UMEM Educational Pearls - By Jenny Guyther

114 children with bronchiolitis had end tidal carbon dioxide (ETCO2) measured on presentation to the ED. The ETCO2 levels did not differ significantly between admitted and discharged patients. In the subset of admitted patients, there was no correlation with ETCO2 on admission and days of oxygen requirement or length of stay.

Bottom line: Initial ETCO2 does not predict outcome for patients with bronchiolitis.

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From 2010-2014 ED visits in the US for injuries from trampoline parks (TPI) increased from 581 visits per year to 6932 visits per year. There was no change in the number of injuries related to home trampoline use. TPI were more likely to involve the lower extremity, be a dislocation and warrant admission and less likely to involve the head.

Bottom line: TPIs are increasing and have a different injury pattern compared to home trampolines.

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Although it is summer, preparations are being made for the 2016-2017 influenza season. The Center for Disease Control (CDC) no longer recommends the live attenuated influenza vaccine (LAIV4). The American Academy of Pediatrics has supported this statement.

The LAIV4 (the only intranasal vaccine available) was offered to patients over the age of 2 years without respiratory problems. Observational studies during the 2013-2015 seasons have shown that the LAIV4 has an adjusted vaccine efficacy of 3% compared to 63% for the inactivated vaccine (intramuscular). Children who received the intranasal vaccine were almost 4 times more likely to get the flu compared to children who received the injection.

Bottom line: Only the intramuscular shot is recommended for this upcoming season. This is causing many primary care practices to scramble to obtain enough vaccine.

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Category: Pediatrics

Title: Hypertensive crisis in children

Keywords: hypertension, pediatrics (PubMed Search)

Posted: 6/17/2016 by Jenny Guyther, MD
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Hypertension is defined as a systolic or diastolic blood pressure > 95% for age, sex and height based on repeated measurements. There is no numeric blood pressure cut of for defining hypertensive emergency in pediatrics. Use a reference book such as Harriet Lane Handbook to determine percentiles. The proper size BP cuff should be used: bladder width that is at least 40% of the arm circumference at the midpoint of the upper arm and a length that is 80-100% of the arm circumference.
Hypertensive crisis in children younger than 6 years may present with: irritability, feeding disturbance, vomiting, failure to thrive, seizure, altered mental status, or congestive heart failure.
Treatment in the Emergency Setting
-Lower the BP to < 95 percentile in children with HTN and no signs of end organ dysfunction
-Lower the BP to < 90 percentile in children with end organ dysfunction or co-morbid conditions
-Start with IV if able
-Few anti hypertensive medications have been studied adequately in children.
-The cited article has a table of antihypertensive medications with doses to be used in children, but only 4 have FDA approved labeling for pediatrics (hydralazine, fenoldopam, sodium nitroprusside and minoxidil)

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Category: Pediatrics

Title: BRUE Restructuring the way we think of ALTE

Keywords: Apparent life threatening event, ALTE, apnea, low risk infants, brief unexplained resolved events (PubMed Search)

Posted: 5/20/2016 by Jenny Guyther, MD
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The American Academy of Pediatrics has developed a new set of clinical practice guidelines to help better manage and think about patients who have experienced an ALTE (Apparent Life Threatening Event). The term BRUE (Brief Resolved Unexplained Event) will replace ALTE.

BRUE is defined as an event in a child younger than 1 year where the observer reports a sudden, brief and now resolved episode of one or more of: cyanosis or pallor; absent, decreased or irregular breathing, marked change in tone or altered level of responsiveness. A BRUE can be diagnosed after a history and physical exam that reveal no explanation.

BRUE can be classified as low risk or high risk. Those that can be categorized as low risk do not require the extensive inpatient evaluation that has often occurred with ALTE.

LOW risk BRUE:

Age > 60 days

Gestational age at least 32 weeks and postconceptual age of at least 45 weeks

First BRUE

Duration < 1 minute

No CPR required by a trained medical provider

No concerning historical features (outlined in the article)

No concerning physical exam findings (outlined in the article)

Recommendations for low risk BRUE:

-SHOULD: Educate, shared decision making, ensure follow up and offer resources for CPR training

-May: Obtain pertussis and 12 lead; briefly monitor patients with continuous pulse oximetry and serial observations

-SHOULD NOT: Obtain WBC, blood culture, CSF studies, BMP, ammonia, blood gas, amino acids, acylcarnitine, CXR, echocardiogram, EEG, initiate home cardiorespiratory monitoring, prescribe acid suppression or anti-epileptic drugs

-NEED NOT: obtain viral respiratory tests, urinalysis, glucose, serum bicarbonate, hemoglobin or neuroimaging, admit to the hospital solely for cardiorespiratory monitoring

*When looking at the evidence strength behind these recommendations, the only one that had a strong level was that you should not obtain WBC, blood culture or CSF

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Typically, if an infant or young child presents to the ED with concern for intracranial hemorrhage (ICH), CT is performed as a rapid diagnostic tool. Now that clinicians are more aware of the radiation associated with head CT, the possible use of ultrasound was studied. Ultrasound is commonly used in the neonatal population for detecting ICH. A study by Elkhunovich et al looked at children younger than 2 years who had cranial ultrasounds preformed. Over a 5 year period, 283 ultrasounds were done on patients between 0 to 485 days old (median 33 days). There were 39 bleeds detected. Ultrasound specificity and sensitivity was calculated by comparing the results with CT, MRI and/or clinical outcome. For significant bleeds, the sensitivity for ultrasound was 81%. The specificity for detecting ICH was 97%.

Only 2 patients in the study were older than 1 year. The proper windows are easiest to visualize in children younger than 6 months.

Bottom Line: The sensitivity of cranial ultrasound is inadequate to justify its use as a screening tool for detection of ICH in an infant with acute trauma, but it could be considered in situations when obtaining advanced imaging is not an option because of availability or patient condition.

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Category: Pediatrics

Title: End tidal capnography to exclude DKA in children and adults

Keywords: End tidal capnography, diabetic ketoacidosis (PubMed Search)

Posted: 3/19/2016 by Jenny Guyther, MD
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A previous pearl has looked at serum HCO3 as a predictor of DKA (see pearl from 8/21/15). The article by Gilhotra looks at using end tidal CO2 (ETCO2) to exclude DKA. 58 pediatric patients were enrolled with 15 being in DKA. No patient with ETCO2 > 30 mmHg had DKA. Six patients with ETCO2 < 30 mmHg did not have DKA. Other studies done in children have shown similar results.

An article recently published by Chebl and colleagues examined patients older than 17 years with hyperglycemia. In this study, 71 patients were included with 32 having DKA. A ETCO2 >35 excluded DKA in this group while a level <22 was 100% specific for DKA.

Bottom line: ETCO2 >35 mmHg is a quick bedside test that can aid in the evaluation of hyperglycemic patients.

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There is not much data published on susceptabilities of urinary pathogens in infants. What resistance patterns are seen in infants < 2 months in gram negative uropathogens?

A retrospective study of previously healthy infants diagnosed with urinary tract infections in Jerusalem over a 6 year period examined this question. The standard treatment at this hospital included ampicillin and gentamycin for less than 1 month olds and ampicillin or cefuroxime for 1-2 month olds.

306 UTIs were diagnosed

74% were resistant to ampicillin

22% were resistant to cefazolin and augmentin

8% were resistant to cefuroxime

7% were resistant to gentamycin

Of the organisms cultured, 76% were E. coli and 14% were Klebsiella.

Bottom line: Know your local resistance patterns.

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ED study of 60 pediatric patients for procedural sedation

  • Fentanyl 1 mcg/kg was followed by 0.1 to 0.2 mg/kg of etomidate IV.
  • One dose of 0.2 mg/kg IV etomidate was adequate for 39/60 patients
  • 16.4% had respiratory depression
  • Desaturation occured in 23 patients
  • No patient required positive pressure ventilation
  • Average recovery in 21 minutes

Bottom line: Etomidate can achieve effective sedation in children for a short procedure. Although respiratory effects were noted, none of them required assisted ventilation.

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Category: Pediatrics

Title: Beware the inflatable bouncer

Keywords: inflatable, trauma, bounce house (PubMed Search)

Posted: 12/17/2015 by Jenny Guyther, MD (Emailed: 12/18/2015) (Updated: 12/18/2015)
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Inflatable bouncers are becoming more popular. A recent study looked at the patients who presented to an Italian emergency department from 2002-2013 after injuries sustained while using them.
-Males had a slight predominance over females
-Preschool children were the most commonly injured
-Upper extremity was injured more commonly than lower extremity
-Injury occurrence increased each year
Bottom line: Beware the inflatable bouncer and have a high suspicion for upper extremity injuries, especially in preschool children

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Category: Pediatrics

Title: Disposition for reduced intussusception

Keywords: air enema, intussusception (PubMed Search)

Posted: 11/20/2015 by Jenny Guyther, MD
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You have successfully identified a patient with intussusception. It has been successfully reduced with an air enema on the first attempt by radiology. What do you do with the patient afterwards? Do you place them in the hospital on the general surgery team, observe in the ED or discharge them home?
Recurrence can occur in up to 10% of patients. Absolute indications for admission include perforation, failed reduction and identification of a lead point that requires further investigation. Relative indications for admission include prolonged prodrome, bloody stools or dehydration.
A study in Pediatrics looked at 80 patients over a 2 year period with intussusception. 46 patients had been successfully reduced with an air enema. 30 patients were discharged from the emergency room. One patient returned and required a repeat enema reduction and 6 returned for viral related symptoms. 16 patients were observed and discharged within 23 hours. These patients had no interventions done during their observation period. Median length of stay for those discharged from the ED was 6.8 hours (compared to 5.4 hours for admitted patients). The cost of patients discharged from the emergency department was much less compared to those admitted.
This study suggests that after successful reduction in a well appearing child, a short post-reduction observation period may be safe. Other studies have suggested a 6-7 hour period of observation compared to 23 hours.

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Category: Pediatrics

Title: Seat Belt Sign in Pediatrics

Keywords: Blunt abdominal trauma, seat belt sign, pediatrics (PubMed Search)

Posted: 10/16/2015 by Jenny Guyther, MD
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Our suspicion of significant abdominal injury increases when there is bruising across the abdomen in adults after a motor vehicle collision, but what about in children? A PECRAN analysis may have provided us with the answer.

Of 3740 pediatric patients after motor vehicle collision, 16% had a seat belt sign. Seat belt sign was defined as a continuous area of erythema, ecchymosis or abrasion across the abdomen due to the seat belt. 1864 children had CT scans of the abdomen. Intra-abdominal injuries (IAI) were more common in those children with seat belt sign than those without (19% versus 12%). Those with seat belt sign had a greater risk of hallow viscous or mesenteric injuries. There was no increased risk of solid organ injury. 33% of patients with seat belt sign did not have complaints of abdominal pain or tenderness on initial exam (with a GCS of 14 or 15); 2% of these patients underwent operative intervention for their injuries.

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Category: Pediatrics

Title: Amsterdam Pediatric Wrist Rules

Keywords: wrist, fracture, trauma (PubMed Search)

Posted: 9/18/2015 by Jenny Guyther, MD
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Is there a set of criteria similar to the Ottawa Ankle or Knee Rule that can be applied to the wrist in children?
The Amsterdam Pediatric Wrist Rules are as follows:
-Swelling of distal radius
-Visible deformity
-Painful palpation of the distal radius
-Painful palpation at the anatomical snuff box
-Painful supination
A positive answer to any of these would indicate the need for an xray.

The study referenced attempted to validate these criteria. This criteria is inclusive of the distal radius in addition to the wrist. The sensitivity and specificity were 95.9% and 37.3%, respectively in children 3 years through 18 years. This model would have resulted in a 22% absolute reduction in xrays. In a validation study, 7/170 fractures (4.1%, 95% CI: 1.7- 8.3%) would have been missed using the decision model. The fractures that were missed were all in boys ages 10-15 and were all buckle fractures and one non displaced radial fracture.

Bottom line: This rule can serve as a guide for when to obtain an xray in the setting of trauma, but it is not perfect.

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Category: Pediatrics

Title: Do you really need a VBG in DKA in children?

Keywords: VBG, DKA, acidosis, hyperglycemia (PubMed Search)

Posted: 8/21/2015 by Jenny Guyther, MD
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The answer may be no, as long as you have a serum HCO3. In this retrospective study, linear regression was used to to assess serum HCO3 as a predictor of venous pH. Logistic regression was also used to evaluate serum HCO3 as a predictor of DKA. Using a HCO3 cutoff of <18 mmol/L had a sensitivity of 91.8% and specificity of 91.7% for detecting a pH <7.3. A HCO3 < 8 had a sensitivity of 95.2 % and specificity of 96.7 % for detecting a pH <7.1.

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A recent meta-analysis published in Pediatrics reviews the diagnostic accuracy of lung ultrasound for pneumonia. According to the commentary, pneumonia is the leading cause of illness and death in children worldwide; it accounts for 18% of the total number of deaths in children <5 years, more than TB, AIDS, and malaria combined.

They performed a systematic search on several major databases using a combination of controlled keywords for age <18 years, pneumonia, and ultrasound. Of the initially 1475 identified studies, 8 were ultimately chosen for further evaluation.

Characterizing the meta-analysis:

- Three were conducted in the ED, 2 on the wards, 1 in the PICU and 2 in the NICU.

- Of the 765 children encompassed, the mean age was 5 years and they were 52% boys.

- Five of the 8 studies noted using highly skilled sonographers.

- The studies originated from Italy (5), US (1), China (1) and Egypt (1).

- All studies used CXR +/- clinical criteria as the diagnostic standard; LUS assessment was blinded to associated CXR results in 7 of 8 studies.


- LUS in the diagnosis of pediatric pneumonia had an overall pooled sensitivity of 96% (95% confidence interval [CI]: 94-97%) and specificity of 93% (95% CI: 90-96%).

- Positive and negative likelihood ratios were 15.3 (95% CI: 6.6-35.3) and 0.06 (95% CI: .03-0.11), respectively. For reference, remember that an LR >1 indicates an increased probability that the target disorder is present and >10 is a large or often conclusive increase in the likelihood of disease. Likewise, an LR <1 indicates a decreased probability that the target disorder is present and <0.1 is large or often conclusive decrease in the likelihood of disease.

- The area under the receiver operating characteristic (ROC) curve was 0.98. The ROC curve represents a measure of the accuracy of a test, >0.9 is considered to be excellent.

- In order to determine whether there are genuine differences underlying the results of the studies (heterogeneity) the I-squared statistic was implemented, with values consistent >0.45, demonstrating significant heterogeneity.

Bottom line: LUS appears to be an accurate test for the diagnosis of pneumonia in children. The limitation of this meta-analysis is mainly in the small number of studies and the significant heterogeneity between them, likely due at least in part to the fact that they used CXR +/- clinical data as the diagnostic standard. Nevertheless, the results provide evidence for the use of LUS as a cost-effective tool that potentially eliminates ionizing-radiation from the work-up of pediatric pneumonia and has application potential in resource-limited settings.


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Previous pearls have focused on diagnosing appendicitis in children including the use of the pediatric appendicitis score and the Alvarado score. Many facilities have begun using focused ultrasound as the initial step in diagnosing appendicitis whilean aging to avoid radiation. The question remains what to do with an indeterminate ultrasound (when the appendix can not be visualized)? The retrospective study cited looked at combining a low Alvarado score (less the 5) with an indeterminate ultrasound and showed a negative predictive value of 99.6%. A total of 522 children were included in this study. 390 of these children had inconclusive ultrasounds. Only 1 patient with a low Alvarado score and inconclusive ultrasound has appendicits. Only children who had surgery or clinical follow up were included.

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Category: Pediatrics

Title: Pediatric Migraine Therapy

Keywords: migraine, sodium valproate, headache (PubMed Search)

Posted: 6/19/2015 by Jenny Guyther, MD
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Sodium valproate (VPA) had been studied and found to be effective in the adult population for migraines, but not in the pediatric population.  This article was a small (12 patient) retrospective study of pediatric migraine patients looking at pain scores before and after VPA administration.  Prior to VPA, patients received NSAIDs, dopamine antagonists, IV fluids and narcotics.  Mean pain reduction prior to VPA was 17%.  After VPA, pain scores were reduced by an additional 36%.

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Lice are spread through direct contact as they crawl. Indirect contact (through brushes or hats) is less likely. One study showed that live lice were found in only 4% of infested volunteers pillowcases.

During an initial infestation, lice can reside on the head for up to 4 to 6 weeks before becoming symptomatic. Therefore, when lice are detected at school, there is no need to send the child home (or to the ED). Children also do not need to be kept out of school while receiving treatment.

Bonus: First line treatment is 1% Permethrin applied on day 0 and 9. The patient should wash their hair first with a non conditioned shampoo, apply Permethrin for 10 minutes and then rinse.

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Category: Pediatrics

Title: Traumatic Lumbar Punctures in Infants 1 to 2 months

Keywords: Traumatic lumbar punctures, fever, infants (PubMed Search)

Posted: 4/17/2015 by Jenny Guyther, MD
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Approximately ¼ of lumbar punctures (LP) are traumatic or unsuccessful in infants.  What is the implication of this?

A retrospective cross sectional study over a 10 year period at Boston Children’s Hospital looked at infants aged 28 to 60 days who had blood cultures sent from the Emergency Department and who had LPs performed. The ED clinicians at this facility routinely follow the “Boston Criteria” to identify infants at low risk for spontaneous bacterial infection (SBI).  Traumatic LPs were defined as CSF red cell count greater than or equal to 10x10^9 cells/L while an unsuccessful LP was defined as one where no CSF was available for cell counts.  A small portion of the unsuccessful LPs did not have CSF cultures sent.

173 infants had traumatic or unsuccessful LPs.  The SBI rate did not differ between the normal LP and the traumatic and unsuccessful LP infants.  Median hospital charges were higher in the traumatic or unsuccessful LPs compared to the normal LP group ($ 5117 US dollars versus $ 2083 US dollars).

Bottom Line:  Traumatic or unsuccessful LPs lead to higher hospital charges.

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Upper gastrointestinal (UGI) bleeds accounts for only 0.2% of complaints for children presenting to the pediatric emergency department. However, these children can present in significant distress. In fact, critically ill children with UGI bleeds while in the ICU had an increase mortality rate compared to those without UGI bleeds.
There is a long differential for the cause of the bleeding, although age may be a clue. In the first month of life, consider maternal blood ingestion or vitamin K deficiency. In infants and toddlers, think of reflux esophagitis or ingestion. In older children, consider ulcer disease.
Remember to ask about different food ingestions that may mimic blood: licorice, red drinks, red fruits and vegetables, spicy/hot flavored snacks, bismuth, and iron.
Key points to remember in the management of pediatric patients:
-Gastroccult (NOT hemoccult)
-Apt-Downey test (looking for maternal blood)
-XRs indicated only for concern of ingestion
-NG lavage are done in 3 to 5 ml/kg aliquots
-If your patients have a G-tube, lavage through this may lead to false-negative findings or underestimation of the severity of the bleeding.

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