UMEM Educational Pearls - Pediatrics

Current American Burn Association guidelines state that any child with a greater than 10% total body surface area (TBSA) burn should be admitted to a center capable of caring for pediatric burns, rather than being discharged after wound management.  However, physician use of TBSA% estimation techniques is variable.  An excellent free tool for estimating TBSA is available online, allows for automatic weight based calculation, and allows printing of your diagram.  The diagram is available at http://www.sagediagram.com/.  More to come...

Show References

Hyperpronation: This reduction technique for a nursemaid's elbow (radial head subluxation)  has been found to have better first attempt success than classic supination/flexion technique.  (Pediatrics July '98).  Support the elbow with a finger on the radial head, and forcefully hyperpronate.  

• Technique may be less painful as well.  
• Reexamine after five minutes, and normal function should be returned
• Xrays are generally unnecessary unless history and physical are not consistent with nursemaid's elbow, symptoms for greater than 12 hours, or reductions attempts are unsuccessful
• Supination/Flexion may be attempted after two failed hyperpronation attempts 

Attachments

1005212340_Hyperpronation_technique.jpg (54 Kb)

Once you've made the presumptive diagnosis of cerebral edema in Pediatric DKA (refer to part 1), here's what's next:

• DO NOT GET A HEAD CT - this will only waste your time, recall that most children with DKA have subclinical cerebral edema
• Reduce the fluid rate by at least half
• Start mannitol at 0.25-1g/kg IV over 20 minutes (may repeat in 2 hours)
• OR (not and) 3% saline at 5-10mL/kg over 30 minutes (slightly less used and supported)
• If you intubate, DO NOT HYPERVENTILATE.  A pCO2 < 22 mmHg is associated with poorer outcomes, presumably secondary to ischemia from reduced bloodflow...

Mortality from cerebral edema in DKA is 20-25%, and 15-35% of survivors have permanent disability. 

The best strategy is to do your best to avoid cerebral edema in the first place, but if you do recognize it, this is a clinical diagnosis, and you should not delay treatment for radiographic studies.

Show References

• seizure disorder occuring in infants and children <1 year of age
• mostly occur between ages 4-8 months
• classic spasm is sudden, simultaneous flexion of the head and trunk with felxion and adduction of the extremities (salaam attack Blitz-krampf)
• occurs in clusters of diminishing severity
• initiated or aggrevated by transition from sleep to wakefulness or emotions
• EEG demonstrates hypsarrhythmia: high-voltage, irregular, slow waves occuring out of synch with multiple foci
• most resolve over time without therapy, but most children have some level of mental retardation or other seizure disorder

• also known as acute cerebellitis of childhood
• most commonly affects children 2-6 years old
• about 50%  have a history of recent URI or viral GI illness
• abrupt onset of ataxia which may be mild to severe, and findings usually include hypotonia, tremor, horizontal nystagmus, and dysarthria
• child often is irritable with nausa/vomiting
• sensory exam and DTR's are normal
• CT and MRI are normal
• CSF usually demonstrates an increase in WBC, with a predemonance of lymphocytes
• 90% recover without any specific therapy in 6-8 weeks (steroids are not indicated).

EMTALA stipulates that any patient presenting to the Emergency Department is required to receive a medical screening exam regardless of age, ability to pay, or whether or not a parent accompanies the child.

EMTALA supersedes any state/local provisions or laws.

In performing a medical screening exam if an emergency medical condition exists then diagnostic testing, surgery or even transfer of hospitals may be appropriate without ever obtaining parental consent

MInors have the right to give or refuse informed assent of a procedure

If their is conflict between physician, parent or patient in the rendering of emergent care the physician must weigh the severity of the condition, risks and benefits of the treatment, as well as the patients maturity and cognition.  The physician may have to seek ethical committee review, or assistance from either social services or the court system.

If an emergent condition does not exist, EMTALA does not apply after the MSE.

Show References

• Cerebral edema develops in 20-90% of children with DKA, and mortality ranges from 20-90%
• Children younger than 5, and with newly diagnosed diabetes are at higher risk, and the risk in children in general is MUCH higher than the risk in adults
• Cerebral edema usually results from osmolarity changes during treatment, but may precede treatment
• Limit fluid repletion to isotonic fluids (Normal Saline), at a rate of no faster than 10-20 mL/kg/hr (In shock, resuscitate as usual)
• Head CT Is of limited value as the majority of children in DKA may show signs of subclinical cerebral edema, TREAT BASED ON CLINICAL SIGNS, and do not delay treatment for head CT which is likely to be abnormal in ALL kids
• Bicarb is implicated in increasing the risk of cerebral edema - focus on correction of acidosis with insulin and appropriate fluids, NOT bicarb

...more to come.

Show References

• the most common cause of stridor in the newborn
• the laryngeal skeleton is not stiff enough to resist the negative pressure during inspiration causing narrowing and stridor
• can occur at birth but most commonly seen at 2 weeks of age, and is more pronounced with agitation
• for most, close observation is sufficient as the cartilage becomes more rigid with age
• usually outgrown by 12-18 months of age
• in severe cases, feeding may be affected and nighttime obstructive hypoxia may occur

Congenital hypothyroidism (CH) is almost uniformly identified before symptoms develop because of newborn screening.  Though this problem will rarely present to the Emergency Department, it is not uncommon for parents with poor access to care to present to EDs after being notified of an abnormal screen.  Here is what you need to know:

• CH affects 1 / 3,000 live births
• When left untreated, there are many sequelae, but the most important by far is almost certain profound mental retardation
• Children treated within two weeks of birth have NORMAL intellect when followed into adolescence (compared to sibs, age matched controls)
• Children treated after two weeks have measurable declines in cognitive ability and motor skills - even though they may not develop MR, they are at VERY HIGH risk

So:

• Start treatment on ALL infants you encounter with CH, IMMEDIATELY if they are approaching 14 days of age
• Consider admission if there is any chance of a parent having poor access to prescription coverage or close followup
• Goal levels of T4 are >10 mcg/dL; infants with very low levels need IMMEDIATE TREATMENT with high dose-range levothyroxine - any delay can lead to drops of up to 20 IQ points
• Initial dose of Levothyroxine is at least 10-15 mcg/kg/day
• Tablets must be crushed and mixed with breast milk or formula, and NOT with soy, calcium or iron-containing substances which decrease levothyroxine absorption.  Liquid preparations are unreliable.

Show References

• a collection of blood UNDER the periosteum of the outer surface of the skull
• occurs in 2.5% of live births
• most commonly occurs ove the parietal bones
• because the blood is below the periosteum, it will NOT cross suture lines
• usually enlarge during the first few days of life, then slowly resolve over weeks or months
• significant bleeding is a risk
• when the blood resorbs, it can aggravate neonatal jaundice
• aspiration and xrays are not routinely indicated

Precedex (Dexmedetomidine) - Great for pediatric imaging procedures

Alpha-2 agonist with sedative properties

No analgesic effect alone, but shown to decrease the amount of opioids required for a painful procedure

Benefits pts go to sleep and awake in a more natural state.  Caregivers tend to prefer this as opposed to other sedatives.  Short recovery time- about 30 minutes

Adverse effects include bradycardia and hypotension.  Not recommended in any child with cardiac abnormalities.  Paradoxical hypertension with loading dose has also been observed

Effective for MRI or CT scans at loading doses of 2mcg/kg over ten minutes, then maintenance of 1mcg/kg/hr

Residents can gain experience with Precedex with Peds sedation on M,W,F mornings with sedation team, contact me to arrange a time for you to participate.

The umbilical site normally heals by 1 month of age. 

Any fluid draining after this period suggests an abnormal connection between the surface of the abdomen and the underlying structures, and requires further investigation.  Clear yellow fluid could represent a persistent connection of the bladder with the umbilicus called a patent urachus. The fluid that leaks is actually urine. The treatment is surgical closure of the connection.

Pus oozing from the umbilical stump would imply infection, especially if there is concomitant redness of the skin around the umbilicus.  An omphalitis can be life-threatening, and requires admission for invtravenous antibiotics.

Umbilical hernias are common in infants, and are usually noted with diastasis of the rectus muscles.  Most umbilical hernias resovle by school age, and do not require surgical intervention.

An umbilical granuloma is a small piece of bright red, moist flesh that remains in the umbilicus after cord separation. It is scar tissue, usually on a stalk, that did not become normally covered with skin cells. It contains no nerves and has no feeling. Most can be simply cauterised with silver nitrate.

Pediatric Constipation is a common presentation to PED and large percentage of GI clinic patient volume

Defined as less than 2 stools per week for two weeks with hard, large pellet like stools

Broad Differential includes functional constipation (most common), stricture, obstruction, celiac disease, Hirschsprung, hypothyroid, Cow's milk protein allergy, CF and spina bifida.  Always inspect the spine and perform rectal

Success of treatment is based on the aggressive nature of treatment and timing of treatment.  Ttreatment is longer and more difficult if patient has to wait on referral to GI specialist.

• Clean out with enema and stool softener (miralax BID for two days, followed by daily maintenance regimen is most common)
• Cheaper and effective regimens include mineral oil, kondremul or lactulose
• Encourage behavioral therapy with routine toilet time and rewards
• Increase fiber in diet to 8-10 grams for toddlers, 12-14 preschool and 14-16 for school age
• Initial treatment is safe and does not require electrolyte monitoring.
• Failed treatment and bounceback may require GI consult, inpatient Golytely therapy with electrolyte monitoring

Hyperleukocytosis is often seen in acute presentations childhood leukemias, and is defined as a WBC count of greater than 30-50K.  Complications usually arise at counts greater than 300, however, keep in mind that automated cell counters may underestimate very high white counts.

Complications include:

• Hyperviscosity Syndrome / Leukostasis
  • Risk of CVA, PE, Mesenteric Ischemia, etc.
• Tumor Lysis Syndrome (TLS)
  • Risk of fatal arrhythmia, may monitor with K, LDH, Uric Acid
• Disseminated Intravascular Coagultion (DIC)

Treatment:

• EMERGENT LEUKOREDUCTION APHERESIS, aka Leukopheresis
• This is a true emergency - if you are at a facility without leukopheresis capability, the fastest transport mode possible is indicated - fly, don't drive
• Temporizing measures include fluids, fluids, and fluids
• Allopurinol / Rasburicase may be considered, but not if this will delay transport, especially if there is no evidence of TLS - this decision may be made in consultation with the pediatric heme/onc specialist who is helping to arrange for leukopheresis

Meningitis Prophylaxis in Children

While H1N1 and garden-variety influenza have been taking the spotlight lately, we can't forget about other disease processes.  Meningitis is still a severe, life-threatening/altering process which occurs in various social groups (e.g. military cadets, college students).

However, with more of our parents working out of the home, child care is more often the norm, and as such, you may find yourself dealing with cases of children who have been in proximity to another child or caregiver diagnosed with meningitis.  What do you do?

The causative agent will often dictate your choice of management.

Neisseria meningitidis - nursery/child care contacts should receive chemoprophylaxis and the Menactra vaccine (if they have not already received it) within 7 days of onset;  casual school or work contacts do NOT require prophylaxis

Streptococcus pneumoniae - no chemoprophylaxis or vaccination required (unless series was not continued)

Haemophilus influenzae - if only one case reported, no intervention;  if 2 or more cases within a 60-day period, Hib vaccination and chemoprophylaxis with rifampin for BOTH children and caregivers (especially if the center cares for young children who have not completed their Hib series)

Show References

After seeing all the electrical and extension cords supplying various seasonal holiday decorations, I thought this would be appropriate.

• most commonly occurs once children establish a grasp at 4months and 4 years when children finally learn not to touch cords, but most common from 1-2 years
• not surprisingly, more common in boys (60%)
• moist oral cavity creates a short circuit and electric arc which produces enough heat (up to 1371C/2500F) to cause a low-voltage electric burn
• 5% may suffer cardiac/respiratory arest
• electrical mouth burns result in significant soft tissue damage which forms an eschar
• beware sloughing of the nonviable eschar from the underlying viable tissue around week 2, that results in labial artery hemmorhage

• 4-5% of Prepubertal Vaginal Complaints are the result of foreign body.
• Vaginal bleeding is the most sensitive (93%), and specific (82%)
• Discharge usually foul-smelling is only seen in 18% of patients
• Undiagnosed symptoms may be chronic, (case reports lasting years).
• Complications of delayed removal include infection, toxic shock syndrome, fistulas, adhesions and even infertility
• Exam in knee chest position, and removal with irrigation or tissue forceps.
• Failure to remove FB may require exam under anesthesia.

Show References

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.

Ductal-Dependent Cardiac Lesions in the Neonate

• Often present in the first 1-2 weeks of life (children born prematurely tend to be at the upper end of the spectrum as they may have delayed closure of the ductus arteriosus)
• May present with tachypnea, sudden onset of cyanosis or pallor (often worse with crying), diaphoresis with feeds, lethargy, or failure to thrive
• Oxygen challenge - place baby on 100% 02 via NRB;  10% improvement in SpO2 (or 30mmHg increase in PaO2 on ABG) suggests a pulmonary issue;  no or minimal change suggests a congenital heart defect
• If congenital heart disease is suspected, start PGE-1 infusion at a rate of 0.05-0.1ug/kg/minute;  improvement may be drastic and is usually seen within 15 minutes
• Side effects of PGE-1 infusion include apnea, fever, hypotension, and seizures;  have your code cart and intubation equipment ready to go prior to beginning infusion

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:

• The hardest metal used in jewelry - cannot be scratched, much less cut, by common tools
• Cheap, easy to buy online, attractive to adolescents

However, it is:

• Extremely brittle
• May be safely and quickly broken with locking pliers (also cheap), by sequentially, gradually tightening the locking plier grip

This video explains how.  Of course, this works on adults as well.

http://www.youtube.com/watch?v=poM423pewRE

_{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.}