Acute bronchiolitis (AB) is a common cause of respiratory tract infections in infants. A recent study looked at the application of Point-of-Care Lung Ultrasound (LUS) in infants <12 months who presented with symptoms of AB.
They scored infant lungs using a cumulative 12-zone system. With the below scale:
0 - A lines with <3 B lines per lung segment.
1 - ≥3 B lines per lung segment, but not consolidated.
2 - consolidated B lines, but no subpleural consolidation.
3 - subpleural consolidation with any findings scoring 1 or 2.
They found that infants with higher LUS scores had increased rates of hospitalization and length of stay.
Here are some tips for ultrasounding a pediatric patient:
Term? Tone? Tantrum?
Immediately after delivery, your initial neonatal assessment should evaluate for:
- Appearance of full or late pre-term gestation (>34 weeks)
- Appropriate tone (flexed extremities, not floppy)
- Good cry and respiratory effort
Newborns meeting this criteria should not require resuscitation. They can be placed skin to skin on mother and allowed to breastfeed. Delayed cord clamping for 60 seconds is recommended, as data shows improved neurodevelopmental outcomes and iron stores in first year of life.
Neonates not meeting these criteria should be brought to the warmer for resuscitation, with the focus being on:
- Warm - via radiant warmer. Maintain temps 36.5 C – 37.5 C
- Dry - Neonates have thin skin and lose heat readily from evaporative loses
- Stim - tactile stimulation on the head, midline of the back and extremities to provoke a cry and encourage respiratory effort
Avoid routinely bulb-suctioning unless there is significant obstructing mucous, as this can increase vagal tone and result in bradycardia. If bulb suctioning is used, first suction the mouth before the nose.
Majority of resuscitations do not require additional support, however if heart rate is <100 or there is poor respiratory effort, the physician should initiate PPV.
PPV settings: PIP 20 PEEP 5 FiO2 21% Rate of 60 breaths per minute
Improvement in the neonate’s HR is the primary indicator of effective PPV!
If HR poorly responding (remains <100), ensure appropriate mask size, reposition, suction, and increase PIP (max 35) and FiO2.
If HR drops below 60, intubate with uncuffed ETT
- Prioritize adequate ventilation as this is the highest priority in neonatal resuscitation
- Initiate compressions at rate of 120/min.
- Epi dosing is 0.01-0.03 mg/kg q3-5 min
- ETT size estimation by gestational age:
25 weeks = 2.5, 30 weeks = 3.0, 35 weeks = 3.5, 40 weeks = 4.0
- Magnets move through the GI tract at different rates and become lodged in adjacent loops of intestine. Adjacent bowel segments can stick together when the magnets attract each other through the bowel walls which can cause obstruction, perforation, fistula formation, and necrotic bowel.
- Obtain xray to identify ingested metallic object(s)
- Any object lodged in the esophagus should be emergently removed by a pediatric gastroenterologist.
- Once an object is past the stomach and beyond the reach of endoscopy, affected patients need to be watched carefully for signs of obstruction or peritonitis, either occurrence requiring the prompt consultation of a pediatric surgeon.
- Enhancement of magnet movement through the GI tract may be aided by a laxative such as polyethylene glycol, but there is no clear data that this approach speeds the passage of the magnet. There is no clear guidance on how frequently to obtain abdominal radiographs to determine movement or passage of ingested magnets.
- More frequently lodge in esophagus due to seize and cause electric urn on contact
- Complications include perforation or fistula formation
- Honey or liquid ulcer medication carafate can slow extent of esophageal injury
- Current recommendations from National Button Battery Hotline: caregiver to give 2 teaspoons of honey every 10 minutes while en route to hospital
- Causes caustic contact to vocal cords, which leads to acute laryngospasm
- Airway compromise, if to occur, occurs rapidly. If after brief obs period, it does not appear, it is very unlikely to be a late occurance.
- Corrosive on GI tract. pH of detergents range from 7-9.
- Any child with difficulty swallowing, drooling, stridor, and recurrent vomiting should have GI consulted for endoscopy
Tiki Torch Oil
- Tiki torch oil looks like apple juice (the container looks similar too)
- Lamp oil ingestion (hydrocarbons) can cause excessive drowsiness, lung injury, difficulty breathing
- Preventing accidental tiki torch oil ingestion: NEVER use torch fuels near area where food or drinks are served, keep out of reach and out of sight of young children, and only buy bottle of torch fuels with child-resistant cap and make sure to replace cap securely after every single use
Hydrogen Peroxide
- 35% hydrogen peroxide has become more popular as food-grade or nutraceutical product (food additive purportedly used for medicinal purposes)
- When hydrogen peroxide reacts with HCl in the stomach, it liberates large volumes of oxygen causing immediate frothy emesis and systemic absorption of oxygen. Gastric oxygen, once absorbed, passes through the portal vein to liver causing gas embolisms in liver
- Preferred evaluation of kids with known ingestion and acute vomiting should image by noncontrast limited upper abdominal CT (to reduce radiation exposure) to assess bubble burden.
- There is no consensus on what is considered a significant air embolism burden that would require hyperbaric treatment
- A single tablet of buprenorphine, or a single dissolvable gel strip of its formulation as Suboxone has been lethal to children.
- Prescribing intranasal naloxone spray to the family of patients on buprenorphine (and methadone as well) is potentially lifesaving to the patient, should they take too much, but also for children in their homes who may accidentally eat a single tablet or chew on what appears to be a “gummy” product, a dissolvable formulation of Suboxone.
- Pediatricians doing anticipatory safety guidance to parents at the 9-month-old to 1-year-old health supervision visit should ask about opiates and medication-assisted therapy present in the home or used by caregivers (especially grandparents) and should offer to write a prescription for naloxone nasal spray
Kids eat everything (except perhaps carefully prepared and balanced meals). While button battery ingestions are feared, there is more to worry about. Magnet ingestions – especially rare earth metal magnet ingestions – can lead to high morbidity and mortality.
When more than one magnet (or a magnet and another metallic object) are ingested, they can become stuck together through walls in the GI tract, creating risk for obstruction, erosion, fistula formation, and perforation. Sharp metallic foreign objects can be particularly dangerous as they can do much damage while being moved around by the magnet.
If there is concern for magnet ingestion, care should be taken to try to determine the number ingested (if parents have the magnets, you can compare the size of an object on xray to the size of the magnets as it can otherwise sometimes be difficult to differentiate if it is one magnet or more than one stuck together).
Higher risk features of ingestion include:
Ingestions should prompt consultation with pediatric GI and surgery when isolated as many will require either endoscopic or surgical removal. This may include need for referral and transfer.
The literature is not completely new regarding the use of intranasal dexmedetomidine for pediatric sedation, with several articles confirming noninferiority to benzodiazepines. It is a potent a2- adrenergic receptor agonist, which allows for sedation without analgesic properties. It can be considered for patients who are undergoing PAINLESS procedures. A recent article gave further clarification for dosing considerations when selecting this option. This study assessed varying weight-based doses and found the best effect with doses of 3 to 4 mcg/kg
Importantly, there is limited data that suggests this may result in longer discharge, duration of procedure and total time in the department compared to other sedation methods. Additionally, this option is not always readily available and approved for pediatric patients in every hospital.
Overall, Dexmedetomidine may be an excellent option for painless procedures, such as CT imaging or even MRI based on the literature, when available.
It's back to school season which means back to school injuries!
Scalp lacerations often require suturing or staple closure, but what if you can close the wound without any sharps that scare the kiddos? Consider using the Hair Apposition Technique (HAT)!
What is HAT?
- A very quick and easy technique for superficial scalp laceration closure made by twisting hair on each side of the laceration and sealing the twist with a small dot of glue for primary closure.
When do I consider HAT?
- For linear, superficial lacerations that are <10cm in length
- Laceration has achieved adequate hemostasis
- Patient has hair on both sides of the laceration
What are contraindications to HAT?
- Hair strands are less than 3cm in length
- Laceration is longer than 10cm in length
- Active bleeding from laceration despite hair apposition
- Significant wound tension
- Laceration is highly contaminated
How do I perform HAT?
- Debride wound as you normally wound for any laceration
- Take approximately 5 strands of hair on one side of the laceration and twist them together to make one twisted bundle
- Take approximately 5 strands of hair directly on the other side of the laceration and twist them together to make another twisted bundle
- Then take each bundle and intertwine the two bundles until the wound edges appose.
- Place a drop of glue on the twist
- Repeat along the length of the laceration until laceration is closed
Benefits of HAT:
- Based on a RCT from Singapore that compared suturing to HAT for superficial scalp lacerations that were <10cm, patient's were more satisfied, had less scaring, lower pain scores, shorter procedure tiems, adn less wound breakdown in the HAT group compared to the sutured group.
- A follow up study by the same group also assessed cost-effectievness of HAT compared to suturing (by taking into account staff time, need for staple/suture removal, treatment of complications, materials, etc) and found that HAT saved $28.50 USD when compared to suturing.
Modified hair apposition of scalp wounds- UpToDate
Bottom Line:
- Consider Hair Apposition Technique (HAT) for linear, superficial scalp lacerations, especially in pediatric patients as it is much more well tolerated (can also do this in adults!)
This was a retrospective study involving several hospitals in Italy. 135 patients who had drowned (the term used in the article) were included. 4.5% of patients died. Most drowning occurred in July and August. The most common comorbidity was epilepsy in about 10% of patients. Several patients were also witnessed to have trauma and syncope. Early resuscitation, either by bystanders or trained professionals, was paramount in survival.
Children who are conscious at presentation and have mild or no respiratory distress have the best prognosis. A well appearing child should be observed for 6-8 hours, given that 98% of children will present with symptoms within the first 7 hours. A chest xray is not indicated in the asymptomatic patient. Patients who are submerged greater than 25 minutes or without ROSC after 30 minutes have a poor prognosis.
Bottom line: Never swim alone and everyone should be trained in bystander CPR.
This study attempts to answer the age old question: What is the importance of fever in pediatric illnesses?
The authors' goal was to assess if response to antipyretics was associated with bacteremia. This article retrospectively reviewed 6,319 febrile children in whom blood cultures were sent and found that 3.8% had bacteremia. They then looked at the fever curve in response to antipyretics for these two groups in the emergency department over 4 hours. The study concluded that patients with bacteremia have a higher rate of persistent fever despite antipyretics. It is important to note the limitations of this study. As this was retrospective, it is unclear what clinical findings resulted in blood cultures being sent - most febrile children did not have any drawn (23,999 were excluded for this reason). They did not assess other vital signs, and did not address other bacterial infections (UTI, cellulitis, meningitis, otitis media, etc). Additionally, while patients with bacteremia did have a higher likelihood of fever, the majority of patients in both groups had fever resolution within 4 hours, and both groups had some children with persistent fevers.
Overall, this does seem to support the decision to consider obtaining further testing in those children with a persistent fever, but also emphasizes the importance of not using fever resolution alone as support for discharge to home or exclusion of bacteremia from the differential.
Some things are easy, even reflexive, and one of those things is putting oxygen on cyanotic patients. Usually, this is a great thing. Blue = bad. Occasionally, though, blue = baseline and even in those patients who are too blue, you want to keep them closer to purple than pink.
This issue is commonly encountered in certain types of congenital heart disease and as well as through various phases of their repair. These include ductal dependent lesions, those with significant shunts, and single ventricle physiology. Oxygen functions as a pulmonary vasodilator and can increase or change the direction of shunting, directly impacting physiology by causing pulmonary overcirculation, increased strain on the right ventricle, and decreases in systemic circulation.
Helpful Hints:
1) Find out and shoot for the patient’s goal oxygen saturation range (many lesions will be 75%-85%). This may be available from parents, in the EMR, or by calling the child’s cardiac center if they are an established patient.
2) In an undiagnosed neonate with hypoxia and signs of heart failure (crackles, enlarged liver, edema to the sacrum and/or occiput) or if unresponsive to initial trial of oxygen, decrease FiO2 and titrate support (nasal cannula with blender to set FiO2, HFNC, NIPPV, or intubation if necessary) to address respiratory distress as well as evaluation and treatment for ductal dependent lesions.
3) You may still need to use additional FiO2 to obtain reasonable oxygen saturations, but titrate thoughtfully.
Neonatal rashes are common and, usually, benign. There are some skin findings, however, that require early recognition and treatment for best outcomes. One of these concerning etiologies is omphalitis, infection of the umbilical stump and surrounding tissues.
Features of omphalitis may include erythema and induration around the umbilicus, purulent drainage, and potentially systemic illness.
Risk factors include poor cord hygiene, premature or prolonged rupture of membranes, maternal infection, low birth weight, umbilical catheterization, and home birth.
Evaluation includes surface cultures from the site of infection as well as age-appropriate fever workup if patient is febrile. Consider ultrasound to evaluate for urachal anomalies as these can co-exist.
Management is IV antibiotics to cover S. aureus and gram negatives with surgical consultation if there are signs of necrotizing fasciitis or abscess. Some newer literature suggests that patients with omphalitis seen and treated in high-income countries may not be as sick as previously thought (as most data has been obtained in lower income countries where incidence is higher) and there has been a suggestion that there may be a role for oral antibiotics in well appearing, lower risk infants. This deserves further exploration but cannot yet be considered standard of care.
Other umbilical cord findings to consider (when it isn’t omphalitis): patent urachus, granuloma, local irritation, or partial cord separation
Background: Intranasal dexmedetomidine has seen usage in the anesthesia and sedation realms over the past few years, with an increasing interest in usage in the ED setting given its generally favorable safety profile and ease of administration. There has been specific interest and consideration in children with autism and neurodevelopmental disorders.
Study: Single center prospective provider study (compared to a retrospective group of patients under 18 who received oral midazolam for indications of agitation or anxiety via chart review) looking at patients 6 months to 18 years of age with an order for intranasal dexmedetomidine. Following use, a provider survey was completed to evaluate indication/rationale for use, satisfaction, comfort with use, and perceived time to onset as well as duration of effect.
Results: 29% of patients receiving IN dexmedetomidine experienced treatment failure compared with 20.7% of patients receiving oral midazolam (not statistically significant). In subgroup analysis, rates of treatment failure were lower for patients diagnosed with autism spectrum disorder receiving IN dexmedetomidine versus oral versed (21.2% versus 66.7%). Length of stay was longer in the IN dexmedetomidine group (6.0 hours versus 4.4 hours). Indication for use had variability between the two groups.
Bottom Line: IN dexmedetomidine may be a reasonable agent to utilize for anxiolysis in pediatric patients, especially those who have previously had paradoxical reactions or poor efficacy of benzodiazepines. It may be specifically useful when effects are desired for a slightly longer time and for non-painful/minimally painful interventions.
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