Keywords: Pediatric, Genital, Foreign Body (PubMed Search)
Keywords: Sexual Assault, Children, Herpes, Gonorrhea, Chlamydia (PubMed Search)
The Emergency Department is often the first line in detecting the sexual abuse of a child. Unfortunately, what you do or don't say/ask/test can significantly affect the legal protection of the abused child.
1. Know your region's dedicated sexual abuse center, if one exists. These centers have personnel trained in interviewing and forensic evidence collection. There may be different centers for children of different ages.
2. Know your state laws regarding what is and is not admissible as evidence of sexual abuse. GC/CT urine testing (NAAT), though more sensitive than swab cultures, is not currently admissible as evidence in many states.
3. Withhold prophylactic antibiotic treatment when possible - antibiotics work well, and often eliminate evidence. Withholding antibiotics is acceptable if the child is asymptomatic or only has very mild symptoms.
4. Any sexually transmitted disease in a child warrants further workup and investigation. Primary genital HSV in a young child warrants testing for Gonorrhea and Chlamydia, and appropriate referral as well as police involvement.
5. Finally, if trained personnel is available to conduct the interview of a child, limit the questions you ask the child directly. Any evidence in your note that you may have suggested something to the child in your line of questioning could negate the validity of their testimony.
Keywords: congenital heart disease, cyanosis, neonate, prostaglandin (PubMed Search)
Ductal-Dependent Cardiac Lesions in the Neonate
Keywords: Tungsten, ring, removal, hand injury, finger injury (PubMed Search)
Ring-removal is a dreaded problem in pediatric hand and finger injuries. Removal can be difficult and time consuming. The relatively recent introduction of Tungsten into the jewelry market has further complicated this problem:
However, it is:
This video explains how. Of course, this works on adults as well.
I have no relationship with the copany which made this video - it was simply chosen for its clear explanation of the solution described in this pearl.
Keywords: conjunctivitis, pinkeye, gonococcal ophthalmia neonatorum (PubMed Search)
Conjunctivitis in Children:
HOWEVER... remember to consider other common etiologies of a red eye in a child!
Emans SJ, Laufer MR, Goldstein DP. Vulvovaginal problems in teh prepubertal child. In: Pediatric and Adolescent Gynecology. 4th ed. Philadelphia, Pa: Lippincott-Raven; 1998:75-107
Forbes D, Withers G. Prophylactic therapy in cyclic vomiting. J Pediatr Gastroenterol Nutr. 1995;21:S57-S59
Symon DN, Russell G. The relationship between cyclic vomiting syndrome and abdominal migraine. J pediatr Gastroenterol Nutr. 1995:21:S42-S43
Keywords: nasal foreign bodies, button battery, batteries, ENT (PubMed Search)
While it is often ok to defer removal of pesky nasal foreign bodies until ENT follow up, if the foreign body may be a button battery, emergent identification and removal is indicated.
Damage can occur in 3 hours, and by 24 hours, near complete necrosis of turbinates and ala has been described.
Dane S, Smally AJ, Peredy TR. A Truly Emergent Problem: Button Battery in the Nose. Academic Emergency Medicine. 2000; 7:204-206
Glynn F, Amin M, Kinsella J. Nasal Foreign Bodies in Children: Should They Have a Plain Radiograph in the Accident and Emergency? Pediatric Emergency Care. 2004;24:217-218.
Keywords: pollutant, breastfeeding, environment, contaminants (PubMed Search)
While breastfeeding is still the preferred source of infant nutrition by the AAP, a little-known fact is that breastfeeding may expose the nursing infant to environmental pollutants to which they might not normally be exposed. If you have a mother that appears ill due to exposure to any of these agents, don't forget to have the infant examined as well for signs of intoxication.
American Academy of Pediatrics Committee on Environmental Health. Chapter 3. In: Etzel RA, ed. Pediatric Environmental Health, 2nd ed. Elk Grove Village, IL: American Academy of Pediatrics; 2003.
Rimoin DL, Connor JM, Pyeritz RE, eds. Emergy adn Rimoin's Principles and Practice of Medical Genetics. 4th ed. New York, NY: Churchill Livingstone; 2002
Ryan S, Scriver CR. Phenylalanine hydroxylase deficiency. GeneReviews. Seattle, Wash: Children's Health System and University of Washington; 2003.
Keywords: Brain Abscess, Pediatrics (PubMed Search)
Keywords: Sickle Cell Trait, Sudden Death, Pediatrics, Military, Sports Medicine, Law Enforcement, Medical Legal (PubMed Search)
You've probably long been taught that Sickle Cell Trait is an irrelevant piece of the PMH, unless you are a genetic counselor. Well, thanks to Dr. Rolnick and a literature search, I (and now you) know that that is incorrect.
Though Sickle Cell Trait (SCT) does not cause exactly the same pathologies as Sickle Cell Disease (SCD), there are believed to be a variety of RBC abnormalities associated with HgbS (such as measurably lower RBC deformability, and low levels of sickling under extreme heat and exercise conditions) which contribute to increased exercise-related sudden death. In one NEJM study of all deaths among 2 million (MILLION) military recruits over a 4 year period, the relative risk of otherwise unexplained sudden death for black recruits with HgbAS vs. black recruits without HgbS was 27.6 (p<0.001), and 39.8 (p<0.001) for all recruits (HgbAS vs. no HgbS).
I must say that this topic is not controversy-free, however, I should also note that my search for "Sickle Cell Trait and Sudden Death" turned up quite a few articles directed at plaintiff's attorneys.
The take-home point is that SCT is likely not a benign condition, and you must be cautious in telling patients that it is. Again, this phenomenon is best described in patients undergoing extreme physical exertion, but hopefully this will change how you think about SCT.
Keywords: infant, neonate, spasm (PubMed Search)
Infantile Spasms (West Syndrome):
Nelson's Essentials of Pediatrics, 5th Edition.
Haslam RH. Seizures in childhood. In: Behrman RE, Kliegman RM, Jenson HB, eds. Nelson Textbook of Pediatrics. 16th ed. Philadelphia, Pa: WB Saunders Co, 2000;1813-1829
Sabo-Graham T, Seay AR. Managemnt of status epilepticus in children. Pediatr Rev. 1998;19:306-309
Keywords: Pediatrics, hypertension, encephalopathy (PubMed Search)
Hypertensive encephalopathy is generally seen in children with renal disease, e.g. acute glomerulonephritis or ESRD.
Signs and symptoms include bp >99th percentile for age and height and neurologic impairment. May present acutely with seizure or coma, or subacute with HA, vomiting, lethargy, blurry vision or change in mental status. Exam findings may also include papilledema.
MRI may show increased signal in occipital lobes of T2 weighted images, known as reversible posterior leukoencephalopathy.
Treatment is to lower BP by 20-25% for the first 8 hours and to normative levels over 24-48 hrs. IV therapy with esmolol drip, labetalol or nicardapine are the treatments of choice. Nitroprusside prudent in most hypertensive adult emergencies must be used cautiously if history of renal disease secondary to cyanide toxicity. Seizure should also be treated as you would with status epilepticus.
Belsha CW - Ann Emerg Med - 01-MAR-2008; 51(3 Suppl): S21-3
Herman, Andrea "Visaul Diagnosis: A Child Who Has a Nosebleed and High Blood Pressure." Pediatrics in Review 2001 22:104-107
Kleigman et al. Nelson Textbook of Pediatrics. 18th edition 598.3.
Keywords: ACS, Sickle Cell (PubMed Search)
PEARL: Any patient that in your Emergency Department with a sickle cell disease (SCD)-related diagnosis requires incentive spirometry and frequent monitoring for acute chest syndrome (ACS). BRIEF WHY: ACS is the most common cause of hospitalization and death in patients with SCD.1,2 Nearly half of all patients who develop ACS are admitted for diagnoses other than ACS. Of those not admitted with ACS, radiographic and clinical findings of ACS appeared a mean of 2.5 days after admission.2 It is because of this that all patients with SCD related diagnoses at presentation, must be treated as though they are in the prodrome stage of ACS, and all require incentive spirometry to reduce the risk of progression to ACS.2 More to come...
PEARL: Any patient that in your Emergency Department with a sickle cell disease (SCD)-related diagnosis requires incentive spirometry and frequent monitoring for acute chest syndrome (ACS).
BRIEF WHY: ACS is the most common cause of hospitalization and death in patients with SCD.1,2
Nearly half of all patients who develop ACS are admitted for diagnoses other than ACS. Of those not admitted with ACS, radiographic and clinical findings of ACS appeared a mean of 2.5 days after admission.2 It is because of this that all patients with SCD related diagnoses at presentation, must be treated as though they are in the prodrome stage of ACS, and all require incentive spirometry to reduce the risk of progression to ACS.2
More to come...
Keywords: Pertussis, Whooping Cough (PubMed Search)
Pertussis (Whooping Cough):
Nelson's Essentials of Pediatrics, 5th Edition
Conners GP, Chamberlain JM, Ochsenschlager DW. Symptoms and spontaneous passage of esophageal coins. Arch Pediatr Adolesc Med. 1995;149:36-39
Macpherson RI, Hill JG, Otherson HB, Tagge EP, Smith CD. Esophageal foreign bodies in children: diagnosis, treatment, and complications. AJR Am J Roentgenol. 1996;166:919-924
Haddad GG. Primary ciliary dyskinesia. In: Behrman RE, Kliegman RM, Jenson HB, eds. Nelson Textbook of Pediatrics. 16th ed. Philadelphia, Pa: WB SaundersCo; 2000:1327-1328
Baskin MN. Injury-knee. In:Fleisher GR, Ludwig S, eds. Textbook of Pediatric Emergency Medicine. 4th ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2000:339-347
Staheli LT. Hip. In: Fundamentals of Pediatric Ortopoedics. 2nd ed. Philadelphia, Pa: Lippincott-Raven; 1998:68-71.