Category: Pediatrics
Keywords: CT scans, radiation exposure, pediatrics (PubMed Search)
Posted: 7/21/2017 by Jenny Guyther, MD
(Updated: 7/20/2025)
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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.
Marchese et al. Reduced Radiation in children presenting to the ED with Suspected Ventricular Shunt Complication. Pediatrics. 2017; 139 (5).
Category: Pediatrics
Keywords: Blunt thoracic trauma, pediatric trauma, chest xray (PubMed Search)
Posted: 6/16/2017 by Jenny Guyther, MD
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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.
This was a retrospective review of children aged 0-17 with blunt trauma requiring trauma team activation who had a chest xray preformed. 483 eligible children were included, all of whom were admitted to the hospital. 108 children had their thoracic injury detected on chest xray, 110 on chest CT and 76 on abdominal CT. Pneumothorax, pulmonary contusion and multiple rib fractures were the most commonly found thoracic injuries. All children also had other injuries.
Weerdenburg et al. Predicting Thoracic Injury in Children with Multi-trauma. Pediatric Emergency Care. Epub ahead of print. 2017.
Category: Pediatrics
Keywords: Psychiatric, agitation, pediatric (PubMed Search)
Posted: 5/19/2017 by Jenny Guyther, MD
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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).
This is the first study looking at ziprasidone in the pediatric emergency department population. This was a retrospective observational study of children 5-18 years old who were treated with IM ziprasidone. 40 patients received IM ziprasidone in a tertiary care pediatric emergency department between 2007-2015. 2/3 of the patients had ADHD and 1/3 had autism spectrum disorder. Other diagnosis included post-traumatic stress disorder, bipolar disorder and intellectual disabilities.
68% of patients responded to the initial dose. The initial dose was 0.19 +/- 0.1 mg/kg in the responder group and 0.13 +/- 0.06 mg/kg in the non-responder group. Single doses ranged from 2.5 mg to 20 mg total.
No patients had respiratory depression. Two patients had potential extra-pyramidal symptoms, but one was prior to ziprasidone administration and the other patient had baseline facial twitching with no documentation if there was a change after ziprasidone administration.
Nguyen T, Stanton J and Foster R. Intramuscular Ziprasidone Dosing for Acute Agitation in the Pediatric Emergency Department: An observational Study. Journal of Pharmacy Practice 1-4. 2017.
Category: Pediatrics
Keywords: Bronchiolitis, asthma (PubMed Search)
Posted: 4/21/2017 by Jenny Guyther, MD
(Updated: 7/20/2025)
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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)
This was a retrospective study of 1991 children younger than 2 years that presented between 2000-2010 who were diagnosed with bronchiolitis. Primary care records were reviewed 1 year after their visit to the ED to see if the patient had a primary care diagnosis of asthma.
Of the initial study population, 817 patients had received a diagnosis of asthma at 1 year.
Since these patients were only followed up at 1 year, the amount of children who were later diagnosed with asthma may be underestimated.
Waseem et al. Factors Predicting Asthma in children with Acute Bronchiolitis. Pediatric Emergency Care. March 2017. Epub ahead of print.
Category: Pediatrics
Keywords: Pediatrics, urinary tract infection, urine concentration (PubMed Search)
Posted: 4/14/2017 by Jenny Guyther, MD
(Updated: 7/20/2025)
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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.
This was a retrospective study of 2700 infants < 3 months old who were evaluated for urinary tract infections (UTI). The UTI prevalence in this group was 7.8%. A UTI was defined as at least 50,000 colony forming units/mL from a catheterized specimen. Test characteristics looked at white blood cell and leukocyte esterase cut-offs, dichotomized into specific gravities: dilute (<1.015) and concentrated (>/=1.015).
Category: Pediatrics
Keywords: unicameral bone cyst, fracture (PubMed Search)
Posted: 2/18/2017 by Jenny Guyther, MD
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A 12 year old with arm pain after doing push ups during gym class. What is the diagnosis?
Diagnosis: Pathologic fracture with a unicameral bone cyst
Unicameral bone cysts are benign lesions that mainly affect children and adolescents. On xray the cyst is noted to be a mildly expansile, lytic, thin walled lesion without periosteal reaction. The most common sites are the proximal humerus and femur. These lesions can resolve spontaneously, but there is a risk of pathologic fracture. If fracture is detected, then the fracture site should be treated as any other fracture in the area. These lesions can also be found incidentally in which case they should be referred to orthopedics for outpatient follow up.
Kadhim, M, Thacker M, Kadhim A and Holmes L. Treatment of unicameral bone cyst: systemic review and meta analysis. J Child Orthop. 2014 Mar; 8(2): 171-191.
Mascard E, Gomez-Brouchet A, Lambot K. Bone cysts: Unicameral and aneurysmal bone cyst. Orthop Traumatol Surg Res. 2015 Feb; 101.
Category: Pediatrics
Keywords: Nail bed injuries, wound closure (PubMed Search)
Posted: 1/20/2017 by Jenny Guyther, MD
(Updated: 7/20/2025)
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More studies are needed, but the existing data shows that medical adhesives may be quicker without impacting cosmetic and functional outcome.
Nail bed injuries occur in 15-24% of children with fingertip injuries.
In 1997, medical adhesive was first used to secure the avulsed nail plate back to the nail bed instead of suturing back into place. By 2008, there were small studies looking at the utility of using medical adhesive to close the laceration of the nail bed. The studies were small, but there was a tendency towards shorter repair times and no difference between pain, cosmetic outcome or function.
A total of 6 articles were included in this review – 2 using histoacryl and 4 using demabond.
Edwards, S, Parkinson L. Is Fixing Pediatric Nail Bed Injuries with Medical Adhesives as Effective as Suturing? A Review of the Literature. Pediatric Emergency Care. 2016.
Category: Pediatrics
Keywords: fever, diarrhea, urinary tract infection (PubMed Search)
Posted: 12/16/2016 by Jenny Guyther, MD
(Updated: 7/20/2025)
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After 4 months old, the answer MAY be no.
80 children between 4 months and 6 years of age with fever > 101 degress F and watery stools (> 3 episodes) were evaluated for hydration status using urine samples. The urine was collected either by catheterization or clean catch, depending on age. All urine cultures were negative.
Nibhanipudi KV. A Study to determine the Incidence of Urinary Tract Infections in Infants and Children Ages 4 months to 6 Years with Febrile Diarrhea. Glob Pediatr Health. 2016. Published online Sept 12, 2016.
Category: Pediatrics
Keywords: Ketamine, conscience sedation, pharmacology, pediatrics (PubMed Search)
Posted: 11/18/2016 by Jenny Guyther, MD
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Using 1.5 mg/kg or 2 mg/kg of IV ketamine led to less redosing compared to using 1 mg/kg IV.
This was a prospective, double blinded, randomized controlled trial of children 3-18 years. 125 children were included in the study. They compared 1mg/kg, 1.5 mg/kg and 2 mg/kg doses. All doses were IV. Adequate sedation was achieved with all 3 doses of ketamine, and there was no increased risk of adverse events with the higher doses. However, using 1.5mg/kg or 2 mg/kg required less redosing.
Previous studies suggested a higher risk of adverse events if the initial dose was greater than 2.5 mg/kg or the total dose was more than 5 mg/kg.
Kannikeswaran et al. Optimal dosing of intravenous ketamine for procedural sedation in children in the ED – a randomized control trial. American Journal of Emergency Medicine 24 (2016) 1347-1353.
Category: Pediatrics
Keywords: Fluid resuscitation, gastroenteritis, dehydration (PubMed Search)
Posted: 10/21/2016 by Jenny Guyther, MD
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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.
This was a prospective randomized double blinded study in 8 pediatric emergency departments. Patients were at least 6 months old and younger than 11 years. To be included they had to have at least 3 episodes of vomiting or diarrhea in the previous 12 hours and a Gorelick score of at least 4. 100 children were included. Serum bicarbonate was measured at 0 and 4 hours and dehydration scores were reassessed. There was a change of bicarbonate of 1.6 mEq/L for plasma-lyte A (PLA) and no change for sodium chloride. There as an improvement in the dehydration score at 2 hours for the PLA group, but the dehydration scores were not statistically significant between the 2 groups at the 4 hours mark.
Allen et al. A randomized trial of Plasma-Lyte A and 0.9% sodium chloride in acute pediatric gastroenteritis. BMC Pediatrics 2016 16:117.
Category: Pediatrics
Keywords: Bronchiolitis, ETCO2 (PubMed Search)
Posted: 9/16/2016 by Jenny Guyther, MD
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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.
Jacob R, Bentur L, Brik R, Shavit I and Hakim F. Is capnometry helpful in children with bronchiolitis? Respir Med 2016; 113:37-41.
Category: Pediatrics
Keywords: Trampoline, injury patterns (PubMed Search)
Posted: 8/19/2016 by Jenny Guyther, MD
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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.
Kasmire K, Rogers S and Sturm J. Trampoline Park and Home Trampoline Injuries. Pediatrics 2016: 138 (3).
Category: Pediatrics
Keywords: Intranasal vaccine, immunizations (PubMed Search)
Posted: 7/15/2016 by Jenny Guyther, MD
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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.
Bernstein HH and Kimberlin DW. Intranasal FluMISSED its target. AAP News. July 2016.
Chung J et al. Seasonal Effectiveness of Live Attenuated and Inactivated Influenza Virus. Pediatrics 2016: 137 (2).
Category: Pediatrics
Keywords: hypertension, pediatrics (PubMed Search)
Posted: 6/17/2016 by Jenny Guyther, MD
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Stein DR, Ferguson MA. Evaluation and treatment of hypertensive crisis in children. Integr Blood Press Control 2016; 9:49-58.
Category: Pediatrics
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
Tieder JS, Bonkowsky JL, Etzel RA, et al. Brief Resolved Unexplained Events (Formerly Apparent Life-Threatening Events) and Evaluation of Lower-Risk Infants. Clinical Practice Guideline. Pediatrics. 2016; 137 (5):e20160590.
Category: Pediatrics
Keywords: Intracranial hemorrhage, ultrasound, non accidental trauma (PubMed Search)
Posted: 4/15/2016 by Jenny Guyther, MD
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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.
Elkhunovich M, Sirody J, McCormick T, Goodarzian F and Claudius I. The Utility of Cranial Ultrasound for Detection of Intracranial Hemorrhage in Infants. Ped Emerg Care 2016 [epub ahead of print].
Category: Pediatrics
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.
Gilhotra Y and Porter P. Predicting diabetic ketoacidosis in children by measuring end-tidal CO2 by non-invasive nasal capnography. J Paediatr Child Health 2007; 43 (10): 677-80.
Chebl BR, Madden B, Belsky J, Harmouche E, Yessayan L. Diagnostic value of end tidal capnography in patients with hyperglycemia in the emergency department. BCM Emerg Med 2016: 16 (1).
Category: Pediatrics
Keywords: UTI, fever, infant (PubMed Search)
Posted: 2/19/2016 by Jenny Guyther, MD
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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.
Segal Z et al. Infants under two months of age with urinary tract infections are showing increasing resistance to empirical and oral antibiotics. Acta Paediatrica. Dec 2015. Epub ahead of print.
Category: Pediatrics
Keywords: etomidate, sedation (PubMed Search)
Posted: 1/15/2016 by Jenny Guyther, MD
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ED study of 60 pediatric patients for procedural sedation
Bottom line: Etomidate can achieve effective sedation in children for a short procedure. Although respiratory effects were noted, none of them required assisted ventilation.
Mandt MJ, Roback MG, Bajaj L, Galinkin JL, Gao D, Wathen JE. Etomidate for short pediatric procedures in the emergency department. Pediatr Emerg Care. 2012 Sep;28(9):898-904.
Category: Pediatrics
Keywords: inflatable, trauma, bounce house (PubMed Search)
Posted: 12/17/2015 by Jenny Guyther, MD
(Updated: 12/18/2015)
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Ferro V, D'Alfanso Y, Vanacore N et al. Inflatable bouncer-related injuries to children: increasing phenomenon in pediatric emergency department, 2002-2013. Eur J Pediatr. October 2015 (epub ahead of print).