Keywords: appendicitis, ultrasound, bedside (PubMed Search)
Emergency Physician Bedside Ultrasound for Appendicitis
To reduce length of stay, improve patient care, and reduce radiation exposure in young patients.
Start with pain medication so you get a better study. (Consider intranasal fentanyl for quicker pain relief and diagnostics in pediatrics.) Study results are also improved with a slim body habitus.
Place the patient supine
Use a high-frequency linear array transducer
Start at the point of maximal tenderness in the RLQ
Transverse and longitudinal planes "graded compression" to displace overlying bowel gas which usually has peristalsis (See Sivitz, et al article for images of "graded compression")
Appendix is usually anterior to the psoas muscle and iliac vein and artery as landmarks
Measure from outer wall to outer wall at the most inflamed portion of the appendix (usually distal end)
A non-compressible, blind-ending tubular structure in the longitudinal axis >6 mm without peristalsis (see second image above with 8.3 mm diameter measurement)
A target sign in the transverse view (see first image above)
Additional suggestive findings: appendiceal wall hyperemia with color Doppler, appendicoliths hyperechoic (white) foci with an anechoic (black) shadow, periappendiceal inflammation or free fluid
Non-visualization of the appendix with adequate graded compression exam in the absence of free fluid or inflammation.
Limitations for visualization and possible false negative result:
Retrocecal appendix and perforated appendix are difficult to visualize with US.
US has good specificity (93% in Sivitz et al article), but limited sensitivity (85% in Sivitz et al article), so trust your clinical judgement. You may need a MRI (pregnant/pediatrics) or CT as they have improved, but not perfect sensitivity.
Valesky, et al. Focus On: Ultrasound for Appendicitis. ACEP Now. June 2012.
Sivitz AB, Cohen SG, Tejani C. Evaluation of Acute Appendicitis by Pediatric Emergency Physician Sonography. Annals of Emerg Med. Oct 2014; 64: 358-363.
Keywords: Lactate (PubMed Search)
The world of pediatrics is still working on catching up to adult literature in terms of lactate utilization and its implications. The study referenced looked at over 1000 children admitted to the pediatric intensive care unit. Lactate levels were collected 2 hours after admission and a mortality risk assessment was calculated within 24 hours of admission (PRISM III). Results showed that the lactate level on admission was significantly associated with mortality after adjustment for age, gender and PRISM III score.
Bottom line: In your critically ill pediatric patient, lactate may be a useful predictor of mortality.
Bai Z et al. Effectiveness of predicting in-hospital mortality in critically ill children by assessing blood lactate levels at admission. BMC Pediatrcs 2014; 14:83.
Bennett NJ, et al. Pediatric Pneumonia Treatment and Management. Medscape. April 2014.
AAP. Management of Communty-Acquired Pneumonia in Infants and Children Older than 3 Months of Age. Pediatrics. Vol 128 No 6 December 1, 2011.
Keywords: E. coli, O0157:H7, hematochezia, diarrhea (PubMed Search)
There are numerous different causes of pediatric hemorrhagic diarrhea. Consider a pediatric patient with bloody diarrhea as being at risk for developing hemolytic uremic syndrome. Most cases of hemolytic uremic syndrome are caused by O157:H7 strains of E Coli that release Shiga-like toxin from the gut. Systemic release of the toxin causes microvascular thromboses in the renal microvasculature. The characteristic microangiopathic hemolysis results with anemia, thrombocytopenia and peripheral schistocytes seen on laboratory studies, in addition to acute renal failure.
Antibiotics have been controversial in the treatment of pediatric hemorrhagic diarrhea due to concern that they worsen toxin release from children infected with E Coli O157:H7 and thus increase the risk of developing hemolytic uremic syndrome. Numerous previous studies have provided conflicting data regarding the true risk (1). A recent prospective study showed antibiotic treatment increases the risk (2). Most recommendations warn against using antibiotics to treat pediatric hemorrhagic diarrhea unless the patient is septic.
Bottom line: Avoid treating pediatric hemorrhagic diarrhea with antibiotics
Risk factors for the hemolytic uremic syndrome in children infected with Escherichia coli O157:H7: a multivariable analysis. Clin Infect Dis. 2012 Jul;55(1):33-41. doi: 10.1093/cid/cis299. Epub 2012 Mar 19.
Keywords: Macklin Phenomenon, asthma, pneumomediastinum (PubMed Search)
16 yo M with pleuritic right upper chest pain that started today. He is suffering from an asthma exacerbation currently in the setting of URI with cough. He is afebrile, tachycardic to 140-150s, respiratory rate 20, and sats 98% on room air. ECG was performed which incidentally diagnosed this patient WPW and he went for ablation as an outpatient. His chest x-ray showed:
Besides a bad day, what do we call this chest x-ray finding?
-asthma exacerbation rupture of the alveoli causing pneumomediastinum
-typically a young man
-most common chief complaint is chest pain
Physical Exam: Hamman’s sign may be present (crackle with heartbeat) or subcutaneous emphysema
Etiology: Esophagus, lungs, or bronchial tree
Rupture of alveoli: asthma exacerbation (bronchial hyper-reactivity/constriction), barotrauma, valsalva maneuvers (lifting, childbirth), deep respiratory maneuvers/Valsalva (strenuous exercise or FVC breathing), drug use (crack cocaine causing bronchial constriction, marijuana), vomiting, blunt thoracic/abdominal trauma, scuba diving with rapid ascent
Aerodigestive tract injuries: bronchoscopy tracheobronchial injuries, laryngeal fx, bronchial fx, tracheal neoplasm, esophageal injuries (Boerhaave syndrome, paripartum, asthma exacerbation, esophageal neoplasm)
Extension from neck: head/neck sx, RPA/PTA, dental abscess/extractions
Extension from RP/chest wall: rupture RP hollow viscus
-treat underlying condition
-swallow study for all cases following emesis to rule out Boerhaave’s syndrome
-no repeat CXR, advance diet as tolerated, 23 hour observation
-Al-Mufarrei, et al suggest without trauma, pleural effusion, hemodynamic instability, pneumoperitoneum, or severe vomiting, the finding of spontaneous pneumomediastinum (with or without Meckler’s triad of esophageal rupture: vomiting, lower chest pain, and cervical subcutaneous emphysema after overindulgence) usually leads to unnecessary radiologic investigations, dietary restriction, and antibiotic administration
-surgery for decompression
Gray JM and Hanson GC. Mediastinal emphysema: aetiology, diagnosis, and treatment. Thorax. 1966; 21: 325-332.
Al-Mufarrej F, Badar J, Gharagozloo F, Tempesta B, Strother E, Margolis M. Spontaneous pneumomediastinum: diagnostic and therapeutic intervnetions. Journal of Cardiothoracic Surgery. November 2008; 3: 59.
Keywords: cervical spine, pediatrics, NEXUS (PubMed Search)
The NEXUS criteria is widely applied to adults who present with neck pain due to trauma. While this study did include about 2000 pediatric patients, there were not enough young children to draw definitive conclusions. For more information on the evaluation of the cervical spine, see Dr. Rice's pearl from 9/7/12. A 2003 study piloted an algorithm for cervical spine clearance in children < 8 years.
Patients were spine immobilized if: unconscious, abnormal neurological exam, history of transient neurological symptoms, significant mechanism of injury, neck pain, focal neck tenderness or inability to assess based on distracting injury (extremity or facial fractures, open wound, thoracic injuries, or abdominal injuries), physical exam findings of neck trauma, unreliable exam due to substance abuse, significant trauma to the head or face, or inconsolable children.
When the 2 pathways (see attached) were implemented, there was a decrease in time to cervical spine clearance. There were no missed injuries in the study period prior to implementation of the pathway or once it was implemented. There was no significant difference in the amount of xrays, CT scans or MRIs.
Lee S, Sena M, Greenholtz, S, Fledderman M. A Multidisciplinary Approach to the Development of a Cervical Spine Clearance Protocol: Process, Rationale, and Initial Results. Journal of Pediatric Surgery 2003; 38 (3): 358-362.
Severe Respiratory Illness Associated With Enterovirus D68--Missouri and Illinois, 2014. CDC MMWR. Vol 63. September 2014.
Keywords: URI, sinusitis (PubMed Search)
6-7% of kids presenting with upper respiratory symptoms will meet the definition for ABS.
The American Academy of Pediatrics (AAP) reviewed the literature and developed clinical practice guideline regarding the diagnosis and management of ABS in children and adolescents.
The AAP defines ABS as: persistent nasal discharge or daytime cough > 10 days OR a worsening course after initial improvement OR severe symptom onset with fever > 39C and purulent nasal discharge for 3 consecutive days.
No imaging is necessary with a normal neurological exam.
Treatment includes amoxicillin with or without clauvulinic acid (based on local resistance patterns) or observation for 3 days.
Optimal duration of antibiotics has not been well studied in children but durations of 10-28 days have been reported.
If symptoms are worsening or there is no improvement, change the antibiotic.
There is not enough evidence to make a recommendation on decongestants, antihistamines or nasal irrigation.
Wald et al. Clinical Practice Guideline for the Diagnosis and Management of Acute Bacterial Sinusitis in Children Aged 1 to 18 Years. Pediatrics. Volume 132, Number 1, July 2013.
Keywords: tympanostomy tubes, antibiotics, otorrhea (PubMed Search)
Up to 26% of patients with tympanostomy tubes (PE tubes) can suffer from clinically manifested otorrhea. This is thought to be the result of acute otitis media that is draining through the tube. Previous small studies suggested that antibiotic ear drops are as effective or more effective and with less side effects for its treatment. This study compared treatment with antibiotic/glucocorticoid ear drops (hydrocortisone-bacitracin-
Study population: Children 1-10 years with otorrhea for up to 7 days in the Netherlands
Exclusion criteria included: T > 38.5 C, antibiotics in previous 2 weeks, PE tubes placed within 2 weeks, previous otorrhea in past 4 weeks, 3 or more episodes of otorrhea in past 6 months
Patient recruitment: ENT and PMD approached pt with PE tubes and they were told to call if otorrhea developed and a home visit would be arranged
Study type: open-label, pragmatic, randomized control trial
Primary outcome: Treatment failure defined as the presence of otorrhea observed otoscopically
Secondary outcome: based on parental diaries of symptoms, resolution and recurrence over 6 months
Results: After 2 weeks, only 5% of the ear drop group compared to 44% of the oral antibiotic group and 55% of the observation group still had otorrhea. There was not a significant difference between those treated with oral antibiotics and those that were observed. Otorrhea
lasted 4 days in the ear drop group compared to 5 days with oral antibiotics and 12 days with observation (all statistically significant).
Key differences: The antibiotic dosing and choice of ear drops are based on availability and local organism susceptibility.
Bottom line: For otorrhea in the presence of PE tubes, ear drops (with a non-aminoglycoside antibiotic and a steroid) may be more beneficial than oral antibiotics or observation.
van Dongen TM, van der Heijden GJ, Venekamp RP, Rovers MM, Schilder AG. A trial of treatment for acute otorrhea in children with tympanostomy tubes. N Engl J Med 2014; 370:723-33.
Wolfe TR, Braude DA. Intranasal Medication Delivery for Children: A Review and Update. Pediatrics. 2010;126:532-7.
Mudd S. Intranasal fentanyl for pain management in children: a systematic review of the literature. J PediatrHealth Care 2011;25:316-22.
Chiaretti A, Barone G, Rigante D, et al. Intranasal lidocaine and midazolam for procedural sedation in children. Arch Dis Child 2011;96:160-3.
Keywords: Ultrasound, pediatrics, appendicitis (PubMed Search)
Keywords: Psychiatric clearance, pediatric (PubMed Search)
Mental health-related visits account for 1.6–6% of ED encounters. Patients with acute psychosis are often brought to the ED for clearance prior to psychiatric evaluation. Is this necessary?
Background: Several adult studies have shown that only 0–4% of patients with isolated psychiatric complaints have organic diagnoses requiring urgent treatment. Routine ED laboratory testing in adults is low yield still, with one study identifying abnormalities in only 2 of 352 patients—both mild hypokalemia. A pediatric study found that 207 of 209 patients were medically cleared.
This study was a retrospective review of pediatric psychiatric patients presenting to a an urban California hospital. They examined 798 patients who had an involuntary psychiatric hold placed by a psychiatric mobile response team.
The authors concluded that few pediatric patients brought to the ED on an involuntary hold required a medical screen and perhaps use of basic criteria in the prehospital setting to determine who required a medical screen (altered mental status, ingestion, hanging, traumatic injury, unrelated medical complaint, sexual assault) could have led to significant savings.
Santillanes, G et al. Is Medical Clearance Necessary for Pediatric Psychiatric Patients? J Emerg Med. 2014 Mar 15. pii: S0736-4679(13)01455-8. [Epub ahead of print]
Keywords: scabies, pediatrics (PubMed Search)
Scabies is considered by the WHO to be one of the main neglected diseases with approximately 300 million cases worldwide each year. One third of cases of scabies seen by dermatologists are in kids less than 16 years old. The belief had been that presentation varies by age. One French study reported a first time miss rate of more than 41% and an overall diagnostic delay of 62 days.
A prospective, multi center observational study of patients with confirmed scabies sought to determine common phenotypes in children. All patients were seen by dermatologists in France and administered standard questionnaires. They were divided into 3 age groups, <2 years, 2-15 years and > 15 years. 323 patients were included.
The study found that:
-infants were more likely to have facial involvement and nodules, especially on the back and axilla
-relapse was more common in < 15 year olds - this was hypothesized to be due to poor compliance with treatment to the head
-family members with itch, or planter or scalp involvement were independently associated with diagnosis of scabies in kids < 2 years
-burrows were seen in 78%, nodules in 67% and vesicles of 43% of patients (see photo)
-itching was absent in up to 10% of patients
Bottom line: Have a high suspicion for scabies in any rash.
Keywords: Head injury, vomiting, PECARN (PubMed Search)
Keywords: asthma, pediatrics, dexamethasone, prednisone (PubMed Search)
Hot off the press! Pediatrics March 2014 just published results of a meta-analysis that compared 1 or 2 dose regimens of Dexamethasone versus 5 day course of Prednisone/Prednisolone for management of acute asthma exacerbations in pediatric patients. The results showed that Dexamethasone was as efficacious as the longer course of Prednisone. End points used were return trips to the emergency department and hospital admissions. On further review of the literature, parents tend to prefer the shorter duration of therapy with Dexamethasone. Also, there is less vomiting associated with Dexamethasone. There have been several articles published that show Dexamethasone is more cost-effective than Prednisone. Bottom line: consider giving single dose of Dexamethasone in the ER and then sending patient home with 1 additional dose.
Keeney G, Gray M, Morrison A, et al. Dexamethasone for Acute Asthma Exacerbations in Children: A Meta-analysis, Pediatrics March 2014, pp 493-499.
Williams K, Andrews A, Heine D, et al. Parental Preference for Short versus Long Course Corticosteroid Therapy in Children With Asthma Presenting to the Pediatric Emergency Department, Clinical Pediatrics January 2012, pp 30-34.
Andrews A, Wong K, Heine D, et al. A Cost-effectiveness Analysis of Dexamethasone versus Prednisone in Pediatric Acute Asthma Exacerbations, Annals of Emergency Medicine July 2012, pp 943-949
Keywords: Passive leg raise, hypotension (PubMed Search)
Passive leg raise (PLR) has been studied in adults as a bedside tool to predict volume responsiveness (see previous pearls from 5/7/13 and 6/17/2008). Can this be applied to children?
A single center prospective study looked at 40 intensive care patients ranging in age from 1 month to 12.5 years. They used a noninvasive monitoring system that could measure heart rate, stroke volume and cardiac output. These parameters were measured at a baseline, after PLR, after another baseline and after a 10 ml/kg bolus.
Overall, changes in the cardiac index varied with PLR. However, there was a statistically significant correlation in children over 5 years showing an increase in cardiac index with PLR and with a fluid bolus.
Bottom line: In children older then 5 years, PLR can be a quick bedside tool to assess for fluid responsiveness, especially if worried about fluid overload and in an under served area.
Lu et al. The Passive Leg Raise Test to Predict Fluid Responsiveness in Children - Preliminary Observations. Indian J Pediatr. Dec 2013. (epub ahead of print).
Keywords: metabolic, inborn errors of metabolism, hyperammonemia (PubMed Search)
Inborn errors of metabolism (IEM) are rare, each typically affecting 1 in 5000 to 1 in 100,000 children, BUT collectively these disorders are more common because there are so many. If you are lucky…when they present to the ED they come with a letter from Dr. Greene (our world renowned metabolic geneticist) detailing exactly what to do. The rest of the time…you are on your own. Think about IEM in any neonate or child with history of feeding difficulties, failure to thrive, recurrent vomiting, unexplained altered mental status and/or acidosis. Pay particular attention to feeding difficulties that appear with changes in diet: switch from soy to cow’s milk formula (galactose), addition of juice or fruit or certain soy formulas (fructose), switch from breast milk to formula or foods (increased protein load), and longer fasting periods from sleeping or illness.
For this pearl, we will focus on primary hyperammonemia from an enzymatic block in ammonia metabolism within the urea cycle. It is important to remember that secondary hyperammonemia can result from metabolic defects such as organic acid disorders, fatty acid oxidation disorders, drugs that interfere with urea cycle, or severe liver disease. Amino acids liberated from excess protein breakdown (stress of newborn period, infection, injury, dehydration, surgery, or increased intake) release nitrogen which circulates as ammonia. Ammonia is then converted to urea via the urea cycle and excreted in the urine. With urea cycle defects (UCD) there is an enzymatic block in the cycle that results in accumulation of ammonia which has toxic effects on the CNS especially cerebral edema. The most common UCD is ornithine transcarbamylase deficiency followed by argininosuccinic academia, and citrullinemia.
Clinical presentation includes poor feeding, lethargy, tachypnea, hypothermia, irritability, vomiting, ataxia, seizures, hepatomegaly, and coma. Hyperammonemic crises in neonates mimic sepsis! If you think about an IEM in your differential, send plasma ammonia (1.5 mL sodium-heparin tube on ice STAT), plasma amino acids, and urine organic acids. Other helpful labs include blood gas, CMP, urinalysis (looking at ketones), lactate, plasma acylcarnitines, and newborn screen if not already sent. Plasma ammonia is a direct index of CNS toxicity and important to follow for acute management. Serum level > 150 in sick neonate or > 100 in sick infant/child is concerning for IEM. The presence of hyperammonemia and respiratory alkalosis suggest urea cycle defect. The presence of metabolic acidosis and hyperammonemia suggests organic acid disorder.
Immediate treatment of hyperammonemia is critical to prevent neurologic damage. Cognitive outcome is inversely related to the number of days of neonatal coma caused by the cerebral edema.
1. Stop all protein intake! You need to stop catabolism.
2. Start D10 at 1.5 times maintenance rate with GIR at least 6-8. Start intralipids 1-3g/kg/day when able (typically in the ICU after central line placed).
3. Give ammonia scavenger medications sodium benzoate and sodium phenylacetate. These are available commercially as Ammonul.
a. 0-20kg: 2.5mL/kg IV bolus over 90 min followed by same dose as 24 hr infusion
b. >20kg: 55 mL/m2 IV bolus over 90 min followed by same dose as 24 hr infusion
4. HEMODIALYSIS! Dialysis is the most effective way to remove ammonia and should be done when level > 300. The decision to hemodialyze is crucial in preventing irreversible CNS damage; when in doubt in the face of elevated ammonia, HEMODIALYZE!
Cruz AT, Perry AM, Williams EA, et al. Implementaion of Goal-Directed Therapy for Children With Suspected Sepsis in the Emergency Department. Pediatrics 2011;127;e758.