Keywords: laceration, suture, absorbable (PubMed Search)
A facial laceration on a child can present a unique challenge which is not limited to the initial visit. The traditional teaching has been to use nonabsorbable sutures and have the patient return in 5 days for removal. A recent study compared the cosmetic outcome of linear facial lacerations 1 to 5 cm that were closed with either Ethicon fast absorbing surgical gut or monocryl nonabsorbable sutures. Patients were randomized and returned to the ED in 4-7 days and 3-4 months. Scars were assessed by caregivers and blinded physicians. Results showed that caregivers preferred absorbable sutures. Visual analog scores as given by caregivers were not statistically different between the 2 groups at the 3 month mark. The blinded physicians did give better cosmetic outcome scores to the absorbable suture group which differs from previous studies that had shown equivocal results. Of note, all absorbable sutures were no longer visible after 14 days.
Bottom line: Try absorbable sutures the next time you are suturing a child and the parents may be happier and you will not have to try and take out your sutures from a squirming, screaming child.
Luck et al. Comparison of Cosmetic Outcomes of Absorbable Versus Nonabsorbable Sutures in Pediatric Facial Lacerations. Pediatric Emergency Care. Vol 29. No 6. 2013.
Clinically important traumatic brain injuries are rare in children. The PECARN study provides decision rules for when to avoid unnecessarily obtaining a CT for children who have suffered head trauma.
For children < 2 years old: <0.02% risk of clinically important TBI
For children > 2 years old: <0.05% risk of clinically important TBI
Kuppermann N, et al. Pediatric Emergency Care Applied Research Network. Identification of childrent at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet 2009 Oct 3;374(9696):1160-70.
Keywords: sedation, pain management (PubMed Search)
Cringing at the thought of sewing up another screaming 2 year old?
Consider intranasal fentanyl.
Who: Young, otherwise healthy pediatric patients undergoing minor procedures (laceration repair, fracture reduction/splinting, etc...)
What: Fentanyl (2mcg/kg)
When: 5 minutes pre-procedure
Why: More effective than PO, less invasive than IV while being equally efficacious.
How: Use an atomizer, splitting the dose between each nostril.
Keywords: lactate, sepsis, pediatric (PubMed Search)
Lactate is commonly used in the adult ED when evaluating septic patients, but there is a lack of literature validating its use in the pediatric ED. Pediatric studies have suggested that in the ICU population, elevated lactate is a predictor of mortality and may be the earliest marker of death.
A retrospective chart review over a 1 year period showed that one elevated serum lactate correlated with increased pulse, respiratory rate, white blood cell count and platelets. Serum lactate had a negative correlation with BUN, serum bicarbinate and age. Elevated lactate levels were higher for admitted patients. However, the mean serum lacate level was not statistically different between those diagnosed with sepsis and those that were not.
The study included 289 patients less then 18 years who had both blood cultures and lactate drawn. This community hospital had a sepsis protocol in place that automatically ordered a lactate with blood cultures. Only previously healthy children were included.
The study is limited by its small sample size and overall low lactate levels. Despite having a protocol in place, only 39% of patients who had blood cultures drawn had lactate levels available for analysis. The mean serum lacate in this study was 2.04 mM indicating that the study population may not have been sick enough to determine mortality implications. There were no serial measurements.
Bottom line: Consider measuring serum lacate in your pediatric patient with suspected sepsis. Pediatric ICU literature does suggest that an serum lactate as low as 3mM is associated with an increased mortality in the ICU.
Reed et al. Serum Lactate as a Screening Tool and Predictor of Outcome in Pediatric Patients Presenting to the Emergency Department With Suspected Infection. Pediatric Emergency Care. 2013; Vol 29: 787-791.
Risk stratisfication score introducted by Maden Samuel in 2002.
The Pediatric Appendicitis Score had a sensitivity of 1, speciificity of 0.92, positive predictive value of 0.96, and negative predictive value of 0.99
Scores of 4 or less are least likely to have acute appendicitis, while scores of 8 or more are most likely.
Pediatric Appendicits Score. Samuel, M. J Pedia Surg.37:877-888. 2002.
Keywords: NIV, intubation (PubMed Search)
Pediatrics Text 19th edition, Nelson
Infant lumbar puncture is often difficut and may require repeated attempts. The traditional body positioning is lateral decubitus. Previous studies have examined the saftey of having the patient in a sitting position, and neonatal studies have suggested that the subarachnoid space increases in size as the patient is moved to the seated position. A study by Lo et al published last month looked to see if the same held true in infants.
50 healthy infants less then 4 months old had the subarachnoid space measured by ultrasound between L3-L4 in 3 positions: lateral decubitus, 45 degree tilt and sitting upright.
This study found that the size of the subarachnoid space did not differ significantly between the 3 positions. Authors postulated that a reason for increase sitting LP success rate that had been reported in anestesia literature with tilt position could be due to other factors such as increased CSF pressure, intraspinous space widening or improved landmark identification.
Sitting or Tilt Position for Infant Lumbar Puncture Does Not Increase Ultrasound Measurements of Lumbar Subarachnoid Space Width. Pediatr Emer Care 2013;29: 588-591.
Ultrasound findings of appendicitis
MedStudy Pediatrics Board Review Core Curriculum
Keywords: stroke, children, infection (PubMed Search)
Acute ischemic stroke occurs in 3.3/100,000 children per year. Up to 30% of these are caused by varicella. This can be diagnosed if the patient has had varicella infection within the past 12 months, has a unilateral stenosis of a great vessel, and has a positive PCR or IgG from the CSF.
Treatment includes anticoagulation, acyclovir for at least 7 days and steroids for 3-5 days.
Outcome is normally good and spontaneous improvement can be seen.
Inflammation of other arteries, including other areas of the brain, can also be seen. Treatment options for this can include high dose glucocorticoids and possibly immunosuppresive agents.
Simma et al. Therapy in pediatric stroke. Eur J Pediatr. Published online 06 November 2012.
An overweight 5 year old male presents with acute onset abdominal pain that localizes to the right lower quadrant. What are some causes of a limited or nondiagnostic ultrasound study in children?
Acute appendicitis is a time sensitive diagnosis. Ultrasound is frequently used as the initial diagnostic imaging in children. There are several reasons why the appendix may not be visualized, including retro-cecal location, normal appendix, perforation, and inflammation around the distal tip. An additional clinical predictor associated with poor or inconclusive ultrasound results in appendicitis is increased BMI (body mass index).
A study examining 263 pediatric patients found when BMI > 85th percentile and clinical probability of appendicitis was <50%, 58% of ultrasounds were nondiagnostic. Children with a BMI <85th percentile and clinical probability of appendicitis was <50%, had nondiagonstic scans 42% of the time. These trends were also mimicked in the patients with a higher clinical probability of appendicitis. In the child with a nondiagnostic ultrasound, options include observation and repeat ultrasound scan or CT scan, both of which have associated risks.
Keywords: antibiotics, wait and see (PubMed Search)
2013 AAP AOM Guidelines UPDATE
Keywords: Conjunctivitis (PubMed Search)
Children frequently present with "pink eye" to the ED. When they do, parents often expect antibiotics. How many of these kids actually need them? Previous studies have shown approximately 54% of acute conjunctivitis was bacterial, but antibiotics were prescribed in 80-95% of cases.
A prospective study in a suburban children's hospital published in 2007, showed that 87% of the cases during the study period were bacterial. The most common type of bacteria was nontypeable H. influenza followed by S. pneumoniae.
Topical antibiotic treatment has been shown to improve remission rates by 6-10 days.
Patel et al. Clinical Features of Bacterial Conjunctivitis in Children. Academic Emergency Medicine 2007; 14:1-5.
You have diagnosed an infant or child with pneumonia. How do you decide if they need admission?
The Pediatric Infectious Disease Society and the British Thoracic Society each have guidelines from 2011 to help with this decision.
In children, it is important to consider the maximum doses of local anesthetics when performing a laceration repair or painful procedure like abscess drainage. If there are multiple lacerations, or large lacerations, it may be possible to exceed those doses if one is not careful.
Max doses of common anesthetics
For example, in a 20 kg child (an average 5-6 year old), the maximum doses would be:
Keywords: UTI, urinary tract infection (PubMed Search)
--The diagnosis and treatment of pediatric urinary tract infections (UTIs) can be broken down into different age groups. The AAP has recently updated its recommendations for children age 2 - 24 months.
--In ill-appearing febrile infants age 2 – 24 months, who require early initiation of antibiotics, clinicians should obtain urinalysis and urine culture by catheterization or suprapubic aspiration prior to administration of the first dose of antibiotics.
--Key components of diagnosing a UTI include: urinalysis with the presence of pyuria (>10 WBCs per µL) and bacteriuria. The ultimate diagnosis relies on identification of >50,000 CFUs per mL of a single urinary pathogen in culture.
--Treatment of most UTIs in well appearing infants 2-24 months can be done with oral antibiotics for a course of 7-14 days. Common antibiotics used include: amoxicillin-clavulanate, trimethoprim-sulfamethoxazole, or cephalosporins (cefpodoxime, cefixime) based on local patterns of susceptibility.
--Febrile infants with UTIs should undergo renal and bladder ultrasound (RBUS) to evaluate the renal parenchyma and identify complications of UTI in children who are not responding to treatment within 48 hours.
--Voiding cystourethrography (VCUG) to diagnose vesicoureteral reflux (VUR) as a cause of UTI should not be obtained routinely, but only in children with abnormal RBUS or with recurrent febrile UTIs.
Urinary Tract Infection: Clinical Practice Guideline for the Diagnosis and Management of the Initial UTI in Febrile Infants and Children 2 to 24 Months. Subcommittee on Urinary Tract Infection, Steering Committee on Quality Improvement and Management. Pediatrics 2011; 595 – 610.
Luu JL, Wendtland CL, Gross MF, et al. Three percent saline administration during pediatric critical care transport. Ped Emerg Care 2011;27(12):1113-1117
This winter season has brought a rise in influenza and RSV activity in Maryland and in many parts of the country. It is also important to remember other potentially lethal infections that are prevalent in the winter and early spring months, such as Neisseria meningitidis. In fact, a recent study2 showed a potential increase in meningococcal disease when influenza and RSV activity is high.
Encapsulated, gram-negative diplococcus
Found in nasopharyngeal secretions, carrier rates 2-30% in normal populations
Age of incidence has 2 peaks: children < 2 years old, teens 15-19 years old
Young adults who live in shared housing, such as college dorms and military recruits
Early non-specific symptoms of URI, fever, malaise, myalgias
Meningitis: non-specific prodrome + headache, stiff neck (not found in younger children who often present atypically with irritability and/or vomiting)
Meningococcemia: above symptoms + hypotension + petechial rash (>60% of patients)
Early (!) antibiotics: 3rd generation cephalosporins (<3mo: cefotaxime; older infants, children, and teens: ceftriaxone); PCN G is antibiotic of choice for susceptible isolates
Early and aggressive management of shock
Tetravalent vaccine, MCV4 (Menactra, Menveo), available for serogroups A, C, Y and W-135 is given routinely at age 11-12 years old with an additional booster at 16-17 years old. MCV4 does not protect against serogroup B which accounts for 30% of infections.
1. Cross JT, Hannaman RA. Infectious Disease. MedStudy Pediatrics Board Review Core Curriculum: 5th edition. 2012; 5-11.
2. Jansen AG, Sanders EA, VAN DER Ende A, VAN Loon AM, Hoes AW, Hak E. Invasive pneumococcal and meningococcal disease: association with influenza virus and respiratory syncytial virus activity?. Epidemiol Infect. Nov 2008;136(11):1448-54.
3. Javid MH. Meningococcemia. Available at http://emedicine.medscape.com/article/221473. Medscape Reference. Last updated Aug. 2. 2012.
Keywords: magnets, bowel perforation, ischemic necrosis, ingestion (PubMed Search)
Patient: A 10 year old female is brought to the ED after swallowing 2 beads (see image). Based on the findings, what are your concerns and what is the disposition?
Answer: Multiple Magnet Ingestion
The mother was eventually able to produce the magnetic beads ingested at home 2 hours prior to presentation
The ingestion of multiple magnets is a medical emergency. If the 2 magnets separate and reconnect it can lead to:
- pressure necrosis
- bowel perforation
- fistula formation
- and/or bowel obstruction secondary to kinking, inflammatory reaction, and/or internal herniation
Patients with a multiple magnet ingestion should be taken emergently to the OR for endoscopic evaluation.
If the magnets have passed the pylorus, conservative management with laxatives and serial X-rays may be performed, however if their position becomes fixed on serial imaging then an emergent laparotomy may need to be performed for the removal of the FBs before the symptoms and signs occur.
Bottom line: Patients presenting with a multiple magnet ingestion need to be admitted regardless of the FB location. Consult GI and pediatric surgery early, since prompt removal can prevent devastating outcomes. Single magnet ingestions can be managed conservatively with serial exams and imaging.
Alzaham AM et al, Ingested magnets and gastrointestinal complications. Journal of Paediatrics and Child Health; 43 (2007) 497–498.