Category: Pediatrics
Keywords: drowning, submersion, seizure, intubation (PubMed Search)
Posted: 4/27/2012 by Mimi Lu, MD
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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.
Category: Pediatrics
Keywords: transfusion, anemia, hemoglobin (PubMed Search)
Posted: 4/20/2012 by Mimi Lu, MD
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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
Category: Pediatrics
Posted: 4/13/2012 by Rose Chasm, MD
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AAP Prep Curriculum
Category: Pediatrics
Keywords: electrical injury, EKG (PubMed Search)
Posted: 4/6/2012 by Mimi Lu, MD
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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.
Category: Pediatrics
Posted: 3/31/2012 by Rose Chasm, MD
(Updated: 2/17/2025)
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2012 Pediatrics Review and Education Program
Category: Pediatrics
Keywords: orthopedics (PubMed Search)
Posted: 3/23/2012 by Mimi Lu, MD
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Patellar dislocations:
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
Category: Pediatrics
Posted: 3/16/2012 by Mimi Lu, MD
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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
Category: Pediatrics
Posted: 3/9/2012 by Rose Chasm, MD
(Updated: 2/17/2025)
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American Academy of Pediatrics PREP Curriculum
Category: Pediatrics
Posted: 2/24/2012 by Mimi Lu, MD
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Category: Pediatrics
Posted: 2/17/2012 by Mimi Lu, MD
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Children & Appendicitis
Category: Pediatrics
Posted: 2/10/2012 by Rose Chasm, MD
(Updated: 2/17/2025)
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Emergency Medicine Clinics of North America
Orothopedic Emergencies
November 2010, Volume 28, Number 4
Category: Pediatrics
Posted: 1/27/2012 by Mimi Lu, MD
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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.
Category: Pediatrics
Keywords: infectious disease, neonatal infections, umbilical disorders (PubMed Search)
Posted: 1/20/2012 by Mimi Lu, MD
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Category: Pediatrics
Keywords: sedation, ketamine (PubMed Search)
Posted: 1/6/2012 by Mimi Lu, MD
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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.
Route Onset Duration Dose
IM 3-5 min 20-30min 3-5 mg/kg
IV 1 min 5-10 min 1-2 mg/kg
Category: Pediatrics
Posted: 12/30/2011 by Rose Chasm, MD
(Updated: 2/17/2025)
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Pediatrics Board Review, MedStudy
Category: Pediatrics
Keywords: Bayonet, fracture reduction technique, radius (PubMed Search)
Posted: 12/16/2011 by Mimi Lu, MD
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Pediatric forearm fractures:
Category: Pediatrics
Posted: 12/9/2011 by Rose Chasm, MD
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NMS Pediatrics
Category: Pediatrics
Keywords: child abuse, skeletal survey (PubMed Search)
Posted: 12/3/2011 by Vikramjit Gill, MD
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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….
References:
Category: Pediatrics
Keywords: Kawasaki, vasculitis, fever, (PubMed Search)
Posted: 11/25/2011 by Mimi Lu, MD
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Classic Kawasaki is diagnosed by fever for greater than 5 days plus 4 out of 5 classic signs.
But what about an 8 month-old with 6 days of fever plus nonexudative conjunctivitis, unilateral cervical adenopathy and a diffuse maculopapular rash? Send some labs!
Incomplete Kawasaki is defined as fever for >5 days with 2 or more of the classic findings plus elevated ESR (>40mm/hr) and CRP (>3.0mg/dL). It is most common in infants under 12 months of age.
Disposition for the 8 month-old?
If the echo is normal, follow up in 24-48 hours and will need a repeat echo if fever persists.
TREAT kids with IVIG and aspirin (which generally means admission) if echo is positive, or with normal echo and the presence of 3 or more supplemental criteria:
Category: Pediatrics
Keywords: Passenger Safety (PubMed Search)
Posted: 11/18/2011 by Mimi Lu, MD
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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.
1. Zonfrillo MR, Nelson KA, Durbin DR. Emergency physician's knowledge and provision of child passenger safety information. Acad Emerg Med 2011;18:145-151.
2. Durbin DR. Child passenger safety. Pediatrics 2011;127:788-793