Category: Pediatrics
Keywords: pediatrics, ultrasound, pneumonia (PubMed Search)
Posted: 8/7/2015 by Jenny Guyther, MD
(Updated: 8/10/2015)
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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.
Results:
- 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.
Category: Pediatrics
Posted: 7/25/2015 by Mimi Lu, MD
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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.
Eison TM, et al. Post-streptococcal acute glomerulonephritis in children: clinical features and pathogenesis. Pediatr Nephrol 2011; 26:165-180.
Category: Pediatrics
Keywords: Alvarado score, ultrasound (PubMed Search)
Posted: 7/17/2015 by Jenny Guyther, MD
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Category: Pediatrics
Keywords: migraine, sodium valproate, headache (PubMed Search)
Posted: 6/19/2015 by Jenny Guyther, MD
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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.
Category: Pediatrics
Posted: 6/12/2015 by Rose Chasm, MD
(Updated: 4/19/2024)
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Therapeutic Hypothermia after Out-of-Hospital Cardiac Arrest in Children. Mosler FW, et al. N Eng J Med 2015; 372:1898-1908. May 2015
Category: Pediatrics
Posted: 5/22/2015 by Mimi Lu, MD
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1) Fox, S. (2012, August 17). Post-Tonsillectomy Hemorrhage. Retrieved April 8, 2015, from 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.
Category: Pediatrics
Keywords: head lice (PubMed Search)
Posted: 5/15/2015 by Jenny Guyther, MD
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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.
Devore CD and Schutze G. Head Lice. Pediatrics. 2015; 135 (5) e1355 -e1365.
Category: Pediatrics
Keywords: Traumatic lumbar punctures, fever, infants (PubMed Search)
Posted: 4/17/2015 by Jenny Guyther, MD
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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.
Category: Pediatrics
Keywords: diabetic ketoacidosis, DKA (PubMed Search)
Posted: 3/27/2015 by Mimi Lu, MD
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ISPAD (International Society for Pediatric and Adolescent Diabetes) Updated their Guidelines for Pediatric Diabetic Ketoacidosis (DKA) in 2014
Fluids:
· 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
Insulin
· 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
Potassium
· 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
Bicarb
· 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.
Category: Pediatrics
Keywords: Upper GI Bleeds (PubMed Search)
Posted: 3/20/2015 by Jenny Guyther, MD
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Category: Pediatrics
Posted: 3/13/2015 by Rose Chasm, MD
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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.
Category: Pediatrics
Keywords: Stroke, congenital heart disease (PubMed Search)
Posted: 2/20/2015 by Jenny Guyther, MD
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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.
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.
Category: Pediatrics
Keywords: Caffeine, Energy Drinks, Overdose, Tox, Pediatrics (PubMed Search)
Posted: 2/13/2015 by Melissa Rice, MD
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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-
Toxic Doses
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.
Category: Pediatrics
Keywords: Trauma, pelvic fractures, imaging (PubMed Search)
Posted: 1/19/2015 by Jenny Guyther, MD
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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.
Kwok et al. Sensitivity of Plain Pelvis Radiography in Children with Blunt Torso Trauma. Annals of Emergency Medicine 2015; 65: 63-71.
Category: Pediatrics
Posted: 1/10/2015 by Rose Chasm, MD
(Updated: 4/19/2024)
Click here to contact Rose Chasm, MD
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.
Category: Pediatrics
Keywords: intraosseous access, pediatrics (PubMed Search)
Posted: 1/3/2015 by Ashley Strobel, MD
(Updated: 4/19/2024)
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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:
Preferred sites:
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).
Category: Pediatrics
Posted: 12/27/2014 by Mimi Lu, MD
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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!
Category: Pediatrics
Keywords: Bronchiolitis, wheezing (PubMed Search)
Posted: 12/19/2014 by Jenny Guyther, MD
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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.
Category: Pediatrics
Posted: 12/13/2014 by Rose Chasm, MD
(Updated: 4/19/2024)
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NMS Pediatrics. Lippincott Williams and Wilkins. 4th Edition. Paul Dworkin editor.
Category: Pediatrics
Keywords: dehydration (PubMed Search)
Posted: 11/28/2014 by Mimi Lu, MD
(Emailed: 11/29/2014)
Click here to contact Mimi Lu, MD
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.