Keywords: Pediatrics, Venipuncture, J-Tip, Jet-Injected, Local anesthesia, Topical anesthesia (PubMed Search)
Many providers may not be familiar with the "J-Tip" (National Medical Products Inc, Irvine, CA) which is a needle-free jet injection system that uses air to push buffered lidocaine into the skin. In theory, it provides quick local anesthesia without a needle, making it an ideal tool to reduce the pain of pediatric venipuncture. Maybe you will consider giving it a try?...but what is the data for it?
Keywords: inflatable, trauma, bounce house (PubMed Search)
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).
Keywords: air enema, intussusception (PubMed Search)
Mehul V, Ravel PC, Minneci K et al. Improving Quality and Efficiency for Intussusception Management After Successful Enema Reduction. Pediatrics. 2015; 136 (5); e1345-e1352.
Keywords: glenohumoral dislocations, anterior shoulder, orthopedics, pediatrics (PubMed Search)
- Anterior shoulder dislocations often require surgical management in young adults due to recurrence, but are less common in pediatric patients, particularly under age 10
- A study this year showed that 14-16 year olds are similar to 17-20 year olds in recurrence risk (around 38%- when non-operative management), and this is especially true of males.
- The recurrence rate is lower in the 10-13 age group, but there are also less dislocations in this group as well, making this group harder to assess
- Remember to consider both chronologic and bone age if you are deciding to refer a patient for outpatient surgery follow up, bone age is more accurate to determine healing and response to non-operative treatment
- Consider early referral for surgical management and counseling regarding recurrence risk in the 14-16 year age group after anterior shoulder dislocations
Leroux T, et al. The epidemiology of primary anterior shoulder dislocations in patients aged 10-16. Amer J of Sports Med. 2014; 42(2): 442-50.
Keywords: UTI, Fever, febrile, AAP, clinical practice guideline (PubMed Search)
Fever is the most common presenting symptoms to pediatric emergency departments 10-20%
Singh S., Sandelich S., Current Status of the Diagnosis and Treatment of Pediatric Urinary Tract Infections. Pediatric Emergency Medicine Reports 2014;19(2):13-22.
Roberts KB, Subcommittee on Urinary Tract Infection, Steering Committee on Quality Improvement and Management. Urinary tract infection: clinical practice guideline for the diagnosis and management of the initial UTI in febrile infactns and children 2 to 24 months. Pediatrics. 2011 Sept; 128(3):595-610.
Keywords: Blunt abdominal trauma, seat belt sign, pediatrics (PubMed Search)
Our suspicion of significant abdominal injury increases when there is bruising across the abdomen in adults after a motor vehicle collision, but what about in children? A PECRAN analysis may have provided us with the answer.
Of 3740 pediatric patients after motor vehicle collision, 16% had a seat belt sign. Seat belt sign was defined as a continuous area of erythema, ecchymosis or abrasion across the abdomen due to the seat belt. 1864 children had CT scans of the abdomen. Intra-abdominal injuries (IAI) were more common in those children with seat belt sign than those without (19% versus 12%). Those with seat belt sign had a greater risk of hallow viscous or mesenteric injuries. There was no increased risk of solid organ injury. 33% of patients with seat belt sign did not have complaints of abdominal pain or tenderness on initial exam (with a GCS of 14 or 15); 2% of these patients underwent operative intervention for their injuries.
Borgialli et al. Association Between the Seat Belt Sign and Intra-abdominal Injuries in Children With Blunt Torso Trauma in Motor Vehicle Collisions. Academic Emergency Medicine, 2014; 21: 1240 1248.
Keywords: pediatric, code, resuscitation, medication error (PubMed Search)
A group from Colorado identified the high-stress of pediatric resuscitation as a high-risk setting for possible medication error. As such, they performed a prospective, block-randomized, crossover study with two mixed teams of docs (ABEM certified) and nurses, managing 2 simulated peds arrest scenarios using either:
1) conventional “draw-up and push” drug administration methods [control] or
2) prefilled medication syringes labeled with color-coded volumes correlating to the weight-based Broselow Tape dosing [intervention].
The objective was to compare the time of preparation and administration of a medication, as well as to assess dosing errors. Participants were blinded to the purpose during recruitment but unblinded just prior to running the scenarios.
The scenarios included advanced airway management and hemodynamic life support efforts to care for an 8-year-old or 8-month-old manikin. The intervention group received a standard 3-minute tutorial on the use of prefilled color-coded syringes just prior to their scenario. After completing the first scenario, the groups switched, utilizing the other sim with the other method of medication administration. After a 4-16 week “wash out” period, the groups reconvened to reverse the medication administration technique across the same 2 scenarios.
Each Broselow tape color zone corresponds to a narrow range of weights. The authors opted to designate medication dosing errors >10% above or below the correct range as critical dosing errors.
The results? Median time to delivery of all conventionally administered medication doses was 47 seconds versus the prefilled color-coded administration system-- 19 seconds. The conventional administration system saw 17% of doses with critical errors versus none for the prefilled color-coded syringe group.
These prefilled color-coded syringes are not currently manufactured. Should they go into commercial production, the hope is that such syringes would be longer and more narrow than conventional syringes to effectively elongate each color-coded section (the delineations for red and purple on a standard syringe differ by as little as 1/8-3/32 of an inch if you want to make your own!-- see picture).
Color-Coded Prefilled Medication Syringes Decrease Time to Delivery and Dosing Error in Simulated Emergency Department Pediatric Resuscitations. Moreira, Maria E. et al. Annals of Emergency Medicine, Volume 66 , Issue 2 , 97 - 106.e3.
Keywords: wrist, fracture, trauma (PubMed Search)
Is there a set of criteria similar to the Ottawa Ankle or Knee Rule that can be applied to the wrist in children?
The Amsterdam Pediatric Wrist Rules are as follows:
-Swelling of distal radius
-Painful palpation of the distal radius
-Painful palpation at the anatomical snuff box
A positive answer to any of these would indicate the need for an xray.
The study referenced attempted to validate these criteria. This criteria is inclusive of the distal radius in addition to the wrist. The sensitivity and specificity were 95.9% and 37.3%, respectively in children 3 years through 18 years. This model would have resulted in a 22% absolute reduction in xrays. In a validation study, 7/170 fractures (4.1%, 95% CI: 1.7- 8.3%) would have been missed using the decision model. The fractures that were missed were all in boys ages 10-15 and were all buckle fractures and one non displaced radial fracture.
Bottom line: This rule can serve as a guide for when to obtain an xray in the setting of trauma, but it is not perfect.
Slaar et al. A clinical decision rule for the use of plain radiography in children after acute wrist injury: development and external validation of the Amsterdam Pediatric Wrist Rules. Pediatr Radiol 2015; published online August 23, 2015.
Keywords: UA, clean catch (PubMed Search)
Making the wee patient pee – a non invasive urinary collection technique in the newborn
Obtaining a urinary sample in a neonate can be challenging and time consuming. The most commonly used non-invasive technique is urine collection using a sterile bag. This technique is limited by patient discomfort and contamination of the urinary sample. Catheterisation and needle aspiration are other options, but are more invasive.
A prospective feasibility and safety study enrolled 90 admitted infants aged under 30 days who needed a urine sample into the study . They performed the following stimulation technique.
1. Feed the baby through breast-feeding or an appropriate amount of formula for their age and weight.
2. Wait twenty-five minutes. After twenty-five minutes clean the infant’s genitals thoroughly with warm water and soap. Dry with sterile gauze.
3. Have an assistant hold a sterile urine container near the infant
4. Hold the baby under their armpits with their legs dangling (if short handed, parents can do this)
5. Gently tap the suprapubic area at a frequency of 100 taps or blows per minute for 30 seconds
6. Massage the lumbar paravertebral zone lightly for 30 seconds
7. Repeat both techniques until micturition starts. Collect midstream urine in the sterile container
In the study, success was defined as obtaining a midstream urinary sample within 5 minutes after initiation of the stimulation procedure. There was a 86% success rate (n=69/80). Mean time to sample collection was 57 seconds. There were no complications, but controlled crying occurred in 100% of infants. The study was limited by the lack of a control group. Previous studies have described longer collection times with traditional non invasive techniques, up to over an hour .
Consider the above mentioned stimulation technique to obtain a urinary sample in the neonate.
1. Herreros Fernández ML, González Merino N, Tagarro García A, et al. A new technique for fast and safe collection of urine in newborns. Arch Dis Child. 2013 Jan;98(1):27-9. http://www.ncbi.nlm.nih.gov/pubmed/23172785
2. Davies P, Greenwood R, Benger J. Randomised trial of a vibrating bladder stimulator--the time to pee study. Arch Dis Child. 2008 May;93(5):423-4. http://www.ncbi.nlm.nih.gov/pubmed/18192318
Keywords: VBG, DKA, acidosis, hyperglycemia (PubMed Search)
The answer may be no, as long as you have a serum HCO3. In this retrospective study, linear regression was used to to assess serum HCO3 as a predictor of venous pH. Logistic regression was also used to evaluate serum HCO3 as a predictor of DKA. Using a HCO3 cutoff of <18 mmol/L had a sensitivity of 91.8% and specificity of 91.7% for detecting a pH <7.3. A HCO3 < 8 had a sensitivity of 95.2 % and specificity of 96.7 % for detecting a pH <7.1.
Von Oettingen J, Wolfsdorf J, Feldman, H and E Rhodes. Use of Serum Bicarbonate to Substitute for Venous pH in New-Onset Diabetes. Pediatrics 2015; 136: e371-e378.
Keywords: pediatrics, ultrasound, pneumonia (PubMed Search)
A recent meta-analysis published in Pediatrics reviews the diagnostic accuracy of lung ultrasound for pneumonia. According to the commentary, pneumonia is the leading cause of illness and death in children worldwide; it accounts for 18% of the total number of deaths in children <5 years, more than TB, AIDS, and malaria combined.
They performed a systematic search on several major databases using a combination of controlled keywords for age <18 years, pneumonia, and ultrasound. Of the initially 1475 identified studies, 8 were ultimately chosen for further evaluation.
Characterizing the meta-analysis:
- Three were conducted in the ED, 2 on the wards, 1 in the PICU and 2 in the NICU.
- Of the 765 children encompassed, the mean age was 5 years and they were 52% boys.
- Five of the 8 studies noted using highly skilled sonographers.
- The studies originated from Italy (5), US (1), China (1) and Egypt (1).
- All studies used CXR +/- clinical criteria as the diagnostic standard; LUS assessment was blinded to associated CXR results in 7 of 8 studies.
- LUS in the diagnosis of pediatric pneumonia had an overall pooled sensitivity of 96% (95% confidence interval [CI]: 94-97%) and specificity of 93% (95% CI: 90-96%).
- Positive and negative likelihood ratios were 15.3 (95% CI: 6.6-35.3) and 0.06 (95% CI: .03-0.11), respectively. For reference, remember that an LR >1 indicates an increased probability that the target disorder is present and >10 is a large or often conclusive increase in the likelihood of disease. Likewise, an LR <1 indicates a decreased probability that the target disorder is present and <0.1 is large or often conclusive decrease in the likelihood of disease.
- The area under the receiver operating characteristic (ROC) curve was 0.98. The ROC curve represents a measure of the accuracy of a test, >0.9 is considered to be excellent.
- In order to determine whether there are genuine differences underlying the results of the studies (heterogeneity) the I-squared statistic was implemented, with values consistent >0.45, demonstrating significant heterogeneity.
Bottom line: LUS appears to be an accurate test for the diagnosis of pneumonia in children. The limitation of this meta-analysis is mainly in the small number of studies and the significant heterogeneity between them, likely due at least in part to the fact that they used CXR +/- clinical data as the diagnostic standard. Nevertheless, the results provide evidence for the use of LUS as a cost-effective tool that potentially eliminates ionizing-radiation from the work-up of pediatric pneumonia and has application potential in resource-limited settings.
Pereda, Maria. "Lung Ultrasound for the Diagnosis of Pneumonia in Children: A Meta-analysis." Pediatrics 135.4 (2015): 714-22. Pediatrics. American Academy of Pediatrics. Web. 7 Aug. 2015.
Post- streptococcal glomerulonephritis (PSGN) is an inflammatory reaction of the kidneys following infection with group A strep, and can occur sub clinically or have a severe presentation requiring admission, Nephrology consult, and careful management.
This diagnosis should be considered in any child between ages 2-12, or adults over 60, presenting with sudden unexplained hematuria or brown urine. Patients may also present with generalized edema secondary to urinary protein loss, hypertension, and acute kidney injury. Since kidney involvement usually trails the throat injection by 2-3 weeks or more, the patient and their family may not relate the two symptoms. A previous or current diagnosis of strep throat is not necessary to consider a patient for PSGN, since they may test negative by throat culture at the time of urinary and renal symptoms
When considering this diagnosis, the EM physician should order the following lab tests:
- Urinalysis (for casts and protein)
- ASO Titer (or full streptozyme assay of 5 tests including ASO)
- Complement C3, C4, C50
Treatment is primarily supportive, and many cases will be mild enough to discharge home with pediatrician or Nephrology follow up. However, some cases may warrant admission for AKI, pulmonary edema, or cerebral edema. Edema can be managed with sodium restriction and loop diuretics. Hypertension can be managed with anti hypertension medications.
Renal biopsy can confirm the diagnosis with the presence of epithelial crescents in the glomeruli, but this is only necessary in severe cases where it is important to determine the etiology of the nephritis.
Eison TM, et al. Post-streptococcal acute glomerulonephritis in children: clinical features and pathogenesis. Pediatr Nephrol 2011; 26:165-180.
Keywords: Alvarado score, ultrasound (PubMed Search)
Keywords: migraine, sodium valproate, headache (PubMed Search)
Sodium valproate (VPA) had been studied and found to be effective in the adult population for migraines, but not in the pediatric population. This article was a small (12 patient) retrospective study of pediatric migraine patients looking at pain scores before and after VPA administration. Prior to VPA, patients received NSAIDs, dopamine antagonists, IV fluids and narcotics. Mean pain reduction prior to VPA was 17%. After VPA, pain scores were reduced by an additional 36%.
Sheridan, D, Sun, B, O’Brien, BS, and Hansen, M. Intravenous Sodium Valproate for Acute Pediatric Headache. The Journal of Emergency Medicine. Article in Press. Accepted February 2015.
Therapeutic Hypothermia after Out-of-Hospital Cardiac Arrest in Children. Mosler FW, et al. N Eng J Med 2015; 372:1898-1908. May 2015
1) Fox, S. (2012, http://pedemmorsels.com/post-
2) Isaacson G. Tonsillectomy Care for the Pediatrician. Pediatrics. 2012; 130(2): pp. 324-334.
3) Perterson J, Losek JD. Post-tonsillectomy hemorrhage and pediatric emergency care. Clin. Pediatr. Jun 2004; 43(5): pp. 445-448.
Keywords: head lice (PubMed Search)
Lice are spread through direct contact as they crawl. Indirect contact (through brushes or hats) is less likely. One study showed that live lice were found in only 4% of infested volunteers pillowcases.
During an initial infestation, lice can reside on the head for up to 4 to 6 weeks before becoming symptomatic. Therefore, when lice are detected at school, there is no need to send the child home (or to the ED). Children also do not need to be kept out of school while receiving treatment.
Bonus: First line treatment is 1% Permethrin applied on day 0 and 9. The patient should wash their hair first with a non conditioned shampoo, apply Permethrin for 10 minutes and then rinse.
Devore CD and Schutze G. Head Lice. Pediatrics. 2015; 135 (5) e1355 -e1365.
Keywords: Traumatic lumbar punctures, fever, infants (PubMed Search)
Approximately ¼ of lumbar punctures (LP) are traumatic or unsuccessful in infants. What is the implication of this?
A retrospective cross sectional study over a 10 year period at Boston Children’s Hospital looked at infants aged 28 to 60 days who had blood cultures sent from the Emergency Department and who had LPs performed. The ED clinicians at this facility routinely follow the “Boston Criteria” to identify infants at low risk for spontaneous bacterial infection (SBI). Traumatic LPs were defined as CSF red cell count greater than or equal to 10x10^9 cells/L while an unsuccessful LP was defined as one where no CSF was available for cell counts. A small portion of the unsuccessful LPs did not have CSF cultures sent.
173 infants had traumatic or unsuccessful LPs. The SBI rate did not differ between the normal LP and the traumatic and unsuccessful LP infants. Median hospital charges were higher in the traumatic or unsuccessful LPs compared to the normal LP group ($ 5117 US dollars versus $ 2083 US dollars).
Bottom Line: Traumatic or unsuccessful LPs lead to higher hospital charges.
Pingree EW, Kimia, AA and Nigrovic LE. The Effect of Traumatic Lumbar Puncture on Hospitalization Rate for Febrile Infants 28 to 60 Days of Age. Academic Emergency Medicine 2015; 22: 240-243.
Keywords: diabetic ketoacidosis, DKA (PubMed Search)
ISPAD (International Society for Pediatric and Adolescent Diabetes) Updated their Guidelines for Pediatric Diabetic Ketoacidosis (DKA) in 2014
· Begin fluid repletion with 10-20ml/kg of 0.9% NS over 1-2 hours
· Estimate losses (mild DKA <5%, moderate 5-7%, severe ~10%) and replete evenly over 48 hours
o Use NS, Ringers or Plasmalyte for 4-6 hours
o Afterwards use any crystalloid, tonicity at least 0.45% NaCl
· Add 5% glucose to IV fluid when glucose falls below 250-300mg/dL
· No bolus
· Low dose 0.05 - 0.1U/kg/hr AFTER initiating fluid therapy
o higher incidence of cerebral edema in patients given insulin in 1st hour
· Short acting subQ insulin lispro or aspart can be substituted for drip in uncomplicated mild DKA
· Give long acting subQ insulin at least 2 hours before stopping infusion to prevent rebound
· If K low (< 3.3): add 40mmol/L with bolus IV fluids (20mmol/L if rate > 10ml/kg/hr)
· if K normal (3.3-5): add 40mmol/L when insulin is started
· If K high (> 5): add 40mEq/L after urine output is documented
· No role for bicarbonate in treatment of Pediatric DKA
o No benefit, possibility of harm (paradoxical CNS acidosis)
Wolfsdorf JI, Allgrove J, Craig ME, et al. Diabetic ketoacidosis and hyperglycemic hyperosmolar state. Pediatr Diabetes. 2014;15 Suppl 20:154-79.
Keywords: Upper GI Bleeds (PubMed Search)