UMEM Educational Pearls - Pediatrics

Category: Pediatrics

Title: Color-Coded Code Drugs: A Novel Idea in Pediatric Resuscitation

Keywords: pediatric, code, resuscitation, medication error (PubMed Search)

Posted: 10/3/2015 by Christopher Lemon, MD
Click here to contact Christopher Lemon, MD

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).


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1510030139_syringes.jpg (255 Kb)

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
-Visible deformity
-Painful palpation of the distal radius
-Painful palpation at the anatomical snuff box
-Painful supination
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.

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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 [1]. 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 [2].


Consider the above mentioned stimulation technique to obtain a urinary sample in the neonate.


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Category: Pediatrics

Title: Do you really need a VBG in DKA in children?

Keywords: VBG, DKA, acidosis, hyperglycemia (PubMed Search)

Posted: 8/21/2015 by Jennifer Guyther, MD
Click here to contact Jennifer Guyther, MD

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.

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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.


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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)
- Creatinine
- 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.

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Previous pearls have focused on diagnosing appendicitis in children including the use of the pediatric appendicitis score and the Alvarado score. Many facilities have begun using focused ultrasound as the initial step in diagnosing appendicitis whilean aging to avoid radiation. The question remains what to do with an indeterminate ultrasound (when the appendix can not be visualized)? The retrospective study cited looked at combining a low Alvarado score (less the 5) with an indeterminate ultrasound and showed a negative predictive value of 99.6%. A total of 522 children were included in this study. 390 of these children had inconclusive ultrasounds. Only 1 patient with a low Alvarado score and inconclusive ultrasound has appendicits. Only children who had surgery or clinical follow up were included.

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Category: Pediatrics

Title: Pediatric Migraine Therapy

Keywords: migraine, sodium valproate, headache (PubMed Search)

Posted: 6/19/2015 by Jennifer Guyther, MD
Click here to contact Jennifer Guyther, MD

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%.

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  • Evidence-based guidelines recommend therapeutic hypothermia in adults following resuscitation from cardiac arrest.
  • Very few trials exist for children.
  • The most recently published study on the subject (New England Journal of Medicine, May 2015) was of 295 children aged 2 days to 18 years old, at 38 different childrens hospitals who underwent targeted temperature management. 
  • There was no significant difference in primary outcome between the hypothermia and normothermia groups.  One year survival and 28-day survival were similar, as were incidences of infection, serious arrhythmias, and use of blood products.
  • "In comotose children who survived out-of-hospital cardiac arrest, therapeutic hypothermia, as compared with therapeutic normothermia , did not confer a significant benefit in survival with a good functional outcome at 1 year."

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  • Large vascular supply to the tonsil and the surrounding tissues that do not compress on themselves which can lead to hemorrhage
  • 2 types of hemorrhage - primary and secondary
    • primary - within 24 hours
    • secondary - after 24 hours
      • most commonly POD 5-10
      • median time to bleed is POD 7
  • Bleeding occurs as the fibrin clot sloughs off from the tonsillar pillar (which occurs on day 5-10)
  • Surgery in older children and acute peritonsillar abscess are at increased risk for bleeding
  • Due to the proximity to arteries and the possibility of pseudoaneurysm formation, bleeding post-procedure can result in significant, life-threatening hemorrhage.
  • When assessing these patients, start with the ABCs
    • Assess the airway for compromise, some patients have heavy bleeding that requires intubation to secure the airway
    • Obtain access if needed due to the concern for exsanguination from these areas
  • Patients that have active bleeding or a clot should be referred to surgery (ENT) for cautery of bleeding area
  • Most patients are not bleeding when they reach the ED. If a patient presents with a history of bleeding, they should be observed (no standardized time frame)
  • If the patient has severe bleeding and awaiting the OR, can place gauze soaked with lidocaine with epinephrine on the bleeding area with Magill forceps
  • Topical hemostatic agents may help with bleeding, however, more severe bleeding requires surgery


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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.

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Category: Pediatrics

Title: Traumatic Lumbar Punctures in Infants 1 to 2 months

Keywords: Traumatic lumbar punctures, fever, infants (PubMed Search)

Posted: 4/17/2015 by Jennifer Guyther, MD
Click here to contact Jennifer Guyther, MD

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.

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Category: Pediatrics

Title: Pediatric DKA (submitted by Anthony Roggio, MD)

Keywords: diabetic ketoacidosis, DKA (PubMed Search)

Posted: 3/27/2015 by Mimi Lu, MD
Click here to contact Mimi Lu, MD

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) 

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Upper gastrointestinal (UGI) bleeds accounts for only 0.2% of complaints for children presenting to the pediatric emergency department. However, these children can present in significant distress. In fact, critically ill children with UGI bleeds while in the ICU had an increase mortality rate compared to those without UGI bleeds.
There is a long differential for the cause of the bleeding, although age may be a clue. In the first month of life, consider maternal blood ingestion or vitamin K deficiency. In infants and toddlers, think of reflux esophagitis or ingestion. In older children, consider ulcer disease.
Remember to ask about different food ingestions that may mimic blood: licorice, red drinks, red fruits and vegetables, spicy/hot flavored snacks, bismuth, and iron.
Key points to remember in the management of pediatric patients:
-Gastroccult (NOT hemoccult)
-Apt-Downey test (looking for maternal blood)
-XRs indicated only for concern of ingestion
-NG lavage are done in 3 to 5 ml/kg aliquots
-If your patients have a G-tube, lavage through this may lead to false-negative findings or underestimation of the severity of the bleeding.

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  • Pediatric forearm fractures are common, and on the rise due to increasing sporting activity and increasing BMI.
  • The most common mechanism is falling on an outstretched hand, which often leads to rotational displacement. 
  • If not properly reduced, it leads to reduced range of motion.
  • The majority do well with closed reduction, if properly reduced.
  • A recent study (Debrovsky, et al. Ann of Emerg Med), found  the accuracy of bedside ultrasonography to determine when pediatric forearm fractures have been adequately realigned was comparable to fluoroscopy. 
  • Consider using US for post-reduction evaluation of pediatric forearm fractures to reduce radiation exposure, cost, and time.

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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.

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Category: Pediatrics

Title: Pediatric Caffeine Overdose

Keywords: Caffeine, Energy Drinks, Overdose, Tox, Pediatrics (PubMed Search)

Posted: 2/13/2015 by Melissa Rice, MD
Click here to contact Melissa Rice, MD

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

  • Tachycardia, dysrhythmia, hypertension
  • Diaphoresis, piloerection
  • Nausea, vomiting
  • Hyperthermia
  • Dilated pupils
  • Agitation, delusions, paranoia
  • Seizures, coma
  • Sometimes: Metabolic acidosis, hypokalemia
  • Rhabdo- muscle breakdown by Ca++ sequestration in the sarcoplasmic reticulum

Available Sources of Caffeine-

  • NoDoz- 200mg/tab
  • Excedrin 65mg/tab
  • Starbuck Double Shot 130mg/6.5oz
  • Monster Energy Drink 160mg/16oz
  • Caffeine Solution for Neonates with Apnea of Prematurity
  • So many more!

Toxic Doses

  • 15 mg/L- tachycardia, arrhythmia, HTN, seizure, vomiting, irritable, delusions, hallucinations (approx 1500 mg for an adult)
  • >80 mg/L- Coma or Death

Management- treat the symptoms (metabolic, cardiovascular, and neurologic)

  • IV Fluids
  • Anti-emetics
  • Sodium Bicarb if refractory metabolic acidosis
  • Benzos for severe agitation or seizure
  • PALS protocols for cardiac arrhythmias

Good Luck on the In-Service!

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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.

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Category: Pediatrics

Title: Intranasal Ketamine

Posted: 1/10/2015 by Rose Chasm, MD (Updated: 6/16/2024)
Click here to contact Rose Chasm, MD

  • Ketamine popularity for procedural sedation is on the rise, again.  It provides pain relief, sedation, and memory loss while maintaining airway reflexes and has little effect on the heart. 
  • Traditional administration has been the intravenous or intramuscular route, but consider intransal now. 
  • Recent articles have touted the intranasal administration of ketamine for pediatric procedural sedation with good success.
  • Admittedly, the number of patients enrolled in the studies to date have been small and the dosages have varied from 1 to 9 mg/kg/dose.  However, none of the studies have reported any bad outcomes or complications.
  • So, consider IN ketamine for your next pediatric procedural sedation. 


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Category: Pediatrics

Title: Happy New Year 2015

Keywords: intraosseous access, pediatrics (PubMed Search)

Posted: 1/3/2015 by Ashley Strobel, MD (Updated: 6/16/2024)
Click here to contact Ashley Strobel, MD

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:

  • Pink=15 mm
  • Blue=25 mm
  • Yellow=45 mm

Preferred sites:

  1. Proximal tibial (place a towel in popliteal fossa to bend the leg, pinch tibia and 1 finger width below the patella inferior and medial if you can’t palpate the tibial tuberosity)
  2. Distal tibia (proximal to medial malleolus by 1 finger width)—preferred in older children
  3. Proximal Humerus (internally rotate humerus and 1 finger width below surgical neck)
  4. Distal Femoral (1-2 finger widths superior to femoral epicondyles)

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).

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