UMEM Educational Pearls - Pediatrics

Submersion injuries are the 2nd leading cause of accidental death in children with 1/3 of survivors sustaining significant neurologic sequelae.  50% of drownings occur from May to August.

40% of all drowning victims are children under age 4, with males affected 3 times as often as females.  Most drownings occur with 10 feet of safety.  Infants and toddlers drown most often in bathtubs (especially if <1 year old), buckets, toilets, pools and hot tubs (most often the pools are in-ground).  Those with seizure disorders have a 10-14 fold higher likelihood of drowning.

Aspiration of as little as 1-3ml/kg of fluid may cause pulmonary edema, surfactant inactivation or washout, pulmonary shunting with resulting V/Q mismatching, or direct injury to the alveolar membrane. 

Immediate and adequate resuscitation, including intubation, is the single most important factor determining survival.  Always check body temperature as hypothermia is common.  In general, prophylactic antibiotics and steroids are not indicated unless drowning occurred in grossly contaminated water/sewage.  

Children are at higher risk for complications related to the transfusion of blood products compared with adults. So when should we consider transfusion?

Normal hemoglobin values:

- highest at birth (14 - 24 g/dL),

- decreasing to 8 to 14 g/dL at 3 months,

- increasing to 10 to 14 g/dL at age 6 months to 6 years, 11 to 16 g/dL at age 7 to 12 years, and 11.5 to 18 g/dL in adulthood.

- Although the number of platelets are in the normal range at birth, their function is impaired.

For infants younger than 4 months, thresholds for red blood cell transfusions:

- hemoglobin levels are 12 g/dL for preterm infants or term infants born anemic,

- 11 g/dL for chronic oxygen dependency,

- 12 to 14 g/dL for severe pulmonary disease,

- 7 g/dL for late anemia in a stable infant,

- 12 g/dL for acute blood loss exceeding 10% of estimated blood volume.

For infants older than 4 months, thresholds for red blood cell transfusions:

- hemoglobin levels are 7 g/dL in a stable infant,

- 7 to 8 g/dL in a critically unwell infant or child,

- 8 g/dL in an infant or child with perioperative bleeding,

- 9 g/dL in an infant or child with cyanotic congenital heart disease (increased oxygen demand).

- 9 g/dl in children with thalassemia major (to slow bone marrow stimulation)

For children with sickle cell disease (SCD):

- threshold is 7 to 9 g/dL, or more than 9 g/dL if the child has previously had a stroke.

- perioperatively for major surgery: 9 to 11 g/dL, and sickle hemoglobin should be less than 30%, or less than 20% for thoracic or neurosurgery.

Bottom line:

A threshold of 7 g/dL is indicated for the transfusion of packed red blood cells in most children.

Reference:

1) Transfusion guidelines in children. Anasethesia and Intensive Care Medicine. 2012;13(1);20–23.

2) Medscape clinical education briefs

• usually in preschool or early school-age children presenting with tea-colored urine
• most commonly is postinfectious (following URI)
• may also have periorbital edema and high blood pressure
• UA shows blood, and microscopy shows RBC's and RBC casts
• no definitive emergent treatment, but prognosis is usually good with resolution of symptoms over 8-10 weeks

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It is likely that during ones career in Emergency Medicine, one will be faced with how to work up a child presenting to the ER following exposure to common house electrical current.  The older recommendations were such that all children exposed, received a screening EKG and were admitted to telemetry for monitoring.  However, a relatively recent article in the Annals of Emergency Medicine suggests otherwise.

In fact, after reviewing several studies the authors conclude that, although there is not enough literature to support evidence based practice “guidelines”, there appears to enough evidence to support that practice of “safely discharging these children without an initial EKG evaluation or inpatient cardiac monitoring after a common household current exposure.” This includes both 120V and 220 V exposures.

Clearly, some patients may require work up and/or admission based on other injuries or clinical presentation.

References:
Chen E H, Sareen A, Do Children Require ECG Evaluation and Inpatient Telemetry After Household Electrical Exposures? Ann Emerg Med. 2007;49:64-67.

• both head tilting to one side and rotation of the chin toward the other side
• develops during infancy with episodes that last for hours to days
• idiopathic neurologic condition which wanes after 2 years and stops by 3 years
• mild delays in fine and gross motor skills are common along with family history of migraines
• no accepted medical treatment or therapy
• must have a normal physical and neurological examination that does not include abnormal/assymetric muscle tone, abnormal eye movements, or cranial nerve palsy

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Patellar dislocations:

• lateral displacement is the most common
• tender with limited range of motion
• caused by sudden twisting movement, either with or without contact
• more common in females and young adolescents
• reduction by extension of the knee and medial pressure on the patella
• knee immobilizer and crutches with orthopedics or sports medicine follow up
• recurrent cases usually require surgery for definitive repair

References:
1. http://emedicine.medscape.com/article/90068-overview
2. New England Musculoskeletal Institute. http://nemsi.uchc.edu/clinical_services/orthopaedic/knee/patellar_dislocation.html

Rashes that include palms/ soles

- Hand-Foot-Mouth Disease

- Kawasaki

- Erythema multiforme/ Stevens Johnson's Syndrome/ Toxic Epidermal Necrolysis

- Rocky Mountain Spotted Fever

- Scabies

- Syphillis

Rashes that have +Nikolsky's sign

- Scalded Skin Syndrome

- TEN

-  Pemphigus Vulgaris

Rashes that desquamate

- Scalded Skin Syndrome

- Toxic Shock Syndrome

- Scarlet Fever

- Kawasaki

- TEN

• acute gastroenteritis is a self-limited illness
• however, damage to the brush border of the small intestine mucosa where lactase is present may lead to a secondary lactase deficiency and subsequent inability to digest lactose properly
• partially or minimally digested lactose moves into the colon where it is fermented by enteric bacteria resulting in hydrogen, carbon dioxide, and acids
• these byproducts result in symptoms reported for those with lactase deficiency: cramps, abominal pain and distension, and flatulence
• the increased solute load in the large intestine leads to increased osmotic pressure, causing watery diarrhea
• early refeeding following gastroenteritis is recommended, but many clinicians recommend dairy restricted diets acutely

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Children & Appendicitis 

• Vomiting may be the first sign. 
• Children may not experience anorexia and may actually request food. 
• Most young children have perforation at the time of diagnosis.
• Children younger than 2 years of age may have generalized symptoms such as irritability and tachypnea. 
• Ultrasonography is useful in evaluation of thin children but is very operator dependent.
• CT with oral contrast and i.v. contrast may be needed to differentiate intraabdominal structures in thin children

• diagnosis of exclusion
• bilateral leg pain only in the evening/night
• should NOT have a limp, pain, or symptoms during the day
• completely normal physical exam
• no systemic symptoms, localizing signs, joint involvement, or limitation of activity
• look for something else if there is anything wrong on review of systems, examination, or imaging studies

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Potential Causes of Neonatal Apnea and Bradycardia

• Central nervous system  

Intraventricular hemorrhage, drugs maternal/fetal, seizures, hypoxic injury, herniation, neuromuscular disorders, brainstem infarction or anomalies (e.g., olivopontocerebellar atrophy), general anesthesia.

• Respiratory

Pneumonia, obstructive airway lesions, upper airway collapse, atelectasis, extreme prematurity  (<1,000 g), phrenic nerve paralysis, severe hyaline membrane disease, pneumothorax, hypoxia, malformations of the chest.

• Infectious

Sepsis, meningitis (bacterial, fungal, viral), RSV

• Metabolic

Hypoglycemia, hyper/hyponatrmia,  hyperammonemia, decreased organic acids, hypothermia.

• Cardiovascular

Hypotension/hypovolemia, heart failure, PDA, anemia, vagal tone.

There are limited direct comparisons of (intravenous (IV) vs. intramuscular (IM) ketamine for pediatric procedural sedation in the emergency department. The only RCT comparing IV and IM ketamine was by Roback et al. and compared an IV dose of 1mg/kg vs. IM 4mg/kg. The study authors reported less procedural pain with IM administration compared with IV.  However, vomiting occurred more frequently in the IM group, 26.3% compared to 11.9% in the IV group and recovery time was 49 minutes shorter with IV vs IM use.

• vasculitis of small vessels with neutrophilic infiltration of venules and arterioles
• classic triad:  painful recurrent oral and genital ulcers with inflammatory eye disease
• key finding of recurrent buccal apthous ulcers (nearly 100% of patients)
• diagnosis is made when recurrence of oral ulceration occurs at least 3 times in 1 year plus 2 of the following: recurrent genital ulceration , eye lesions, skin lesions, or positive pathergy test.
• initial ED treatment is corticosteroids (oral or topical).  Reserve colchicine and pentoxifylline for ulcerative maifestations.

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Pediatric forearm fractures:

• causes gastric outlet obstruction and vomiting
• 1 in every 500 infants; with a 4:1 male-to-female ratio and a family history in another sibling
• symptoms begin 2-4 weeks after birth, with projectile NON-bilious vomiting
• firm, mobile, nontender, olive-shaped mass in right hypochondrium or epigastric area
• diagnosis confirmed with US or upper GI series
• treatment is a pyloromyotomy, but fluid and electrolyte replacement is vital in ED

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You just finished assessing a 6 month old in the Pediatric ED who can’t move his right leg.  You suspect child abuse.  You’re ready to order labs, a head CT, ophtho consult, skeletal survey and call Child Protective Services.   While your doing all of this, your medical student asks you, “What exactly are you looking for on the skeletal survey?”

A skeletal survey is mandatory for cases of suspected child abuse in children under the age of 2 years.  Approximately 60% of the fractures seen in abused children are younger than 18 months old.

When you are looking at a skeletal survey, carefully look for the following:

1. Multiple, healing fractures of various ages

2. Rib fractures, especially in the posterior ribs

3. Metaphyseal chip and buckle fractures

4. Spiral fractures in long bones (especially in children that can’t walk)

5. Skull fractures which are not simple and linear

6. Scapula fractures

More to come about child abuse…. 

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Attachments

1111251332_2009_Red_Book.doc (384 Kb)

Child Passenger Safety.

Perhaps one of the greatest contributions emergency physicians can provide to society comes in the  form of anticipatory guidance. It is important to take the opportunity during the ED encounter to provide information to parents to prevent future injuries. Child passenger safety is one clear example. With over 330,000 pediatric visits to EDs  across the US annually attributed to motor vehicle collisions, the need to provide clear recommendations to parents on how to restrain their children in their vehicle is paramount. Despite a recent survey of over 1000 EPs in which 85% of respondents indicated child passenger safety should routinely be a part of pediatric MVC discharge instructions, only 36% of EPs knew the latest guidelines on child passenger safety.   The American Academy of Pediatrics provides such guidelines. These recommendations were recently adjusted in 2011.

(1) Infants up to 2 years must be in REAR-facing car seats
(2) Children through 4 years in forward-facing car safety seats
(3) Belt-positioning booster seat for children through at least 8 years old
(4) Lap-and-shoulder seat belts for those who have outgrown booster seats. How does one know when the child has outgrown the booster seat?
     a. Can the child sit with his/her knees bent at the edge of the seat?
     b. Does the shoulder belt lie across the middle of the chest/shoulder?
     c. Does the lap belt lie across the upper thighs and not the abdomen?
(5) Children younger than 13 should sit in the rear seats

Special Thanks to JV Nable, MD, EMT-P for writing this pearl.

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