Debrovsky AS, Kempinska A, Bank I, Mok E. Accuracy of Ultrasonography for Determining Successful Realignment of Pediatric Forearm Fractures. Annals of Emergency Medicine. Vol 65;Number 3. March 2015.
Keywords: Stroke, congenital heart disease (PubMed Search)
This study is a case control study of the association of congenital heart disease (CHD) and stroke using a base population of 2.5 million Kaiser patients in California. 412 cases of stroke were identified and compared to 1236 controls. Of these stroke patients, 11/216 ischemic strokes and 4/196 hemorrhagic strokes were attributed to CHD (both cyanotic and acyanotic lesions). CHD was found in 7/1236 controls.
Children with CHD and history of cardiac surgery had the strongest risk of stroke (31 fold over the control group). Many of these children had strokes years after their surgery. Children with CHD who did not have cardiac surgery had a trend towards elevated stroke risk, but the confidence intervals included the null. More children without CHD history presented with headache.
Bottom line: Stroke risk (both hemorrhagic and ischemic) extend past the immediate postoperative period in patients with CHD.
Fox CK, Sidney S and Fullerton HJ. Community-Based Case Control Study of Childhood Stroke Risk Associated With Congenital Heart Disease. Stoke 2015; 46:336-340.
Keywords: Caffeine, Energy Drinks, Overdose, Tox, Pediatrics (PubMed Search)
Pediatric Caffeine Overdose
As the in-service draws closer and the hours to study wind down, I find myself becoming more and more of a caffeine enthusiast. While a No-Doz or Diet Mt. Dew may put a little more pep in my step, the caffeine found in energy drinks, caffeine pills, and diet supplements can quickly result in an dangerous overdose in a young child.
Caffeine Overdose Presentation- Sympathomimetic Toxidrome
Available Sources of Caffeine-
Management- treat the symptoms (metabolic, cardiovascular, and neurologic)
Good Luck on the In-Service!
Jones, Maya A., and Elizabeth R. Alpern. "A 16-Month-Old Girl With Irritability After Ingesting White Pills." Pediatric emergency care 30.1 (2014): 69-71.
Wolk, Brian J., Michael Ganetsky, and Kavita M. Babu. "Toxicity of energy drinks." Current opinion in pediatrics 24.2 (2012): 243-251.
Keywords: Trauma, pelvic fractures, imaging (PubMed Search)
Of pediatric patients who have anteroposterior (AP) pelvic xrays (XR), there is a 4.6% rate of pelvic fracture or dislocation, compared to 10% in adults.
This study is a sub analysis of a prospective observational cohort of children with blunt torso trauma conducted by PECARN. 7808 patients had pelvic imaging, with 65% of them having an AP XR. The XR sensitivity ranged from 64-82% (based on age groups) for detecting fractures. All but one patient with a pelvic fracture not detected on XR had a CT scan. The CT scan detected all but 2 fractures both of which were picked up later as healing fractures on repeat pelvic XR. Some of the patients who had a missed fracture on XR were hemodynamically unstable or wound up requiring operative intervention.
The authors support the following algorithm:
-With hemodynamically unstability children, obtain a pelvic XR
-For hemodynamically stable children when the physician is planning to get a CT, there is no indication for XR
Bottom line: Consider using AP pelvic radiographs in the hemodynamically stable patient with a high suspicion for fracture or dislocation who are not undergoing CT.
Kwok et al. Sensitivity of Plain Pelvis Radiography in Children with Blunt Torso Trauma. Annals of Emergency Medicine 2015; 65: 63-71.
Andolfatto G, et al. Intranasal ketamine for analgesia in theemergency department: a prospective observational study. Acad Emerg Med. 2013. Oct;20(10):1050-4.
Tsze DS, et al. Intranasal ketamine for procedural sedation in pediatric laceration repair: a preliminary report. Pediatr Emerg Care. 2012. August;28(8);767-70.
Hall D, et al. Intranasal ketamine for procedural sedation. Emerg Med J. 2014;31:789-90.
Keywords: intraosseous access, pediatrics (PubMed Search)
Are you comfortable with Intraosseous Catheter Placement in Children during a code? A pediatric code or child in distress is also distressing to care providers. Your staff may not feel comfortable with IO access in children. Read on to be more comfortable with your options as IO access in children can be difficult, especially the chubby toddlers. The basics for a patient in distress are "IV, O2, Monitor". Access is vital to giving resuscitation medications.
Indications for IO access: Any child in whom IV access cannot readily be obtained, but is necessary.
All IOs are 15G for infusion equal to central vascular access.
Different colors indicate different sizes:
Kids-do NOT use the sternum or distal radius
The reference from NEJM has videos to review placement and different tools (manual, EZ IO, and autoinjector).
Cyanotic (right to left shunt) Congenital Heart Disease (CHD) lesions can be easily remembered with the 1,2,3,4,5 method.
1- Truncus Arteriosis (ONE trunk)
2- Transposition of the Great Vessels (TWO vessels flipped)
3- TRIcuspid Atresia
4-TETRAlogy of Fallot
5- Total Anomolous Pulmonary Venous Return (TAPVR=5 words/letters)
A few other important DUCTAL-DEPENDENT lesions: Coarctation of the Aorta, Hypoplastic Left Heart Syndrome, and Pulmonary Atresia.
Patients present to the emergency department within the first week of life in severe distress, including hypoxia, tachypnea, and hypotension. The above cyanotic CHD all reflect DUCTAL-DEPENDENT lesions, meaning they need a widely open PDA (which closes in the first week of life) to maintain sufficient oxygenation for viability.
These patients will not survive without timely intervention with prostaglandin (PGE1), so be sure to initiate this life-saving medication as soon as possible! Side effects include apnea…be prepared to intubate your neonate!
Keywords: Bronchiolitis, wheezing (PubMed Search)
Now that respiratory season is upon us, we are faced with an increasing number of bronchiolitis children. The updated clinical practice guidelines for managing these kids were recently published and emphasize supportive care only.
Some of the key points:
-When clinicians diagnose bronchiolitis on the basis of history and physical examination, radiographic or laboratory studies should not be obtained routinely.
-Medications such as albuterol, nebulized epinephrine or steroids should not be administered routinely in children with a diagnosis of bronchiolitis.
-Nebulized hypertonic saline should not be administered to infants with a diagnosis of bronchiolitis in the emergency department
-Clinicians may choose not to administer supplemental oxygen if the oxyhemoglobin saturation exceeds 90% in infants and children with a diagnosis of bronchiolitis
-Clinicians may choose not to use continuous pulse oximetry for infants and children with a diagnosis of bronchiolitis.
Check out the full guidelines for the quality of evidence and rational behind these recommendations.
The bottom line is that not much really works, and we just need to support their respiratory effort and ensure hydration.
Ralston et al. Clinical Practice Guideline: The diagnosis, Management and Prevention of Bronchiolitis. Pediatrics 2014; 134: e1474-e1502.
NMS Pediatrics. Lippincott Williams and Wilkins. 4th Edition. Paul Dworkin editor.
Keywords: dehydration (PubMed Search)
Dehydration is a common pediatric ED presentation. Oral rehydration (although first choice) is often not possible secondary to patient cooperation and/ or persistent vomiting. Intravenous (IV) hydration is often difficult, requiring multiple attempts especially in the young dehydrated infant.
Hyaluronan is a mucopolysaccharude present in connective tissue that prevents the spread of substances through the subcutneous space. Hyaluronidase is a human DNA-derived enzyme that breaks down hyaluronan and temporarily increases its permeability, thereby allowing fluid to be absorbed with the capillary and lymphatic systems.
In one study, patients age 1 month to 10 years were randomized to recieve 20 mL/kg bolus NS via subcutaneous (SC) or IV route over one hour, then as needed. The mean volume infused in the ED was 334.3 mL (SC) vs 299.6 mL (IV). Succesful line placement occured in all 73 SC patients and only 59/75 IV patients. There was a higher proportion of satisfaction for clinicians and parents for ease of use and satisfaction, respectively.
Bottom line: Consider subcutaneous hyaluronidase faciliated rehydration in mild to moderately dehydrated children, especially with difficult IV access.
Spandorfer PR, et al. A Randomized Clinical Trial of Recombinant Human Hyaluronidase-Fcilitated Subcutaneous Versus Intravenous Rehydration in Mild to Moderately Dehydrated Children in the Emergency Department. Clinical Therapeutics, 2012; 34(11): 2232-2245.
Keywords: Medications, overdose, pediatric, over the counter (PubMed Search)
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.