Category: Pediatrics
Keywords: procedural sedation (PubMed Search)
Posted: 8/26/2016 by Mimi Lu, MD
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Alai, A. Nitrous Oxide Administration. Medscape/emedicine. http://emedicine.medscape.com/
Guideline for Monitoring and Management of Pediatric Patients During and After Sedation Diagnostic and Therapeutic Procedures. American Academy of Pediatrics. 2011
Clinical Policy: Critical Issues in the Sedation of Pediatric Patients in the Emergency Department. Annals of Emergency Medicine, 51(4):378-399 (2008)
Category: Pediatrics
Keywords: Trampoline, injury patterns (PubMed Search)
Posted: 8/19/2016 by Jenny Guyther, MD
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From 2010-2014 ED visits in the US for injuries from trampoline parks (TPI) increased from 581 visits per year to 6932 visits per year. There was no change in the number of injuries related to home trampoline use. TPI were more likely to involve the lower extremity, be a dislocation and warrant admission and less likely to involve the head.
Bottom line: TPIs are increasing and have a different injury pattern compared to home trampolines.
Kasmire K, Rogers S and Sturm J. Trampoline Park and Home Trampoline Injuries. Pediatrics 2016: 138 (3).
Category: Pediatrics
Keywords: airway. mac (PubMed Search)
Posted: 7/29/2016 by Mimi Lu, MD
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The pediatric epiglottis is more "U" shaped, often overlies the glottic opening, and is "less in line with the trachea."1 Because of this, it has traditionally been taught that a Miller blade is the ideal laryngoscope.
Varghese et al compared the efficacy of the Macintosh blade and the Miller blade when placed in the vallecula of children between the ages of 1 and 24 months. The blades provided similar views and suffered similar failure rates. When the opposite blade was used as a backup, it had a similar success rate as the opposing blade.2 Passi et al also compared these two blades, this time placing the Miller blade over the epiglottis. Again, similar views were achieved.3
1. Harless J, Ramaiah R, Bhananker S. Pediatric airway management. Int J. Crit Illn Inj Sci. 2014;4(1):65-70.
2. Varghese E, Kundu R. Does the Miller blade truly provide a better laryngoscopic view and intubating conditions than the Macintosh blade in small children? Paediatr Anaesth. 2014;24:825-829.
3. Passi Y, Sathyamoorthy M, Lerman J, et al. Comparison of the laryngoscopy views with the size 1 Miller and Macintosh laryngoscope blades lifting the epiglottis or the base of the tongue in infants and children <2 yr. of age. Br J Anaesth. 2014;113(5):869-874.
Category: Pediatrics
Keywords: Intranasal vaccine, immunizations (PubMed Search)
Posted: 7/15/2016 by Jenny Guyther, MD
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Although it is summer, preparations are being made for the 2016-2017 influenza season. The Center for Disease Control (CDC) no longer recommends the live attenuated influenza vaccine (LAIV4). The American Academy of Pediatrics has supported this statement.
The LAIV4 (the only intranasal vaccine available) was offered to patients over the age of 2 years without respiratory problems. Observational studies during the 2013-2015 seasons have shown that the LAIV4 has an adjusted vaccine efficacy of 3% compared to 63% for the inactivated vaccine (intramuscular). Children who received the intranasal vaccine were almost 4 times more likely to get the flu compared to children who received the injection.
Bottom line: Only the intramuscular shot is recommended for this upcoming season. This is causing many primary care practices to scramble to obtain enough vaccine.
Bernstein HH and Kimberlin DW. Intranasal FluMISSED its target. AAP News. July 2016.
Chung J et al. Seasonal Effectiveness of Live Attenuated and Inactivated Influenza Virus. Pediatrics 2016: 137 (2).
Category: Pediatrics
Keywords: hypertension, pediatrics (PubMed Search)
Posted: 6/17/2016 by Jenny Guyther, MD
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Stein DR, Ferguson MA. Evaluation and treatment of hypertensive crisis in children. Integr Blood Press Control 2016; 9:49-58.
Category: Pediatrics
Keywords: Apparent life threatening event, ALTE, apnea, low risk infants, brief unexplained resolved events (PubMed Search)
Posted: 5/20/2016 by Jenny Guyther, MD
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The American Academy of Pediatrics has developed a new set of clinical practice guidelines to help better manage and think about patients who have experienced an ALTE (Apparent Life Threatening Event). The term BRUE (Brief Resolved Unexplained Event) will replace ALTE.
BRUE is defined as an event in a child younger than 1 year where the observer reports a sudden, brief and now resolved episode of one or more of: cyanosis or pallor; absent, decreased or irregular breathing, marked change in tone or altered level of responsiveness. A BRUE can be diagnosed after a history and physical exam that reveal no explanation.
BRUE can be classified as low risk or high risk. Those that can be categorized as low risk do not require the extensive inpatient evaluation that has often occurred with ALTE.
LOW risk BRUE:
Age > 60 days
Gestational age at least 32 weeks and postconceptual age of at least 45 weeks
First BRUE
Duration < 1 minute
No CPR required by a trained medical provider
No concerning historical features (outlined in the article)
No concerning physical exam findings (outlined in the article)
Recommendations for low risk BRUE:
-SHOULD: Educate, shared decision making, ensure follow up and offer resources for CPR training
-May: Obtain pertussis and 12 lead; briefly monitor patients with continuous pulse oximetry and serial observations
-SHOULD NOT: Obtain WBC, blood culture, CSF studies, BMP, ammonia, blood gas, amino acids, acylcarnitine, CXR, echocardiogram, EEG, initiate home cardiorespiratory monitoring, prescribe acid suppression or anti-epileptic drugs
-NEED NOT: obtain viral respiratory tests, urinalysis, glucose, serum bicarbonate, hemoglobin or neuroimaging, admit to the hospital solely for cardiorespiratory monitoring
*When looking at the evidence strength behind these recommendations, the only one that had a strong level was that you should not obtain WBC, blood culture or CSF
Tieder JS, Bonkowsky JL, Etzel RA, et al. Brief Resolved Unexplained Events (Formerly Apparent Life-Threatening Events) and Evaluation of Lower-Risk Infants. Clinical Practice Guideline. Pediatrics. 2016; 137 (5):e20160590.
Category: Pediatrics
Posted: 4/29/2016 by Mimi Lu, MD
(Updated: 4/30/2016)
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Neonatal jaundice- Incidence ~85% of term newborns
Bili levels are EXPECTED to rise during first 5 days of life
Be aware of CONJUGATED hyperbilirubinemias (biliary atresia, infection)
Majority of cases due to increase in unconjugated (indirect) bilirubin 2/2 residual fHgb breakdown and insufficient capacity of hepatic conjugation
Severe hyperbilirubinemia (Tbili >20mg/dL) <2% of term infants
⇒
Acute bilirubin encephalopathy(ABE)- Hypertonia, arching, opisthotonos, fever, high pitched cry
⇒
Kernicterus (5% of ABE)-CP, MR, auditory dysfunction, upward gaze palsy
When to refer for phototherapy/exchange transfusion
“Evaluation and Treatment of Neonatal Hyperbilirubinemia” Muchowski MD, Naval Hospital Camp Pendleton Family Medicine Residency Program, Camp Pendleton, California; Am Fam Physician. 2014 Jun 1;89(11):873-878.
Management of Hyperbilirubinemia in the Newborn Infant35 ore More Weeks of Gestatiion, Pediatrics 2004 July; 114(1)
Category: Pediatrics
Keywords: Intracranial hemorrhage, ultrasound, non accidental trauma (PubMed Search)
Posted: 4/15/2016 by Jenny Guyther, MD
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Typically, if an infant or young child presents to the ED with concern for intracranial hemorrhage (ICH), CT is performed as a rapid diagnostic tool. Now that clinicians are more aware of the radiation associated with head CT, the possible use of ultrasound was studied. Ultrasound is commonly used in the neonatal population for detecting ICH. A study by Elkhunovich et al looked at children younger than 2 years who had cranial ultrasounds preformed. Over a 5 year period, 283 ultrasounds were done on patients between 0 to 485 days old (median 33 days). There were 39 bleeds detected. Ultrasound specificity and sensitivity was calculated by comparing the results with CT, MRI and/or clinical outcome. For significant bleeds, the sensitivity for ultrasound was 81%. The specificity for detecting ICH was 97%.
Only 2 patients in the study were older than 1 year. The proper windows are easiest to visualize in children younger than 6 months.
Bottom Line: The sensitivity of cranial ultrasound is inadequate to justify its use as a screening tool for detection of ICH in an infant with acute trauma, but it could be considered in situations when obtaining advanced imaging is not an option because of availability or patient condition.
Elkhunovich M, Sirody J, McCormick T, Goodarzian F and Claudius I. The Utility of Cranial Ultrasound for Detection of Intracranial Hemorrhage in Infants. Ped Emerg Care 2016 [epub ahead of print].
Category: Pediatrics
Keywords: End tidal capnography, diabetic ketoacidosis (PubMed Search)
Posted: 3/19/2016 by Jenny Guyther, MD
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A previous pearl has looked at serum HCO3 as a predictor of DKA (see pearl from 8/21/15). The article by Gilhotra looks at using end tidal CO2 (ETCO2) to exclude DKA. 58 pediatric patients were enrolled with 15 being in DKA. No patient with ETCO2 > 30 mmHg had DKA. Six patients with ETCO2 < 30 mmHg did not have DKA. Other studies done in children have shown similar results.
An article recently published by Chebl and colleagues examined patients older than 17 years with hyperglycemia. In this study, 71 patients were included with 32 having DKA. A ETCO2 >35 excluded DKA in this group while a level <22 was 100% specific for DKA.
Bottom line: ETCO2 >35 mmHg is a quick bedside test that can aid in the evaluation of hyperglycemic patients.
Gilhotra Y and Porter P. Predicting diabetic ketoacidosis in children by measuring end-tidal CO2 by non-invasive nasal capnography. J Paediatr Child Health 2007; 43 (10): 677-80.
Chebl BR, Madden B, Belsky J, Harmouche E, Yessayan L. Diagnostic value of end tidal capnography in patients with hyperglycemia in the emergency department. BCM Emerg Med 2016: 16 (1).
Category: Pediatrics
Posted: 2/26/2016 by Mimi Lu, MD
(Updated: 2/27/2016)
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Perianal Group A Strep is an infectious dermatitis seen in the perianal region that is caused by Group A beta-hemolytic Strep. Children will have a characteristic rash with a sharply-demarcated area of redness, swelling, and irritation around the perianal region. There may be associated swelling and irritation of the vulva and vagina (in girls) and penis in boys. Patients can have bleeding or itching during bowel movements.
The age range is often <10 years of age. There is often an absence of fever or other systemic symptoms.The diagnosis can be confirmed by obtaining a Rapid Strep swab from the area of interest. You can also collect a bacterial culture of the area.
Treatment requires a 14 day course of penicillin. Amoxicillin (40 mg/kg/day divided TID) and clarithromycin are alternative treatments. The additional of topical bactroban (mupirocin) can be effective, but it should not be used as monotherapy. Re-occurrence is common, so close follow-up is key.
Category: Pediatrics
Keywords: UTI, fever, infant (PubMed Search)
Posted: 2/19/2016 by Jenny Guyther, MD
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There is not much data published on susceptabilities of urinary pathogens in infants. What resistance patterns are seen in infants < 2 months in gram negative uropathogens?
A retrospective study of previously healthy infants diagnosed with urinary tract infections in Jerusalem over a 6 year period examined this question. The standard treatment at this hospital included ampicillin and gentamycin for less than 1 month olds and ampicillin or cefuroxime for 1-2 month olds.
306 UTIs were diagnosed
74% were resistant to ampicillin
22% were resistant to cefazolin and augmentin
8% were resistant to cefuroxime
7% were resistant to gentamycin
Of the organisms cultured, 76% were E. coli and 14% were Klebsiella.
Bottom line: Know your local resistance patterns.
Segal Z et al. Infants under two months of age with urinary tract infections are showing increasing resistance to empirical and oral antibiotics. Acta Paediatrica. Dec 2015. Epub ahead of print.
Category: Pediatrics
Keywords: etomidate, sedation (PubMed Search)
Posted: 1/15/2016 by Jenny Guyther, MD
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ED study of 60 pediatric patients for procedural sedation
Bottom line: Etomidate can achieve effective sedation in children for a short procedure. Although respiratory effects were noted, none of them required assisted ventilation.
Mandt MJ, Roback MG, Bajaj L, Galinkin JL, Gao D, Wathen JE. Etomidate for short pediatric procedures in the emergency department. Pediatr Emerg Care. 2012 Sep;28(9):898-904.
Category: Pediatrics
Keywords: Pediatrics, Venipuncture, J-Tip, Jet-Injected, Local anesthesia, Topical anesthesia (PubMed Search)
Posted: 1/2/2016 by Christopher Lemon, MD
(Updated: 3/18/2025)
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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?
Category: Pediatrics
Keywords: inflatable, trauma, bounce house (PubMed Search)
Posted: 12/17/2015 by Jenny Guyther, MD
(Updated: 12/18/2015)
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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).
Category: Pediatrics
Keywords: air enema, intussusception (PubMed Search)
Posted: 11/20/2015 by Jenny Guyther, MD
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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.
Category: Pediatrics
Keywords: glenohumoral dislocations, anterior shoulder, orthopedics, pediatrics (PubMed Search)
Posted: 11/6/2015 by Kathleen Stephanos, MD
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- 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.
Category: Pediatrics
Keywords: UTI, Fever, febrile, AAP, clinical practice guideline (PubMed Search)
Posted: 10/23/2015 by Mimi Lu, MD
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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.
Category: Pediatrics
Keywords: Blunt abdominal trauma, seat belt sign, pediatrics (PubMed Search)
Posted: 10/16/2015 by Jenny Guyther, MD
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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.
Category: Pediatrics
Keywords: pediatric, code, resuscitation, medication error (PubMed Search)
Posted: 10/3/2015 by Christopher Lemon, MD
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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.
Category: Pediatrics
Keywords: wrist, fracture, trauma (PubMed Search)
Posted: 9/18/2015 by Jenny Guyther, MD
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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.
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.