UMEM Educational Pearls - Pediatrics

Category: Pediatrics

Title: Removal of Auricular Foreign Body

Keywords: foreign body, ear, insect, button battery (PubMed Search)

Posted: 1/7/2022 by Natasha Smith, MD (Updated: 1/16/2022)
Click here to contact Natasha Smith, MD

Many types of foreign bodies may be found in a child's ear. Some examples include: beads, cotton swabs, food, insects, and button batteries. 

Patients can be asymptomatic. However, they often have otalgia, pruritus, fullness, tinnitus, hearing loss, otorrhea, or bleeding. Obtain a history of the type of foreign body, when/how it entered the ear, and if there was a prior attempt at removal. Also ask if there are foreign bodies elsewhere, such as in the nose. Perform Rinne and Weber tests before and after removing the foreign body if the child is old enough to participate. 

Delayed presentation can result in edema and otitis externa. When the foreign body is sharp, there may be damage to the tympanic membrane (TM) and ossicles. 

Consult ENT when there is suspicion of damage to TM, when hearing loss is present, or when removal is especially challenging. Spherical foreign bodies are more difficult to remove. 

Remove foreign body if it can be visualized. Wax curettes, right-angled hooks, alligator forceps, and Frazier tip suctions can facilitate removal. Avoid additional trauma due to concern for edema, bleeding, TM perforation, or distal displacement of the object. Anxiety in the child will lead to increased difficulty with removal. 

A button battery in the ear is an emergency that can result in severe damage, including TM perforation, scarring or stenosis of the ear canal, and deeper injury. Seeds such as beans or peas and other absorptive material in the ear can expand, so do not irrigate when such foreign bodies are present. Living insects should be killed with alcohol, lidocaine, or mineral oil prior to performing foreign body removal. 

After removal, reassess ear canal and TM. Some foreign bodies require removal in the operating room. If the object has been successfully removed, evaluate for otitis externa or iatrogenic injury to the ear canal, and prescribe antibiotic otic drops when needed. When TM has perforated, refer for formal audiogram. ENT follow up is recommended for all patients.  

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  • Pediatric acute gastroenteritis has always been a major cause of ED visits and hospitalizations.
  • Pediatric complaints of vomiting and diarrhea have been on the rise, whether it be secondary to the new Omicron-variant of COVID-19, or norovirus and rotavirus which traditionally account for nearly 60% of all cases.
  • Zofran (Ondansteron) 4mg for children 4-11yo weighing greater than 40kg, and up to 8mg for those older.
  • Zofran prescription at discharge was associated with reduced rate of return at 72-hours and was not associated with masking alternative diagnosis like appendicitis and intussusception.
  • Oral rehydration therapy (ORT) consisting of a low osmolarity solution containing sugar and salts along with zinc has also been shown to optimize treatment and diminish return visits. ORT is available in commercial packets, pre-mixed solutions, or can be made at home with table salt and sugar.
  • Bottom Line: Consider providing a prescription of Zofran along with recommendations for oral rehydration therapy consisting of a low osmolarity solution containing sugar and salts to prevent outpatient treatment failure and return visits.

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Category: Pediatrics

Title: Sever Disease - What a Heel

Keywords: peds ortho, calcaneus, stress injury (PubMed Search)

Posted: 12/3/2021 by Rachel Wiltjer, DO
Click here to contact Rachel Wiltjer, DO

Sever Disease

  • Calcaneal apophysitis – inflammation of the growth plate of the calcaneus
  • One of the most common causes of heel pain in adolescents, caused by repetitive stress (overuse injury)
  • Most common in those who are involved in sports, especially those with lots of running and jumping
  • Symptoms are heel pain and tenderness at/underneath the heel, with possible mild swelling
  • Pain is reproduced by squeezing the posterior calcaneus and standing on tip toes
  • Does not require imaging for typical presentation
  • Treat with reduction of activity (specifically avoid painful activities), NSAIDs, and stretching exercises

 

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Category: Pediatrics

Title: The dangers of monkey bars

Keywords: orthopedics, upper extremity fractures, playgrounds (PubMed Search)

Posted: 11/19/2021 by Jenny Guyther, MD
Click here to contact Jenny Guyther, MD

While playgrounds can be enjoyable for children, they are a land mine for possible injuries.  In a study looking at playground safety in Australia, monkey bars were the leading cause of upper extremity fractures.  The fractures caused by monkey bars were also more likely to require reduction or operative fixation.  The risk of fracture significantly increases after a fall above 1.5 meters.  Children ages 5-9 years were the most susceptible to playground falls.
Why does this matter?  Playgrounds have made modifications to prevent other types of injury (such as the modification of the playground surface to prevent head injuries).  Reduction in the height of monkey bars, may reduce or limit the severity of these upper extremity fractures.  

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Incidence of T1DM is 1.93/1000 of youth <20 years old in the United States, with a bimodal distribution of onset. Onset peaks from ages 4-6 and again at puberty. 

 

Prior to the development of DKA, diabetes often has an insidious onset with symptoms of polydipsia, polyphagia and polyuria with weight loss in children. It can also be asymptomatic. 

 

When DKA is present, symptoms will include neurological manifestations (confusion, lethargy), GI symptoms (abdominal pain, nausea, vomiting), or respiratory abnormalities (Kussmaul respirations.) Polyuria and polydipsia are frequently present as well.

 

Diagnosis of DKA includes: serum glucose of >200 mg/dL, serum or urine ketones, and a pH <7.30 or bicarbonate <15 mEq/L. 

 

DKA is classified as mild, moderate or severe:

Mild: pH 7.21-7.30, HCO3 11-15 mEq/L

Moderate: pH 7.11-7.20, HCO3 6-10 mEq/L 

Severe: pH < 7.10, HCO3 <5 mEq/L

 

Initial treatment is 10 ml/kg of isotonic fluid bolus to a max of 500 ml, then reassess. Continue to replace fluids gradually to cover maintenance fluids as well as to treat dehydration. Do NOT bolus insulin. Rather, start a drip at 0.05-0.1 units/kg/hr. Continue insulin until acidosis has completely resolved. Once the serum glucose falls below 250 mg/dL, start dextrose to prevent hypoglycemia until the gap closes. 

 

Cerebral edema can develop 4-12 hours after treatment has been initiated. Observe for change in mental status, posturing, decreased response to pain, cranial nerve palsy, bradycardia, or abnormal respiratory pattern. This is a clinical diagnosis! Although a head CT can be obtained, it is often negative and treatment with mannitol or hypertonic saline should be started as soon as there are clinical changes.

 

DKA has resolved when pH > 7.3 and HCO3 is >15.

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This was a retrospective, noninferiority analysis looking at patients 14 years old and younger treated for nontraumatic seizures by EMS with a midazolam dose of 0.1 mg/kg (regardless of route).  There were just over 2000 patients with a median age of 6 years included in the study.  Midazolam redosing occurred in 25% of patients who received intranasal midazolam versus only 14% who received midazolam via intramuscular, intravenous, or intraosseous routes.
Bottom line: In the prehospital setting, intranasal midazolam at a dose of 0.1 mg/kg was associated with an increased need to redose compared to other routes.  This dose may be subtherapeutic for intranasal administration.

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Category: Pediatrics

Title: AAP Guidelines on the Febrile Infant 2021

Keywords: febrile infant, neonatal fever (PubMed Search)

Posted: 10/1/2021 by Rachel Wiltjer, DO
Click here to contact Rachel Wiltjer, DO

What they are: Clinical practice guidelines put together by an AAP subcommittee over a span of several years based on changing bacteriology and incidence of illness, advances in testing, and evidence that has accumulated

Includes: Healthy infants 8 to 60 days of life with an episode of temperature greater than or equal to 38.0 C who at now at home after being born at home or after discharge from the newborn nursery, born between 37 and 42 weeks, without focal infection on exam (cellulitis, vesicles, etc)

Recommendations:

For the well appearing 8-21 day old:

  • Obtain UA (and culture if + UA), blood culture, CSF (including enterovirus PCR if pleocytosis in CSF or seasonal periods), inflammatory markers are optional
  • Start empiric antimicrobials regardless of results of UA/CSF or any inflammatory markers
  • Infant should be admitted

For well appearing 22- 28 day olds:

  • Obtain UA (and culture if +UA), blood culture, and inflammatory markers
    • procalcitonin preferred over CRP if available, ANC is helpful but less so than others
    • several studies used in making these guidelines used more than 1 inflammatory marker
      • Temp >38.5 is considered an inflammatory marker
  • If any inflammatory marker is abnormal:
    • Obtain CSF and start empiric antibiotics
      • CSF is optional if no inflammatory markers are abnormal (provider judgment/risk assessment)
    • If CSF is not obtained, infant should be hospitalized for observation
  • Discharge home is acceptable if all of the following are true: UA is normal, CSF is normal or enterovirus +, no obtained inflammatory marker is abnormal (or if abnormal they have subsequently had normal CSF testing), return precautions are discussed and follow up is assured within 24 hours for clinical re-examination
    • Infants being discharged home should receive empiric parental antibiotics prior to discharge
  • If the infant is hospitalized antibiotics should be started if: CSF with pleocytosis or uninterpretable or if UA is +
    • If workup is normal, antibiotics optional
    • If CSF not obtained, may start antibiotics but not required
  • Shared decision making with parents is recommended for decisions regarding LP and disposition in this group

For well appearing 29-60 day olds:

  • Obtain UA ( and culture if +UA), blood culture, and inflammatory markers
  • If inflammatory markers are normal LP does not need to be performed, antibiotics do not need to be administered (unless UTI present), and patient can be monitored closely at home with follow up in 24-36 hours
  • If positive UA in this group with normal inflammatory markers, obtain cath urine culture and start oral antibiotics
  • Consider obtaining CSF if abnormal inflammatory markers
  • If CSF obtained and normal antibiotics are optional, may be observed in hospital or closely at home
  • If CSF is not obtained or is uninterpretable with abnormal inflammatory markers, administer parenteral antibiotics
    • May be observed in hospital or closely at home

Notable changes:

  • UTIs have been differentiated from bacteremia and bacterial meningitis, the guideline discourages the use of the historic “serious bacterial illness”
  • A 2 step process where decision for catheretized urine culture is based on UA is suggested, UA to be obtained by bag or stimulated void

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Category: Pediatrics

Title: Amusement park safety

Keywords: roller coasters, summer, death (PubMed Search)

Posted: 9/17/2021 by Jenny Guyther, MD
Click here to contact Jenny Guyther, MD

Over a one year study period, 182 accident events at amusement parks were reported in the news from 38 countries.  51 events involved a fatality. Mechanical rides and roller coasters were involved in 87 events. 
The risk of injury associated with spending a day at an amusement park is very low, but not non-existent.
The high g forces of certain thrill rides (ie roller coasters) can predispose to injury in some children and adolescents with preexisting medical conditions.
Among the conditions that are considered contraindications to exposure to high g force or other thrill rides are Marfan syndrome, Down syndrome, hypermobility-related disorders, coagulation disorders, and many cardiac disorders, particularly ones with rhythm abnormalities.

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Category: Pediatrics

Title: Sickle Cell Disease and Fever

Keywords: sickle cell, HgSS, fever, sepsis (PubMed Search)

Posted: 9/3/2021 by Natasha Smith, MD
Click here to contact Natasha Smith, MD

  • Watch out for Streptococcus pneumoniae sepsis! Patients can look well for several hours, then suddenly decline, leading to shock or death.
  • Note that nearly half of patients with HgSS will have diminished spleen function by 1 year of age
  • Start antibiotics early, even if patients are immunized or are taking prophylactic penicillin
  • Antibiotic recommendations: long-acting cephalosporin +/- Vancomycin 
  • Order CBC, reticulocyte count, blood culture, CXR, and other testing as needed based on presentation
  • Admit patients with high fever, toxic appearance, infiltrate on CXR, hypoxia, tachypnea not explained by fever, poor intake/dehydration, severely abnormal CBC, history of S. pneumoniae sepsis, pain crisis + fever

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Category: Pediatrics

Title: Pediatric heat related car deaths

Keywords: hyperthermia, pediatrics, car (PubMed Search)

Posted: 8/20/2021 by Jenny Guyther, MD (Updated: 1/16/2022)
Click here to contact Jenny Guyther, MD

- A higher metabolic rate, reduced capacity for sweating, greater thermolability, and a larger body surface-to-volume ratio make infants and young children more susceptible to hyperthermia.

- Temperatures can rise rapidly within enclosed vehicles, reaching maximum temperatures within 5 minutes. In an open area with an ambient temp of 98 F (36.8 C), interior temperatures reach 124-152 F (51 to 67 C) within 15 minutes of closing the car doors.

- Texas leads the country in the numbers of pediatric heatstroke fatalities due to unattended children left in cars, followed by Florida and California.

- Most heatstroke victims (78.2%) were unknowingly left in vehicles by their caregivers.

- Most organizations interested in child safety issues recommend placing a phone, briefcase, or handbag in the back seat when traveling with a child as one way to prevent heatstroke fatalities.

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  • Generally a seasonal illness that circulates in fall/winter (Maryland’s season is October-April)
  • Following low incidence since April 2020, there is current ongoing circulation outside of the normal seasonal patterns
  • Updated regional trends are available via the National Respiratory and Enteric Virus Surveillance System (https://www.cdc.gov/surveillance/nrevss/rsv/index.html)
  • Causes upper respiratory illness characterized by copious nasal secretions which may cause increased work of breathing and necessitate hospitalization
  • Severity tends to peak at around day 5 of illness
  • In infants younger than 6 months, may also present with poor feeding, lethargy, or apnea
  • Risk of apnea is highest in premature infants (post conception age <48 weeks) and infants under 1 month of age
  • Routine administration of albuterol has not been shown to have benefit, the most recent AAP guidelines have a recommendation against trial of albuterol (common practices continue to be variable). It should be noted that children with severe disease were excluded from the studies used to make this recommendation.
  • Hypertonic saline administration has not shown to be helpful in the ED setting, but may decrease length of stay in patients being admitted
  • Consider admission for persistent tachypnea, hypoxia, inability to adequately feed, moderate to severe increased work of breathing at rest, or apnea

 

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  • Testicular torsion is a straightforward diagnosis ultimately based on lack of blood flow to the affected painful, swollen testicle.
  • Testicular torsion is the most common cause of acute unilateral testicular pain in peripubertal boys due to rapid increase in testicle size during puberty.
  • Infarction begins as soon as after 2 hours of ischemia.
  • There is nearly a 100% salvage rate if blood flow is re-established within 6 hours.
  • Intermittent testicular torsion is challenging to diagnosis due to spontaneous resolution of symptoms and return of normal blood flow during ultrasound.
  • Beware complaints of repeated episodes of acute unilateral testicular pain and swelling.
  • Up to 50% of boys with testicular torsion reported at least one prior similar episode of acute pain and swelling. 
  • Ultrasound findings of a whirlpool sign (spiral-like pattern of spermatic cord), boggy spermatic cord, and a psuedomass of the distal spermatic cord are concerning even in the setting of normal blood flow.
  • Bottom Line: Peripubertal boys presenting with complaints of acute unilateral testicular pain and swelling should always be referred for urgent follow up even if their symptoms have resolved and when ultrasound may show normal blood flow as intermittent testicular torsion can not be ruled out.

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Category: Pediatrics

Title: Does atropine prevent bradycardia during rapid sequence intubation in pediatric patients?

Keywords: Bradycardia, intubation, RSI, atropine (PubMed Search)

Posted: 7/16/2021 by Jenny Guyther, MD (Updated: 1/16/2022)
Click here to contact Jenny Guyther, MD

Atropine has historically been used in the pediatric population as a premedication for rapid sequence intubation (RSI) in order to prevent bradycardia.   Recent research indicates that bradycardia that occurs during intubation may be driven by hypoxia as opposed to a vagal response. In 2002, the American Heart Association guidelines recommended pretreatment with atropine for all children younger than 1 year, children receiving succinylcholine, adolescents receiving a second dose of succinylcholine and anyone with bradycardia at the time of induction. The 2015 AHA Pediatric Advanced Life Support guidelines revised the statement on atropine to say that "it may be reasonable for practitioners to use atropine as a premedication in specific emergency intubations when there is higher risk of bradycardia." 
This study retrospectively looked at 62 patients who underwent rapid sequence intubation.  3 patients experienced a bradycardic event during intubation, 1 of which received atropine.  15 patients received atropine for pretreatment. The incidence of bradycardia was similar between those received atropine and those who did not.
Bottom line: Although atropine is generally considered safe, larger studies are needed to determine if there are any specific indications for atropine as a premedication in RSI or if atropine is needed at all for the prevention of bradycardia.

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Category: Pediatrics

Title: Treatment of fingernail avulsion injuries

Keywords: finger injuries, nail bed (PubMed Search)

Posted: 6/18/2021 by Jenny Guyther, MD (Updated: 1/16/2022)
Click here to contact Jenny Guyther, MD

Traditional management (referred to as "operative management") of a nail avulsion is to replace the nail in the epicanthal fold and suture this in place.  A study was done to see if wound cleaning and placement of a non-adhesive dressing was non inferior to this traditional management.  The primary outcome was the appearance of the new nail at 6 months as determined by 2 separate physicians using a Nail Appearance Score (NAS) and who were blinded to the treatment groups.  The secondary outcomes were patient and parental satisfaction and infection rate.  There were no statistically significant differences in the NAS or patient and parental satisfaction scores between the 2 groups.
Parents were informed of both options and allowed to choose between the treatments.  Patients between 1-16 years with proximal or complete nail bed avulsion injuries were included.
Conclusions: In this small study, non-operative management for fingernail avulsions was not inferior to operative management.

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Category: Pediatrics

Title: Sodium bicarbonate in pediatric cardiac arrests

Keywords: pediatric, cardiac arrest, metabolic acidosis, sodium bicarbonate (PubMed Search)

Posted: 5/21/2021 by Jenny Guyther, MD (Updated: 1/16/2022)
Click here to contact Jenny Guyther, MD

During cardiac arrest, metabolic acidosis develops because of hypoxia-induced anaerobic metabolism and decreased acid excretion caused by inadequate renal perfusion.  Sodium bicarbonate (SB) administration was considered as a buffer therapy to correct metabolic acidosis.  However,  SB has several side effects such as hypernatremia, metabolic alkalosis, hypocalcemia, hypercapnia, impairment of tissue oxygenation, intracellular acidosis, hyperosmolarity, and increased lactate production.  The 2010 Pediatric Advanced Life Support (PALS) guideline stated that routine administration of SB was not recommended for cardiac arrest except in special resuscitation situations, such as hyperkalemia or certain toxidromes.  An evidence update was conducted in the 2020 Pediatric Life Support (PLS) guideline and the recommendations of 2010 remain valid.  This article was a systematic review and meta-analysis of observational studies of pediatric in hospital cardiac arrests.  The primary outcome was the rate of survival to hospital discharge after in hospital cardiac arrests. The secondary outcomes were the 24-hour survival rate and neurological outcomes.   

 
Bottom line: The result of this study supports current PLS guidelines that “routine administration of SB  is not recommended in pediatric cardiac arrest in the absence of hyperkalemia or sodium channel blocker (eg. tricyclic antidepressant) toxicity”.

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  • Electronic cigarette (E-cigs) smoking (vaping) continues to be a major concern among adolescents and teens, who mistakenly think it is safer than smoking traditional cigarettes or don't consider it as smoking at all.
  • Typically, they contain nicotine which is highly addictive and can cause harm in the developing brain, but can also contain other dangerous chemicals, flavorings and drugs.
  • They often contain higher amounts and concentrations of nicotine. 1 JUUL pod can contain the equivalent of 20 packs of nicotine cigarettes.
  • Inhaled aerosols of the various chemicals, flavorings, and heavy metals have resulted in lung disease and acute respiratory failure. Bilateral infiltrates on chest imaging is a common finding.
  • Nicotine toxicity can also occur. Symptoms include vomiting, diarrhea, abdominal pain, salivation, headache, dizziness, confusion, and seizures. Hypertension and tachycardia acutely, followed by hypotension and bradycardia can be expected.
  • Bottom Line: Ask specifically about electronic cigarette use in adolescents and teens who present with acute complaints. One study found that of those who regularly used and presented for evaluation of symptoms, 98% were respiratory, 81% were gastrointestinal, and 100% were constitutional in nature.

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Category: Pediatrics

Title: Pediatric stroke

Keywords: stroke, altered mental status, TPA (PubMed Search)

Posted: 4/16/2021 by Jenny Guyther, MD (Updated: 1/16/2022)
Click here to contact Jenny Guyther, MD

Stroke diagnosis is often delayed in pediatric patients due to delay in seeking care, misdiagnosis and lack of stroke being included in the initial differential diagnosis. 
Perinatal strokes (occurring between 20 weeks gestation and 28 days of life) are more common than strokes in ages 29 days to 18 years.  The incidence of perinatal stroke is 37/100,000 births and 2.3/100,000 children after 29 days.  Infants age 29 days to < 1 year had the highest rate of stroke outside of perinatal strokes, followed by 15-19 year olds.
The most common risk factors for pediatric strokes include: arteriopathies (such as arterial dissection, moyamoya and vasculitis), cardiac disorders (single ventricle physiology have the highest risk) and infections.  Sickle cell disease and cerebral venous thrombosis are other risk factors for acute ischemic stroke.
Children younger than 6 years were more likely to present with altered mental status or seizures.  Other presentations included facial weakness, speech disturbances, hemiparesis, headache, nausea and vomiting.
There is a pediatric NIH stroke scale that can be used in children at least 2 years old that accounts for developmental differences.
Differential Diagnosis includes (most to least common): migraines, seizures, Bell's palsy, conversion disorder and syncope. Once study found that up to 63% of patients that were suspected of having a stroke, but did not, had another significant disease process that required further evaluation. These other processes included vascular anomalies, seizures, inflammatory disease, metabolic anomalies and drug ingestions.
MRI brain and MRA of the head and neck are gold standard for diagnosis.  If this is not obtainable or would be delayed, then head CT followed by CTA of the head and neck should be obtained.
The treatment of acute ischemic stroke is still not fully researched and much is adopted from adult protocols.   TPA and endovascular thrombectomy are not well established.  There has been a small study of patients treated with TPA, but a subsequent NIH funded trial could not recruit enough patients.  Adult dosing guidelines for TPA have been adopted if TPA is going to be used and should be given within 4.5 hours of symptom onset.  Endovascular therapy should be considered only in patients with persistent, disabling neurological defects and a confirmed large vessel occlusion.  Patient selection is limited by the side of the catheter used.  Patients with confirmed ischemic stroke who do not receive TPA or endovascular therapy should receive antiplatelet therapy.
Cerebral venous thrombosis is treated with anticoagulation.  Hemorrhagic strokes in children are treated similar to adults.
Exchange transfusion is the mainstay of treatment for sickle cell patients with a goal to decrease HbS to < 30%.

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Category: Pediatrics

Title: When should troponin be ordered in a pediatric patient?

Keywords: Chest pain, ischemia, pediatrics, myocarditis (PubMed Search)

Posted: 3/19/2021 by Jenny Guyther, MD (Updated: 1/16/2022)
Click here to contact Jenny Guyther, MD

Even though acute myocardial ischemia (AMI) does not present as commonly in the pediatric patient as in the adult and the literature is limited, it is reasonable to obtain a troponin when acute cardiac ischemia is suspected based on the history and physical exam. 

Recreational drugs including cocaine, amphetamine, cannabis, Spice, and K2 (cannabis derivatives) have been shown to result in myocardial injury including AMI. Coronary vasospasm secondary to drug use is well documented in the pediatric population. While cocaine use is a known risk factor for coronary vasospasm, the same condition has been reported in pediatric patients after marijuana use.

In a study of pediatric patients with blunt chest trauma, 3 of 4 patients with electrocardiographic or echocardiographic evidence of cardiac injury had elevations in troponin I above 2.0 ng/mL. Cardiac troponins are an accurate tool for screening for cardiac contusion after blunt chest trauma in pediatric patients even with limited data.

Cardiac troponins are also useful in the evaluation for myocarditis. In one study, myocarditis was the most common diagnosis (27%) in pediatric ED patients presenting with chest pain and an increased troponin. Eisenberg et al showed a 100% sensitivity and an 85% specificity for myocarditis using a troponin of 0.01 ng/mL or greater as a cut off.  A normal troponin using this cutoff can be used to exclude myocarditis. Abnormal troponin in the first 72 hours of hospitalization in pediatric patients with viral myocarditis is associated with subsequent need for extracorporeal membrane oxygenation and IVIg.

Bottom line: Troponin can be used in pediatric patients with clinical concern for cardiac ischemia, cardiac contusion and myocarditis

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Category: Pediatrics

Title: Is there utility in measuring BNP in pediatric patients in the emergency room?

Keywords: Congestive heart failure, trouble breathing, basic natriuretic peptide (PubMed Search)

Posted: 2/19/2021 by Jenny Guyther, MD (Updated: 1/16/2022)
Click here to contact Jenny Guyther, MD

In children with known congenital heart disease, BNP measurements are higher in those patients with heart failure compared to those without heart failure.

The utility of BNP in differentiating a cardiac from pulmonary pathology in patients with respiratory distress has been studied in pediatrics. In one study involving 49 infants with respiratory distress, the patients with a final diagnosis of heart failure had a higher mean BNP concentration than those patients with other causes.  Also, there is a suggestion that the relative change in NT proBNP levels may be useful in patients with underlying pulmonary hypertension.  However, currently there is not enough literature to support the routine use of BNP or NT proBNP in acute management.

Bottom line: BNP can be useful in your patient with congenital heart disease who is decompensating and may be used in a patient where there is difficulty in differentiating a primary respiratory from cardiac etiology.

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Category: Pediatrics

Title: Lactate use in pediatric sepsis

Keywords: Infection, sepsis, lactic acid (PubMed Search)

Posted: 1/15/2021 by Jenny Guyther, MD (Updated: 1/16/2022)
Click here to contact Jenny Guyther, MD

Despite a lack of formal guidelines and evidence, lactate measurement has become a component of many pediatric emergency sepsis quality programs, with one survey showing that up to 68% of responding pediatric emergency medicine providers routinely measured it.

The Surviving Sepsis Campaign, last updated in February 2020, could not make a recommendation on the use of lactate in pediatric patients with suspected shock. The authors did state that lactate levels are often measured during the evaluation of septic shock if the lab can be obtained rapidly. However, lactate levels alone would not be an appropriate screening test.

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