If there is a single truth of pediatric emergency medicine, it is that kids love to stuff things into their noses. A particular danger (aside from batteries, covered in a previous pearl) is the magnet.
Specifically, two magnets (as seen with magnet ear and nose rings, frequently worn by children and teens whose pesky parents won't allow piercings), attracted across the nasal septum can cause necrosis and perforation within hours.
Here's how to save yourself (and some noses):
"Ear to sternal notch" positioning has gained wide acceptance in the emergency medicine and anesthesia literature. Most often, this teaching is brought up with respect to obese adult patients whose large body habitus requires the raising of the neck and head to achieve airway alignment.
However, the correct anatomic positioning principle applies to all ages. Specifically, with regard to neonates, a shoulder roll is often placed indiscriminately to put the patient into the now out-dated "sniffing position," usually worsening the view of the airway.
Though this positioning is frequently misused, it can be easily adapted to apply ear to sternal notch positioning to neonates, whose misaligned airway is the result of a large occiput rather than a large torso. In all ages, if you follow these positioning principles, you will improve your view of the airway:
1. Align the ear to the sternal notch
2. Keep the face parallel to the ceiling (do NOT hyperextend the neck, as in the sniffing position)
3. In adults, the head usually needs to be raised (Image 1), while in infants, the torso usually needs to be raised (image 3).
Continuing the theme of endotracheal tube size pearls... You get a box call for a pre-term baby delivered precipitously by mom at home and baby is blue. EMS is bagging but unable to secure a definitive airway. What size ETT do you reach for? If you try to apply the formula "uncuffed ETT = (age/4) + 4", how much smaller than size 4 can you go?
You decided to intubate a child and wisely remembered that you should also follow with an NG/ OG after intubation to decompress the stomach. In order to avoid the blank stare when asked "what size"? Here's a nice mneumonic about Pediatric "tube" sizes... easy as 1-2-3-4!!! Please note ETT = endotracheal tube size.
So for example, a 4-year-old child would get intubated with a 5-0 ETT inserted to depth of 15 cm (3x ETT), a 10Fr NG/OG/foley (2x ETT), and a 20Fr chest tube (4x ETT).
Also, remember that you can use cuffed tubes in any child except neonates but the formula needs to be adjusted as follows: cuffed endotracheal tube ID (mm) = (age/4) + 3.5
So the magnesium didn't work, and the baby is on the way! You're prepared with everything you need for the delivery from bulb suction to a tripod for Dad's camera... But what is going to special about this baby?
Babies born to mothers who received magnesium therapy for any reason are at risk for hypotonia and severe respiratory depression.
Now that influenza season is in full swing, remember that early antiviral treatment can reduce the risk of complications in high-risk individuals. One of those high-risk groups is children <2 years, with the highest hospitalizations and mortality in infants <6 months.
According to the CDC website:
Recommended antiviral medications (neuraminidase inhibitors) are not FDA-approved for treatment of children aged <1 year (oseltamivir) or those aged <7 years (zanamivir). Oseltamivir was used for treatment of 2009 pandemic influenza A (H1N1) virus infection in children aged <1 year under an Emergency Use Authorization, which expired on June 23, 2010. Nevertheless,
Current CDC guidance on treatment of influenza should be consulted; updated recommendations from CDC are available at http://www.cdc.gov/flu
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Head injuries in children under 2yo are stress provoking, particularly with regard to when you should be getting a head CT. Luckily, a large (42,412 children, 10,718 <2yo) multi-center trial exists to guide your behavior.
Hyponatremic seizures are a frightening entity. Anticonvulsants don't work well, and will likely cause apnea well before they halt the seizure. Hypertonic saline carries with it the fear of inducing central pontine myelinolysis (CPM) with overly rapid correction of the hyponatremia.
However:
So, you can safely correct hyponatremia rapidly in the setting of seizures. Do it like this:
Give 2-3 mL/kg of 3% NaCl in rapid sequential boluses, until seizures stop. A theoretical maximum dose is 100mL/kg, but recall that only a relatively small correction is required to stop the seizure.
After you've stopped the seizure, correct the hyponatremia slowly, as you would otherwise.
In the past several years it has become common practice to use cuffed tubes for pediatric intubations. However, a recent study suggests that cuff pressures are not as well regulated in pediatric patients, particularly when the patients are quickly intubated prior to aeromedical transport. Cuff pressures >30 cm H2O are associated with tracheal damage, however, up to 41% of pediatric patients transferred had cuff pressures >30 cm H2O, and 30% of those had pressures >60 cm H2O!
So:
Check your cuff pressures in all patients, particularly prior to transport
Cuff pressures must be <30cm H2O
Recall that for years uncuffed tubes were the standard, so as long as effective ventilation is achieved, it is best to err on the low side...
If you work at a facility that routinely transfers out the sickest pediatric patients, you will save their life by securing an airway in this most stressful of circumstances, but careful attention to this seemingly small detail can save your patient from long term complications.
We've all been there. It's 2am, and a 4 week old with a temperature of 38.1 rolls in the door. You grab the LP kit and your "best holder." This person then holds the baby's head and neck flexed with one hand, while the other brings the bottom and legs up to the chest as much as possible...all, usually, without pulse oximetry monitoring.
Necrotizing Enterocolitis
Colic
