UMEM Educational Pearls - By Jenny Guyther

Category: Pediatrics

Title: Indeterminate ultrasound results in kids

Keywords: Ultrasound, pediatrics, appendicitis (PubMed Search)

Posted: 6/20/2014 by Jenny Guyther, MD
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Ultrasound is gaining favor as a radiation free tool for evaluating appendicitis.  However, we are all faced with a challenge when the ultrasound is unable to visualize the appendix. What is the next step? Do we CT these kids? Observe them?  MRI them? Admit to surgery? Certainly some of these decisions are made by the institution where you practice, but one study looked at the clinical outcomes in kids where the "appendix was not fully visualized."
 -Retrospective chart review in a tertiary Canadian hospital of kids 2-17 who had US for suspected appendicitis (968 pts)
 -526 kids had incompletely visualized appendices:
           55 went to the OR
           160 were observed
                   -105 were discharged home with no return visits
                   - 55 had appendectomies
                    -39 had appendicitis confirmed by pathology
 -311 went home
          58 bounced-back
          1 had appendicitis confirmed by pathology
-442 kids had fully visualized appendices
           232 were consistent with appendicitis
Bottom line: 15% of kids with an incompletely visualized appendix have appendicitis, so serial reexamination is imperative.  If repeat clinical exams are reassuring, then the miss rate (for this study) was <0.3%.

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Category: Pediatrics

Title: Pediatric Mental Health Screening

Keywords: Psychiatric clearance, pediatric (PubMed Search)

Posted: 5/16/2014 by Jenny Guyther, MD
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Mental health-related visits account for 1.6–6% of ED encounters.  Patients with acute psychosis are often brought to the ED for clearance prior to psychiatric evaluation.  Is this necessary?

Background: Several adult studies have shown that only 0–4% of patients with isolated psychiatric complaints have organic diagnoses requiring urgent treatment.  Routine ED laboratory testing in adults is low yield still, with one study identifying abnormalities in only 2 of 352 patients—both mild hypokalemia.  A pediatric study found that 207 of 209 patients were medically cleared.

This study was a retrospective review of pediatric psychiatric patients presenting to a an urban California hospital.  They examined 798 patients who had an involuntary psychiatric hold placed by a psychiatric mobile response team.

  • 72 (9.1%) were determined to require medical screening (based on patient complaints).
  • Only 35 (4.4%) holds were found to require further medical care prior to psychiatric hospitalization.
  • Total charges for laboratory assessments, secondary ambulance transfers and wages for sitters were $1,241,295 or US$17,240 per patient requiring a medical screen.
  • Patients were in the ED for an average of 7 h with a cumulative time of 5538 hours.

The authors concluded that few pediatric patients brought to the ED on an involuntary hold required a medical screen and perhaps use of basic criteria in the prehospital setting to determine who required a medical screen (altered mental status, ingestion, hanging, traumatic injury, unrelated medical complaint, sexual assault) could have led to significant savings.

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Category: Pediatrics

Title: Scabies diagnosis in kids

Keywords: scabies, pediatrics (PubMed Search)

Posted: 4/18/2014 by Jenny Guyther, MD
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Scabies is considered by the WHO to be one of the main neglected diseases with approximately 300 million cases worldwide each year. One third of cases of scabies seen by dermatologists are in kids less than 16 years old. The belief had been that presentation varies by age.  One French study reported a first time miss rate of more than 41% and an overall diagnostic delay of 62 days.

A prospective, multi center observational study of patients with confirmed scabies sought to determine common phenotypes in children. All patients were seen by dermatologists in France and administered standard questionnaires.  They were divided into 3 age groups, <2 years, 2-15 years and > 15 years.  323 patients were included.

The study found that: 
-infants were more likely to have facial involvement and nodules, especially on the back and axilla
-relapse was more common in < 15 year olds - this was hypothesized to be due to poor compliance with treatment to the head
-family members with itch, or planter or scalp involvement were independently associated with diagnosis of scabies in kids < 2 years
-burrows were seen in 78%, nodules in 67% and vesicles of 43% of patients (see photo)
-itching was absent in up to 10% of patients

Bottom line:  Have a high suspicion for scabies in any rash.



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Category: Pediatrics

Title: Isolated vomiting in pediatric head injuries

Keywords: Head injury, vomiting, PECARN (PubMed Search)

Posted: 3/21/2014 by Jenny Guyther, MD
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Parents will often bring children to the ED for evaluation after a minor head injury.  Vomiting has been considered a risk factor for traumatic brain injury (TBI).  Is isolated vomiting clinically significant?
A PECARN study looked at children < 18 years.
Isolated vomiting with minor head trauma was defined as: No history of LOC, GCS of 15, no altered consciousness (ie sleepiness, agitation), no palpable skull fracture or signs of basilar skull fracture, acting
normally per parent/guardian, no scalp hematoma or other traumatic scalp finding (ie abrasion or laceration), no headache (for patients 2-18 y), no seizure after the head trauma, no neurological deficits
(eg, motor or sensory abnormalities) and no amnesia (for patients 2-18 y).
42,112 children were enrolled.
5,557 (13.2%) had a history of vomiting, of whom 815 of 5,392 (15.1%) with complete data had isolated vomiting.
Clinically important TBI (death, neurosurgical procedure, intubation for at least 24 hours for TBI, or hospitalization for 2 or more nights because of the head trauma in association with TBI on cranial CT) occurred in 2 of 815 patients with isolated vomiting compared with 114 of 4,577 with non isolated vomiting.
Of patients with isolated vomiting for whom CT was performed, TBI on CT occurred in 5 of 298 compared with 211 of 3,284 with non isolated vomiting
There was no association found with timing of onset or time since the last episode of vomiting.
Bottom line: TBI on CT is uncommon and clinically important traumatic brain injury is very uncommon in children with minor blunt head trauma when vomiting is their only sign or symptom. Observation in the emergency department before determining the need for CT appears appropriate for these children to observe for deterioration.

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Category: Pediatrics

Title: Passive Leg Raise in Children

Keywords: Passive leg raise, hypotension (PubMed Search)

Posted: 2/21/2014 by Jenny Guyther, MD (Updated: 12/6/2023)
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Passive leg raise (PLR) has been studied in adults as a bedside tool to predict volume responsiveness (see previous pearls from 5/7/13 and 6/17/2008). Can this be applied to children?
A single center prospective study looked at 40 intensive care patients ranging in age from 1 month to 12.5 years.  They used a noninvasive monitoring system that could measure heart rate, stroke volume and cardiac output.  These parameters were measured at a baseline, after PLR, after another baseline and after a 10 ml/kg bolus.
Overall, changes in the cardiac index varied with PLR.  However, there was a statistically significant correlation in children over 5 years showing an increase in cardiac index with PLR and with a fluid bolus.
Bottom line:  In children older then 5 years, PLR can be a quick bedside tool to assess for fluid responsiveness, especially if worried about fluid overload and in an under served area.

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Category: Pediatrics

Title: Maintenance Sodium in the Pediatric Patient

Keywords: hyponatremia, maintenance fluid (PubMed Search)

Posted: 1/17/2014 by Jenny Guyther, MD (Updated: 12/6/2023)
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What sodium base should be given to children who are unable to eat?  Recent studies have suggested that the traditional teaching of 0.45% normal saline (NS), 0.33% NS or 0.2% NS may cause iatrogenic hyponatremia when compared to an isotonic solution (0.9% NS, Ringers lactate or Hartmann's solution).  
A meta-analysis of 8 studies with 855 patients examined the rate of hyponatremia when using hypotonic versus isotonic solutions.
-Studies included were randomized controlled trials with children age 1 month to 17 years.
-Children needing any type of resuscitation were excluded.
-Hyponatremia was defined as a sodium < 136 mmol/L.
-There is a higher risk when using hypotonic fluids for developing hyponatremia (RR 2.24) and severe hyponatremia (RR 5.29).
-The decrease in sodium was greater when hypotonic solutions were used.
-No significant difference in the rate of hypernatremia (Na>150 mmol/L)
-The type of fluid given (not rate) correlated with the risk of hyponatremia.
-Conclusions could not be drawn on the clinical significance of the iatrogenic hyponatremia
Bottom line: Make a conscience decision about maintenance fluids.  Be sure to monitor Na levels for patients that you place on maintenance fluids and who are in your ED for prolonged periods of time.

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Category: Pediatrics

Title: Growth parameters - corrected

Posted: 12/20/2013 by Jenny Guyther, MD (Updated: 12/6/2023)
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Please see below for the correct information.
-Birth weight doubles by 4 months, triples by 12 months and quadruples by 24 months
-After age 2, normal weight gain averages 5 pounds per year until adolescence
-Birth length increases by 50% at 1 year
-Birth length doubles by 4 years and triples by 13 years
-After age 2, average height increases by 2 inches per year until adolescence

Category: Pediatrics

Title: Abdominal pain and fever

Keywords: Intussusception, abdominal pain, fever (PubMed Search)

Posted: 11/10/2013 by Jenny Guyther, MD (Emailed: 11/15/2013) (Updated: 11/16/2013)
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Case: A 3 year 9 month female presents with fever to 39.4 C and intermittent abdominal pain worsening over 2 days.  The patient had been tolerating food and had no change in her bowel habits.  Based on the imaging below, what is your diagnosis and treatment?

Show Answer

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Category: Pediatrics

Title: Isolated skull fractures in pediatrics

Keywords: skull fracture (PubMed Search)

Posted: 10/18/2013 by Jenny Guyther, MD (Updated: 12/6/2023)
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Pediatric patients with an isolated skull fracture and normal neurological exam have a low risk of neurosurgical intervention and outpatient follow up may be appropriate (assuming no suspicion of abuse and a reliable family).  In a study published in 2011, a retrospective review over a 5 year period at a level 1 trauma center showed that 1 out of 171 admitted patients with isolated skull fractures developed vomiting.  This patient had a follow up CT showing a small extra-axial hematoma that did not require intervention.  58 patients were discharged from the ED within 4 hours.

You can also check out another recent article published in Annals of Emergency Medicine on the same topic this month!

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Category: Pediatrics

Title: Compartment Syndrome in Pediatrics

Keywords: orthopedics, compartment syndrome (PubMed Search)

Posted: 9/20/2013 by Jenny Guyther, MD (Updated: 12/6/2023)
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We have learned how to diagnose compartment syndrome in adults, but how do you determine the early warning signs in a nonverbal or even frightened child?  

Rising compartment pressures are related to increasing anxiety and agitation in children.  A Boston study in 2001 showed that increasing pain medication requirements were detected 7 hours earlier than a vascular exam change.  90% of the patients with compartment syndrome in this study reported pain, but only 70% had another ‘P” (pallor, parasthesia, paralysis or pulselessness).

This has led to the proposal of the 3 “A”s for early identification of compartment syndrome in children: increasing anxiety, agitation and analgesia requirement.

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Category: Pediatrics

Title: Laceration Repair

Keywords: laceration, suture, absorbable (PubMed Search)

Posted: 8/17/2013 by Jenny Guyther, MD (Updated: 12/6/2023)
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A facial laceration on a child can present a unique challenge which is not limited to the initial visit.  The traditional teaching has been to use nonabsorbable sutures and have the patient return in 5 days for removal.  A recent study compared the cosmetic outcome of linear facial lacerations 1 to 5 cm that were closed with either Ethicon fast absorbing surgical gut or monocryl nonabsorbable sutures.  Patients were randomized and returned to the ED in 4-7 days and 3-4 months. Scars were assessed by caregivers and blinded physicians.  Results showed that caregivers preferred absorbable sutures.  Visual analog scores as given by caregivers were not statistically different between the 2 groups at the 3 month mark.  The blinded physicians did give better cosmetic outcome scores to the absorbable suture group which differs from previous studies that had shown equivocal results.  Of note, all absorbable sutures were no longer visible after 14 days.

Bottom line:  Try absorbable sutures the next time you are suturing a child and the parents may be happier and you will not have to try and take out your sutures from a squirming, screaming child.

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Lactate is commonly used in the adult ED when evaluating septic patients, but there is a lack of literature validating its use in the pediatric ED.  Pediatric studies have suggested that in the ICU population, elevated lactate is a predictor of mortality and may be the earliest marker of death.
A retrospective chart review over a 1 year period showed that one elevated serum lactate correlated with increased pulse, respiratory rate, white blood cell count and platelets.  Serum lactate had a negative correlation with BUN, serum bicarbinate and age.  Elevated lactate levels were higher for admitted patients. However, the mean serum lacate level was not statistically different between those diagnosed with sepsis and those that were not.
The study included 289 patients less then 18 years who had both blood cultures and lactate drawn.  This community hospital had a sepsis protocol in place that automatically ordered a lactate with blood cultures.  Only previously healthy children were included.
The study is limited by its small sample size and overall low lactate levels.  Despite having a protocol in place, only 39% of patients who had blood cultures drawn had lactate levels available for analysis.  The mean serum lacate in this study was 2.04 mM indicating that the study population may not have been sick enough to determine mortality implications.  There were no serial measurements.

Bottom line:  Consider measuring serum lacate in your pediatric patient with suspected sepsis.  Pediatric ICU literature does suggest that an serum lactate as low as 3mM is associated with an increased mortality in the ICU.

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Infant lumbar puncture is often difficut and may require repeated attempts.  The traditional body positioning is lateral decubitus.  Previous studies have examined the saftey of having the patient in a sitting position, and neonatal studies have suggested that the subarachnoid space increases in size as the patient is moved to the seated position.  A study by Lo et al published last month looked to see if the same held true in infants.
50 healthy infants less then 4 months old had the subarachnoid space measured by ultrasound between L3-L4 in 3 positions: lateral decubitus, 45 degree tilt and sitting upright.
This study found that the size of the subarachnoid space did not differ significantly between the 3 positions.  Authors postulated that a reason for increase sitting LP success rate that had been reported in anestesia literature with tilt position could be due to other factors such as increased CSF pressure, intraspinous space widening or improved landmark identification.

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Category: Pediatrics

Title: Varicella-related stroke

Keywords: stroke, children, infection (PubMed Search)

Posted: 5/3/2013 by Jenny Guyther, MD (Updated: 12/6/2023)
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Acute ischemic stroke occurs in 3.3/100,000 children per year.  Up to 30% of these are caused by varicella.  This can be diagnosed if the patient has had varicella infection within the past 12 months, has a unilateral stenosis of a great vessel, and has a positive PCR or IgG from the CSF.

Treatment includes anticoagulation, acyclovir for at least 7 days and steroids for 3-5 days.

Outcome is normally good and spontaneous improvement can be seen.

Inflammation of other arteries, including other areas of the brain, can also be seen.  Treatment options for this can include high dose glucocorticoids and possibly immunosuppresive agents.

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Category: Pediatrics

Title: Conjunctivitis

Keywords: Conjunctivitis (PubMed Search)

Posted: 4/5/2013 by Jenny Guyther, MD
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Children frequently present with "pink eye" to the ED.  When they do, parents often expect antibiotics.  How many of these kids actually need them?  Previous studies have shown approximately 54% of acute conjunctivitis was bacterial, but antibiotics were prescribed in 80-95% of cases.

A prospective study in a suburban children's hospital published in 2007, showed that 87% of the cases during the study period were bacterial.  The most common type of bacteria was nontypeable H. influenza followed by S. pneumoniae.

Topical antibiotic treatment has been shown to improve remission rates by 6-10 days.

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Trampoline injuries doubled between 1991 and 1996, increasing from 39,000 injuries per year to more then 83,000 injuries per year.  Injury rates and trampoline sales peaked in 2004 and have been decreasing since; however, hospitalization rates are still between 3% and 14%.

Risk Factors:

¾ of injuries occur when multiple people are on the trampoline at once

Smaller participants were 14x more likely to be injured then their heavier playmates

Falls account for 27-39% of all injuries

Springs and frames account for 20% of injuries

Up to ½ of injuries occur despite adult supervision

Injury types:

Lower extremity injuries are more common than upper extremity

Head and neck injuries accounted for 10-17% of trampoline injuries

Unique Injuries:

Proximal tibial fractures

Manubriosternal dislocations and sternal injuries

Vertebral artery dissection

Atlanto-axial subluxation

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Conventional pediatric nasal cannula can safely deliver up to 4 lpm but are limited by cooling and drying of the airway. This leads to decreased airway patency, nasal mucosal injury, bleeding and possibly increase in coagulase negative staph infections.

HFNC delivers flow up to 40 lpm with 95-100% relative humidity at a controlled temperature. In infants, the initial flow rate is set between 2-4 lpm and can be increased to 8 lpm. Older children and can be started at 10 lpm and increased as high as 40 lpm. Oxygen is also adjustable.

Studies have shown improved comfort, respiratory rate and oxygenation compared to nasal CPAP.

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Category: Pediatrics

Title: Vaccines in children less then 1 year

Keywords: Vaccines (PubMed Search)

Posted: 10/5/2012 by Jenny Guyther, MD (Updated: 12/6/2023)
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We often ask our pediatric patients if there vaccines are up to date, but what does this mean?

Hepatitis B: birth, 2 and 6 months

Diphtheria/Tetanus and Acellular Pertussis: 2, 4 and 6 months

Pneumococcal vaccine: 2, 4 and 6 months

Haemophilus influenzae B : 2, 4 and 6 months

Polio: 2, 4 and 6 months

Rotavirus: 2 and 4 months or 2, 4 and 6 months depending on the brand. 

Influenza: 6 months and older

Children less than 8 years old should receive 2 doses of flu vaccine at least 4 weeks apart during the first flu season that they are immunized.  Children older than 2 years are eligible for the nasal vaccine if they do not have asthma, wheezing in the past 12 months or other medical conditions that predispose them to flu complications.

To see the full vaccine schedule including exact time frames between doses and catch up schedules, see:

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Category: Pediatrics

Title: Apnea and bronchiolitis

Keywords: hospitalization, RSV, bronchiolitis (PubMed Search)

Posted: 12/17/2021 by Jenny Guyther, MD (Emailed: 12/6/2023) (Updated: 12/6/2023)
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Typical admission considerations for patients with bronchiolitis are work of breathing, hypoxia, and dehydration.  The patients risk of apnea should also be considered.  Younger infants with bronchiolitis are at a risk for apnea.  Studies have cited anywhere from a 16-25% risk in younger infants.  The problem lies in identifying those patients who are at risk and those who are not.  This older study looked at 691 infants and developed criteria which identified all of the 2.7% of patients who developed apnea.
The high risk criteria used in this study were: 1) Full term and younger than 1 month; 2) Born < 37 weeks gestation and younger than 48 weeks post conception or 3) Parents already noted an episode of apnea with this illness.
Bottom line: Incorporate the infants risk of apnea into your disposition decision for patients with bronchiolitis.

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