Keywords: pediatric trauma, tranexamic acid (PubMed Search)
Bottom line: There is not clear evidence for efficacy, but trends are positive and the documented rates of adverse effects in this population are low. It is reasonable to give, especially in patients requiring massive transfusion or who are critically ill.
Eckert MJ, Wertin TM, Tyner SD, et al. Tranexamic acid administration to pediatric trauma patients in a combat setting: the pediatric trauma and tranexamic acid study (PED-TRAX). J Trauma Acute Care Surg. 2014;77(6):852-858.
Hamele M, Aden JK, Borgman MA. Tranexamic acid in pediatric combat trauma requiring massive transfusions and mortality. J Trauma Acute Care Surg. 2020;89(2S Suppl 2):S242-S245.
Nishijima, DK, VanBuren, JM, Linakis, SW, et al. Traumatic injury clinical trial evaluating tranexamic acid in children (TIC-TOC): A pilot randomized trial. Acad Emerg Med. 2022; 29: 862– 873.
Keywords: trauma informed care, pediatric resuscitation (PubMed Search)
Beaulieu-Jones BR, Bingham S, Rhynhart KK, Croitoru DP, Singleton MN, Rutman MS, Baertschiger RM. Incorporating a Trauma-Informed Care Protocol Into Pediatric Trauma Evaluation: The Pediatric PAUSE Does Not Delay Imaging or Disposition. Pediatr Emerg Care. 2022 Jan 1;38(1):e52-e58. doi: 10.1097/PEC.0000000000002278. PMID: 33181796.
Keywords: pediatric trauma, ultrasound, FAST (PubMed Search)
Bottom line: A positive FAST warrants further workup and may be helpful in the hemodynamically unstable pediatric trauma patient, but a negative FAST does not exclude intraabdominal injury and evidence for performing FAST in hemodynamically stable pediatric patients is limited.
Guyther, J. Advances in Pediatric Abdominal Trauma: What’s New is Assessment and Management. Trauma Reports 2016; 17: 1-15.
Holmes JF, Kelley KM, Wootton-Gorges SL, Utter GH, Abramson LP, Rose JS, Tancredi DJ, Kuppermann N. Effect of Abdominal Ultrasound on Clinical Care, Outcomes, and Resource Use Among Children With Blunt Torso Trauma: A Randomized Clinical Trial. JAMA. 2017 Jun 13;317(22):2290-2296.
Keywords: PNA, pediatrics, duration of treatment (PubMed Search)
Williams DJ, Creech CB, Walter EB, Martin JM, Gerber JS, Newland JG, Howard L, Hofto ME, Staat MA, Oler RE, Tuyishimire B, Conrad TM, Lee MS, Ghazaryan V, Pettigrew MM, Fowler VG Jr, Chambers HF, Zaoutis TE, Evans S, Huskins WC; The DMID 14-0079 Study Team. Short- vs Standard-Course Outpatient Antibiotic Therapy for Community-Acquired Pneumonia in Children: The SCOUT-CAP Randomized Clinical Trial. JAMA Pediatr. 2022 Mar 1;176(3):253-261. doi: 10.1001/jamapediatrics.2021.
Keywords: motrin, narcotics, oxycodone, fracture care (PubMed Search)
Ali et al. An observational cohort study comparing ibuprofen and oxycodone in children with fractures. PLos ONE 16(9): e0257021.
Keywords: autism spectrum disorder, neurodevelopmental disorder (PubMed Search)
Keywords: abdominal trauma, MVC, CT scans, radiation (PubMed Search)
Fornari M and Lawson S. Pediatric Blunt Abdominal Trauma and Point of Care Ultrasound. Pediatric Emergency Care 2021. 37 (12): 624-629.
Keywords: inborn error of metabolism (IEM), organic acidemia (PubMed Search)
Laura L. Guilder, Jonathan B. Kronick; Organic Acidemias. Pediatr Rev March 2022; 43 (3): 123–134.
Keywords: peds, chest xray, pneumonia. (PubMed Search)
Lipsett, Susan C. MD*,†,‡; Hirsch, Alexander W. MD*,†; Monuteaux, Michael C. ScD*,†; Bachur, Richard G. MD*,†,‡; Neuman, Mark I. MD, MPH*,†,‡ Development of the Novel Pneumonia Risk Score to Predict Radiographic Pneumonia in Children, The Pediatric Infectious Disease Journal: January 2022 - Volume 41 - Issue 1 - p 24-30.
Keywords: SCIWORA, trauma, pediatrics, myelopathy (PubMed Search)
Pediatric spines are elastic in nature.
SCIWORA is a syndrome with neurological deficits without osseous abnormality on XR or CT.
Many patients with SCIWORA have myelopathy.
Mechanism of injury: Most commonly caused by hyperextension or flexion. Other possible mechanisms include rotational, lateral bending, or distraction.
Population: More common in younger children. This comprises 1/3 of pediatric trauma cases that have neuro deficits on exam.
Severity depends on degree of ligamentous injury. It can be mild to severe, and cases have the potential to be unstable.
Management: Immobilize cervical spine and consult neurosurgery. Patients often need prolonged spinal immobilization.
If the patient is altered and an adequate neurological exam cannot be obtained, a normal CT or XR of the cervical spinal is not sufficient to rule out spinal cord injury. It is important to continue monitoring neurological status. One possible etiology is spinal cord hemorrhage, and serial exams are essential.
Nagler J, Farrell CA, Auerbach M et al. "Trauma." Atlas of Pediatric Emergency Medicine, edited by Binita S, 3rd edition. McGraw Hill, 2019, 996-997.
Keywords: pediatric trauma, complications (PubMed Search)
Khalil M, Alawwa G, Pinto F, O'Neill PA. Pediatric Mortality at Pediatric versus Adult Trauma Centers. J Emerg Trauma Shock. 2021 Jul-Sep;14(3):128-135. doi: 10.4103/JETS.JETS_11_20. Epub 2021 Sep 30. PMID: 34759630; PMCID: PMC8527062.
Keywords: bell's palsy, pediatric malignancy (PubMed Search)
Acute facial palsy is common in children and while bell’s palsy is significant proportion, there are other more concerning etiologies that make up a number of cases. A retrospective cohort study of pediatric patients with an ED diagnosis of Bell’s palsy was done using the Pediatric Health Information System and showed an incidence of 0.3% (0.03% in control) for new diagnosis of malignancy within the 60 days following the visit at which bell’s palsy was diagnosed. Younger age increased the risk. There was also a subset of patient’s excluded for diagnosis of bell’s palsy as well as malignancy at the index visit.
These numbers are small but may be clinically significant. They likely do not warrant laboratory or imaging workup as a rule but do make a case for detailed history taking and thorough exam. Consider avoiding steroids which are used commonly but lack high quality data and may undermine later efforts at tissue diagnosis of malignancy or even worsen prognosis.
Walsh PS, Gray JM, Ramgopal S, Lipshaw MJ. Risk of malignancy following emergency department Bell's palsy diagnosis in children. Am J Emerg Med. 2021 Dec 29;53:63-67.
Keywords: pediatrics, COVID, vaccination, hospitalization (PubMed Search)
Woodruff RC, Campbell AP, Taylor CA, et al. Risk Factors for Severe COVID-19 in Children. Pediatrics. 2022;149(1):e2021053418.
Keywords: foreign body, ear, insect, button battery (PubMed Search)
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.
Butts, SC, Goldstein NA, Rosenfeld RM et al. Atlas of Pediatric Emergency Medicine: 3rd Edition. Binita Shah. Brooklyn, NY: McGraw Hill, 2019. 437-438. Print.
Benary, Lozano, Higley, Lowe. Pediatrics. Ondansteron Prescription is Associated with Reduced Return Visits to the Pediatric Emergency Department for Children with Gastroenteritis. 76,5. November 2020.
Rivera-Dominguez, Ward. StatPearls. Pediatric Gastroenteritis. April 2021.
Managing Acute Gastroenteritis Among Children. CDC. MMWR.
Keywords: peds ortho, calcaneus, stress injury (PubMed Search)
Smith JM, Varacallo M. Sever Disease. [Updated 2021 Jul 18]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK441928/
Keywords: orthopedics, upper extremity fractures, playgrounds (PubMed Search)
Curnow H and Millar R. Too far to fall: Exploring the relationship between playground equipment and paediatric upper limb fractures. Journal of Pediatrics and Child Health. 2021.
Keywords: T1DM, DKA, pediatrics (PubMed Search)
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.
Naga, O. (2020). Pediatric Board Sudy Guide: A Last Minute Review, 2nd Edition. Springer Nature Switzerland AG.
Dean, T. and Bell L. (2019). Nelson Pediatrics Board Review Certification and Recertification. Elsevier.
Keywords: seizure, status epilepticus, midazolam (PubMed Search)
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.
Keywords: febrile infant, neonatal fever (PubMed Search)
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)
For the well appearing 8-21 day old:
For well appearing 22- 28 day olds:
For well appearing 29-60 day olds:
Pantell, R., Roberts, K., et al. Evaluation and Managment of Well-Appearing Febrile Infants 8 to 60 Days Old. Pediatrics. Aug 2021, 148(2) e2021052228