrease surgical blood loss and transfusions in cardiac, spine and craniofacial surgeries. Studies have also been done in pediatric patients with diffuse alveolar hemorrhage using doses of 250 mg for children less than 25 kg and 500 mg for those who are greater than 25 kg.
Bottom line: There are case reports of nebulized TXA use in the pediatric population with no adverse outcomes noted. More research is needed.
Historically uncuffed endotracheal tubes were used in children under the age of 8 years due to concerns for tracheal stenosis. Advances in medicine and monitoring capabilities have resulted in this thinking becoming obsolete. Research is being conducted that is showing the noninferiority of cuffed tubes compared to uncuffed tubes. Multiple other studies are looking into the advantages of cuffed tubes compared to uncuffed tubes.
The referenced study is a meta-analysis of 6 studies which compared cuffed to uncuffed endotracheal tubes in pediatrics. The pooled analysis showed that more patients needed tube changes when they initially had uncuffed tubes placed. There was no difference in intubation duration, reintubation occurrence, post extubation stridor, or racemic epinephrine use between cuffed and uncuffed tubes.
Bottom line: There is no difference in the complication rate between cuffed and uncuffed endotracheal tubes, but uncuffed endotracheal tubes did need to be changed more frequently.
Coins are the most commonly ingested foreign body in the pediatric age group with a peak occurrence in children less than 5 years old. X-rays are considered the gold standard for definitive diagnosis and location of metallic foreign bodies. This study aimed to find a way to decrease radiation exposure by using a metal detector.
19 patients ages 10 months to 14 years with 20 esophageal coins were enrolled in the study. All proximal esophageal coins were detected by the metal detector. 5 patient's failed initial detection of the coin with the metal detector and all of those patients had the coin in the mid or distal esophagus with a depth greater than 7 cm from the skin.
Bottom line: A metal detector may detect proximal esophageal coins. This may have a role in decreasing repeat x-rays.
Historically, the C-reactive protein (CRP) has been used in the assessment of the febrile child and is the only biomarker recommended by the National Institute for Health and Care Excellence (NICE).
CRP increases 4-6 hours after the onset of inflammation, doubling every 8 hours and peaking at 36-50 hours. It rapidly decreases once the inflammation has resolved.
An elevated CRP alone is not conclusive of a serious bacterial infection (SBI).
A CRP >75 mg/L increased the relative risk of SBI by 5.4.
A CRP <20 mg/L decreased the risk of SBI, but there was still a small subset of children where SBI was present.
In infants < 3 months initial CRP measurements are poorly accurate, but when trended may be useful in deciding when to stop antibiotics (rather then when to start them). A normalizing CRP demonstrated a 100% negative predictive value for excluding invasive bacterial infection.
Bottom line:
CRP is not a rule in/rule out test
CRP is not helpful in diagnosing SBI, but serial measurements may be useful in monitoring response to treatment
CRP has a limited role in well appearing children older than 3 months
Is there an association between pulmonary aspiration, vomiting or any serious adverse event and the preprocedural fasting time?
The odds ratio of any adverse event did not increase significantly with each additional hour of fasting duration for both solids and liquids.
The guidelines set by the American Society of Anesthesiology for fasting include a minimum of 2 hours for clear liquids, 4 hours for breast milk, 6 hours for formula and light meals and 8 hours for solid meals containing fatty foods or meat.
This was a secondary analysis of a multicenter prospective cohort study of children 0-18 years who received procedural sedation in 6 Canadian pediatric emergency departments from 2010-2015. 6183 children were included with 99.7% meeting ASA 1 or 2 categories. 2974 patients did not meet the American Society of Anesthesiology fasting guidelines for solids and 510 patients did not meet the fasting guidelines for liquids. The overall incidence of adverse events was 11.6%. There were no cases of pulmonary aspiration. There was a total of 717 adverse events. 315 events were vomiting. Oxygen and vomiting were the most common adverse events.
Chest xrays (CXRs) may lead to longer length of stay, increased cost, unnecessary radiation exposure, and inappropriate antibiotic use.
CXR in asthma are indicated for:
-severe persistent respiratory distress, room air saturations <91%
- focal findings (localized rales, crackles, decreased breath sounds with or without a documented fever > 38.3) not improving on >11 hours of standard asthma therapy
- concern for pneumomediastinum or pneumothorax
The rate of occult bacteremia in infants 3 months to 24 months with a temperature higher than 40.5C was slightly higher when compared to those with a temperature higher than 39C.
363 infants (3 months to 24 months) with a fever > 40.5C who were well appearing were evaluated in this study. 4 were diagnosed with occult bacteremia (1.1%). 3 of these were caused by S. pneumoniae and 2 were fully immunized.
A larger sample size is needed to see if reconditions to include empiric blood cultures on this subgroup of patients is warrented.
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.
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.
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.
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?
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.
