UMEM Educational Pearls - Pediatrics

This was a retrospective analysis of pediatric cardiac arrests that occurred out of hospital in Japan, where no pediatric termination of resuscitation is allowed.  1007 arrests were included.  Patients that were placed on ECMO were excluded.  This study included both medical and traumatic arrests looking at a primary outcome of 1 month moderate or better neurological disability.  CPR time for both EMS and the hospital prior to ROSC were included.  Bystander CPR was not included in these calculations.  Possible downtime prior to CPR was not taken into consideration.

Overall, less than 1% of pediatric patients exhibited one-month moderate disability or better neurological outcome when total CPR duration is more than 64 minutes.

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Simple Febrile Seizures are a very common cause for presentation to the Emergency Department. 

Up to 5% of children will have one in their lifetime, and a single febrile seizure increases risk of recurrence. 

Definition:

• Age 6 months to 60 months (5 years)
• <15 minutes of seizure activity
• No focal seizure activity
• Fever of >100.4 within 24 hours
• 1 seizure within 24 hours
• Return to baseline with no focal deficits
• No history of seizures without fever (this is provoked

While not part of the formal definition, the following details are critical to obtain on history, and high risk features that should not be missed on initial evaluation:

• Antibiotics use (within 48 hours of the seizure)
• Vaccination status

Evaluation and Management:

Consider a finger stick

Most patients can be discharged to home after a period of observation - most use a 2-4 hour minimum. More recent literature suggests considering a longer observation period in patients who have seizures at lower core body temperatures (<39°C) or those with a history of recurrent simple febrile seizures (2 simple febrile seizures within 24 hours with return to baseline in between)

Obtain a lumbar puncture in all patients with symptoms of meningitis 

Consider a lumbar puncture, lab evaluation, and prolonged observation in patients who are under-vaccinated/unvaccinated/unknown vaccination status between 6 months and 12 months of age, or received antibiotics within the last 48 hours

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This was a retrospective cohort study of the national trauma data bank that included about 64000 pediatric trauma patients in the derivation group and the same amount in the validation group.  The authors empirically created upper and lower cut off values for the shock index based on age.  They compared the shock index based on age cut offs with major trauma as defined by the standardized triage assessment tool criteria.  

The empirically derived age adjusted values had a sensitivity of 43.2% and a specificity of 79.4% for major trauma.  The sensitivity of the pediatric shock index (PSI) in that same group was 33.9% with a specificity of 90.7%. The pediatric-adjusted shock index (SIPA) had a 37.4% sensitivity and 87.8% sensitivity for 4-16 year olds.

Shock index = (Heart Rate / Systolic BP)  

• Shock Index, Pediatric Adjusted (SIPA)
  • 4-6 years = 1.2
  • 6-12 years = 1
  • > 12 years = 0.9
  • Patients with an elevated SIPA had a 3.82 odds of major trauma compared to those with a normal SIPA.

Pediatric Shock Index (PSI)

For children age 1-12 years

SI > 1.55 - (0.5) x (age in years)

Patients with an elevated shock index had a 5.02 greater odds of major trauma in this study.  

This study used age specific cut offs such as:

1 yr to < 3 years = lower limit of 0.73 and an upper limit of 1.40

(see article for a full table).

Patients with a shock index below the lower limit had a 1.55 greater offs of major trauma and patients with a shock index above the upper limit had a 3.97 greater risk of major trauma.  

Bottom line: Shock index alone has a limited role in the identification of major trauma in children.  Of these three methods for calculating/interpreting shock index, PSI seemed to do better.

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PECARN, in 2012, published a decision tool aimed at helping avoid unnecessary abdominal CT scans in children with blunt torso trauma. While a prior retrospective validation was done, the tool had not been prospectively validated and generally has not been in widespread use as a standalone, although the original paper may have helped to influence development of local pediatric trauma protocols. Recent prospective validation may make the tool more applicable for broader usage.  

The tool is useful as a rule out given that when all criteria are negative, the risk of intraabdominal injury requiring intervention is less than 0.1%.  The criteria are: 

• Evidence of abdominal wall trauma or seatbelt sign 
• GCS <14 and blunt abdominal trauma 
• Abdominal tenderness 
• Evidence of thoracic wall trauma 
• Abdominal pain 
• Decreased breath sounds 
• Vomiting

If using the rule, it is important to note that the presence of one or more of the criteria does not indicate that the patient needs a CT. Patients who do not rule out should be evaluated based on local pediatric trauma protocols and/or in collaboration with the local pediatric trauma center, which often will involve a stepwise approach based on historical information, laboratory workup, and physical exam findings.

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This was a retrospective, multicenter cross-sectional study of pediatric sedations over 3 years using the Pediatric Sedation Research Consortium database.

85,599 pediatric sedations were included.  These sedations did include the operating rooms.  

8.7% of sedations required an intervention for airway/breathing/circulation in patients who did NOT have procedural oxygenation while 10.1% of patients in the group that did have procedural oxygenation required an intervention.  The majority of these interventions were minor, ie airway repositioning.  The group that did have procedural oxygenation did have a lower rate of hypoxia compared to the group without procedural oxygenation (2.5% vs 4.5%).

The authors concluded that preemptive procedural oxygenation did NOT decrease the overall need for interventions in the ABCs compared to no procedural oxygenation.

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Infants are typically obligate nasal breathers and the increased mucus production associated with bronchiolitis can impair both breathing and feeding.  AAP bronchiolitis guidelines state that the routine use of deep suctioning may not be beneficial.    

This was an observational study of 121 infants aged 2-23 months with bronchiolitis who received either nasal suction (31), deep suction (68) or a combination (52).  Groups were based on clinician discretion.  Respiratory scores and pulse ox were obtained pre-suction and at 30 and 60 minutes post suction.  

There was no difference between suction type and respiratory score.  However, there was an improvement in respiratory score between the 0-30 and 0-60 time point with any suctioning.  Suction type had no effect on pulse ox, airway adjunct escalation, length of stay or outpatient outcomes.

The study also showed no association between albuterol use and respiratory scores (albuterol is not recommended by the AAP in the management of bronchiolitis).

Bottom line: In this small study, nasal aspiration and deep suction appear to be equal in improving respiratory scores up to 1 hour post suction suggesting that deep suctioning may not be needed.

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Infantile Spasms (now known as Infantile Epileptic Spasms Syndrome- IESS) is a subtle, can't miss diagnosis occurring in children under the age of 2, with 90% presenting before 1 year of age. 

History:

Presentation for these patients can be sporadic, recurrent, flexion or extension of the limbs or head. The patient typically remains alert during an episode, but they can be startled or appear uncomfortable from the sudden movement. 

With smart phone use, parents often have videos of the events that a provider can see as they are often no events in the ED. 

Prognosis is very poor with up to 50% having long-term neuro-cognitive complications or regression. 

Examination:

A complete physical exam should be performed with particular attention to focal neurologic deficits which would require emergent imaging, signs of electrolyte abnormalities (eg. Chvostek's sign in hypocalcemia), and evidence of neurocutenous syndromes (eg. Neurofibromatosis, tuberous sclerosis).

Testing:

Diagnosis is made with EEG showing hypsarrhythmia. This should be done as soon as possible, most often requiring an inpatient admission. 

Lab work can be done to exclude other possible causes of abnormal movements including assessing for electrolyte abnormalities. 

Imaging in the ED is not typically indicated unless there is concern based on exam. MRI is the imaging modality of choice, and is often completed after EEG confirmed diagnosis. 

Treatment:

Management is initiated in conjunction with a pediatric neurologist with most common therapies being corticotropin (ACTH) and vigabatrin.

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This article was a review of randomized control trials using intranasal (IN) fentanyl.  There were 8 studies included that showed IN fentanyl was superior to controlling pain compared to other pain medications at the 15-20 minute mark, but not at the 30 and 60 minute marks.  There were less reports of nausea and vomiting with IN fentanyl, but no difference in dizziness or hallucinations compared to the other medications included in the various trials (ie morphine, ketamine, po narcotics, ect)

The bioavailability of IN fentanyl ranges from 71-89% with effects noted in 2 minutes with maximal concentrations noted at 7 minutes.  The half life is approximately 60 minutes.

Bottom line: Consider IN fentanyl for quick acute pain management in the pediatric patient.

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Neonates are more prone to seizures than children of other ages. Ultimately, a cause of seizures is more likely to be identified in the newborn. Neonatal seizures are subtle and careful attention to repetitive motions of the face, arms or legs should be considered worrisome for seizure. Generalized tonic clonic seizures are rare in this patient population.  

Common Causes:  

Hypoxic ischemic encephalopathy (most common), infection, stroke, non-accidental trauma, intracranial hemorrhage (including from vitamin K deficiency), metabolic disorders, and structural abnormalities.  

Guidelines for Treatment:  

Phenobarbital should be used as first line, unless there is concern for channelopathy based on family history. Some literature does suggest possible benefits of a benzodiazepine in conjunction with phenobarbital for seizure cessation, but care should be given due to high risk for respiratory suppression in neonates.  

For seizures that are unresponsive to first line treatment, consider phenytoin, levetiracetam, midazolam, or lidocaine. 

A trial of pyridoxine can be attempted in patients who are unresponsive to initial measures 

Evaluation:  

Neonatal seizures require a full evaluation, including labs, head imaging (MRI preferred), low threshold for LP post imaging, concern for trauma  

Disposition:  

Neonates presenting with seizures require admission to the hospital for ongoing evaluation and monitoring.

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CHECK-CALL-COMPRESS  is the recommended algorithm by the International Liaison Committee on Resuscitation to teach school age children.  Several studies show that school aged children are highly motivated to learn and perform CPR.  They also serve as CPR multipliers meaning they go home, talk about what they have learned and inspire others to learn.

By age 4, children are able to assess the first step in the chain of survival - CHECK - assessing for responsiveness and breathing.  By age 6, children can dial the emergency number and give the correct information for the location of the call.  By age 10-12 children are able to get correct chest compression depths and ventilation volumes in CPR manikins.  Hands-on training is more beneficial compared to verbal only instruction.

Areas where CPR is taught to school age children as a part of the school curriculum have higher rates of bystander CPR.

Bottom line: CPR should be introduced to elementary school children.

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Hypernatremia in Pediatric patients is less common than other electrolyte abnormalities occurring in <1% of hospitalized patients. The most common cause is water loss, either from poor absorption in the cases of vomiting, diarrhea, malabsorption or insensible losses, or via diabetes insipidus. Congenital disorders may cause decreased thirst receptors resulting in inadequate intake. Finally, excess sodium intake can occur via hypertonic fluids, ingestions or hyperaldosteronism or hypercortisolism. 

Symptoms are often nonspecific- including fatigue, vomiting, hypertonia or hyperreflexia in lower states, but may result in lethargy, mental status changes or seizures as levels approach and exceed 160mmol/L

Treatment is similar to adults - free water deficit should be calculated: 

Total body water (%) x weight (kg) x [(serum Na)/140 - 1]  

Total Body Water (TBW) varies by age:

24-31 weeks- 90%

32-35 weeks - 80%

Term -  12 months - 70%

12 months and up - 60%

IV fluids should be started with a goal of decreasing the sodium level by 0.5 mmol/L/h with close monitoring of sodium levels.

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This study looked at the success rates of femoral vs proximal tibial IOs in the prehospital setting.  Over a 9 year period, there were 163 pediatric patients who received either a tibial or femoral IO.  Femoral IOs were introduced into the EMS protocol in this study area in 2015 as a location option and were the recommended site starting in 2019.  The success rate of femoral IO placement was 89% and for proximal tibial sites was 84.7%.  After further data analysis the study found an adjusted odds ratio of 2 for successful IO placement in the distal femur compared to the proximal tibia.  The complication rates for both sites were similar.  

Bottom line: This study suggests that the distal femur is a reasonable site for IO access in the pediatric population.

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Continuing with the electrolyte derangements in children: Hyponatremia 

Hyponatremia is defined as a Sodium of less than 135 mmol/L and does not depend on patient age.  

This is the most common electrolyte abnormality in pediatric patients. Excessive free water is often the culprit and is usually thought of in the neonate or infant whose guardians are mixing formula incorrectly. * Additional causes include inappropriate ADH (Antidiuretic hormone) secretion, or in the case of dehydrated patients appropriate ADH secretion. Sodium wasting is rare.  

Total body water (TBW) is important to consider, and preterm neonates have higher TBW (80%) than full term (70%) and 1 year old infants (~60%) putting them at higher risk of hyponatremia.  

Recognizing the volume status of the patient aids in determining the etiology of the hyponatremia and allows for appropriate treatment. This may require obtaining urine sodium.  

Treatment: 

Hypertonic saline should be used only for patients with severe neurologic complications including seizures or altered mentation. In these patients, a hypertonic saline bolus should be given at 3-5 ml/kg of 3% NaCl over 10-15 minutes.  

In hypovolemic patients without neurologic symptoms, fluid resuscitation is the mainstay with caution to increase sodium levels by no more than 6-8mmol/L/day. For euvolemic or hypervolemic patients, fluid restriction is advised.  

Prevention: 

Importantly, when children receive IV fluids, the choice should be made to select isotonic fluids (0.9% NaCl) rather than hypotonic fluids (0.45% NaCl) to avoid iatrogenic development of hyponatremia.  

*Reminder: 2 ounces (about 60 ml) of water should be placed in the bottle, and then 1 full scoop of formula, unless directed to have higher caloric content by their doctor- in which case the amount of formula in the mixture should be higher

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Autism Spectrum Disorder (ASD) can often be a diagnosis that complicates usual ED evaluation and management. One of the frequently asked questions is “what medications work well for patients with autism?” It is often said, although with quite variable evidence in the literature, that benzodiazepines should be avoided in patients with ASD due to the risk of paradoxical reaction. 

This study was a meta-analysis that included 20 different studies that looked at efficacy and adverse effect of various medications and medication combinations for procedural sedation for a variety of painful and nonpainful procedures. Although the heterogeneity of the indications, medications, and other details of study design of the studies included precludes a definitive recommendation as to the best medication or regimen, it does suggest overall reasonable efficacy of midazolam both as a single agent as well as in combination with dexmedetomidine, especially when balanced against adverse effects noted with some of the more efficacious regimens. 

Take Home Point: Medication choice for patients with ASD should be individualized to the patient based on prior experiences, parental or patient input, and prescriber experience given proven efficacy of multiple regimens. Benzodiazepines should be considered within the toolkit.

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This was an observational study where ultrasound was used to evaluate if the diaphragm came into view at the 5th intercoastal space (ICS) at the midaxillary line in pediatric patients during maximal respiration. A convenience sample of pediatric patients who presented to the an academic pediatric emergency department was used.

In 10.3% of patients, the diaphragm crossed the 5th ICS during normal respirations and 27.2% crossed during maximal respirations.  This was a more common occurrence on the right compared to the left.  An increase in body mass index was also associated with an increased risk of the diaphragm crossing the during both tidal respiration and maximal respirations.

Bottom line: Using a blind insertion of a chest tube at the 5th ICS, midaxillary line in the pediatric patient poses a not insignificant risk of piercing the diaphragm.  this study recommends using ultrasound prior to chest tube placement.

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Hyperkalemia is less common than hypokalemia in pediatric patients, though it is not uncommon to have hemolysis in patients who receive heel stick lab work. 

The age of the patient is critical to determining the cutoff for hyperkalemia:

• Premature infant 4.0–6.5 mmol/L
• Newborn 3.9–5.9 mmol/L 
• Infant 4.1–5.3 mmol/L 
• Child 3.4–4.7 mmol/L

Typically, levels up 6.0mmol/L are well tolerated in children, unless the shift is rapid. For any child meeting age related hyperkalemia or who have a known lower prior potassium level should receive an ECG. 

Treatment for hyperkalemia is similar to adults 

Calcium Chloride (20mmg/kg - Max 1g) or Calcium Gluconate (0.5ml/kg - Max 20ml) is given for cardiac stability. 

Albuterol can be given based on weight

Insulin and dextrose can be used with extreme caution and close monitoring for hypoglycemia. (Dextrose should be given as D10% in children under 5 years of age, D25% can be used if  > 5 years old)

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Emergency department visits for pediatric mental health and behavioural concerns have been increasing.  This study attempted to further characterize medications, both home and for sedation, that were given to these patients.  

This study included 670,911 youth with a mental or behavioral health diagnosis over a 9 year inclusion period.  The most common diagnses were depressive disorder, suicide or self injury and disruptive, impulse control and conduct disorder.  During this time, a total of 12.3% of patients had a psychotropic medication given while in the ED.  The percentage and odds of administering these medications increased from 7.9% in 2013 to 16.3% in 2022.  Those with intellectual disability and autism spectrum disorder had the highest frequency of medication administration.  

Bottom line: As mental health visits in pediatrics continue to increase along with boarding times, clinicians should become more familiar with psychotropic medications used in this population and become comfortable in making sure that these patients have their home medications and have a plan for chemical sedation if other areas of de escalation fail.

Hypokalemia is a common electrolyte abnormality found in pediatric patients. The cut off for low potassium is based on age, with young infants having higher baseline levels of potassium when compared to older children and adults. The most common cause of hypokalemia in children is GI losses (diarrhea), though other considerations include malnutrition, congenital adrenal hyperplasia, renal abnormalities and medication effects. 

Typically, hypokalemia is well tolerated, and the focus of management is based on treating the underlying cause, rather than repleting the potassium. 

Medications should ONLY be initiated in patients who have potassium levels < 3.0 mmol/L OR with those with levels < 3.5 mmol/L with ECG changes. 

In patients receiving treatment, oral potassium administration is typically recommended unless any of the following criteria are met:

• Potassium level < 2.5 mmol/L
• Inability to tolerate PO
• There are any ECG changes concerning for hypokalemia

In these patients IV potassium should be given (typically KCl at 0.5-1mEq/kg/DOSE - Max of 40 mEq/dose). 

Just like in adults, ALL patients require continuous cardiac monitoring when receiving potassium infusions.

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Teaching has circulated that a temperature of 40 degrees Celsius or above (hyperpyrexia), was associated with a greater incidence of serious bacterial infection.  However, this teaching originated in a time prior to the availability of childhood vaccinations. In fact, the largest retrospective study to support this used data from 1966-1974.  

2565 WELL APPEARING patients between the ages of 61 days and their 18th birthday who presented to a single tertiary care pediatric emergency department with the chief complaint of fever were included.  The prevalence of serious bacterial infection was compared to the presence of hyperpyrexia, age, chronic conditions, gender and vaccination status.

Serious bacterial infections (SBIs) included: deep space infections, appendicitis, pneumonia, mastoiditis, lymphadenitis, acute bacterial rhinosinusitis, urinary tract infection, pyelonephritis, cholecystitis, tubo-ovarian abscess, septic arthritis, osteomyelitis, bacteremia or bacterial meningitis.

There was NO statistically significant association between hyperpyrexia and SBIs. Older age and make sex were associated with a higher risk of SBIs.

Bottom line: In well appearing children 61 days and older, having a temperature >/= to 40 degrees was not associated with serious bacterial infections.

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The supracondylar fracture is one of the most common pediatric fractures. It typically occurs due to a FOOSH injury and is a result of fracture through an area of high growth (and therefore weaker bone structure) in the pediatric distal humerus. Appearance on x-ray depends on the degree of displacement, however in cases without obvious displacement, providers must look for more subtle signs on x-ray. For example, a “sail sign” of the anterior fat pad and appearance of a posterior fat pad indicate a joint effusion and are suggestive of a fracture. However, there are often still equivocal x-rays in children with notable tenderness on exam, and failure to appropriately immobilize these fractures can result in pain and higher risk of injury resulting in displacement. 

In 2021, Varga et al, looked into the ability to assess for supracondylar fractures with ultrasound. This prospective study evaluated 5 locations in the pediatric elbow for signs of fracture. Ultimately, this was able to identify more fractures than x-ray alone, and was a useful tool for equivocal cases. This is not an isolated study, but one of the most comprehensive, looking into ultrasound as a tool for supracondylar fracture identification.

It may be time to grab that ultrasound probe to look for fractures in pediatric patients with pain but an unclear elbow x-ray.

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