Category: Pediatrics
Keywords: hypertonic saline, seizures, hyponatremia, hyponatremic, encephalopathy, pediatric, children (PubMed Search)
Posted: 1/6/2011 by Adam Friedlander, MD
(Emailed: 1/7/2011)
(Updated: 1/7/2011)
Click here to contact Adam Friedlander, MD
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.
Category: Pediatrics
Posted: 12/25/2010 by Rose Chasm, MD
Click here to contact Rose Chasm, MD
Pediatrics Board Review
MedStudy
Category: Pediatrics
Keywords: Pediatric Intubation, Airway Control, Cuff Pressure (PubMed Search)
Posted: 12/10/2010 by Adam Friedlander, MD
Click here to contact Adam Friedlander, MD
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.
Tollefsen, William W. et al. Endotracheal Tube Cuff Pressures in Pediatric Patients Intubated Before Aeromedical Transport. Pediatric Emergency Care: May 2010 - Volume 26 - Issue 5 - pp 361-363
Category: Pediatrics
Keywords: pediatric, lumbar puncture, positioning, interspinous space (PubMed Search)
Posted: 12/3/2010 by Adam Friedlander, MD
Click here to contact Adam Friedlander, MD
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.
Category: Pediatrics
Posted: 11/26/2010 by Rose Chasm, MD
(Updated: 11/2/2024)
Click here to contact Rose Chasm, MD
MedStudy Pediatric Board Review
Core Curriculum
Category: Pediatrics
Posted: 10/28/2010 by Rose Chasm, MD
(Emailed: 10/29/2010)
Click here to contact Rose Chasm, MD
Necrotizing Enterocolitis
MedStudy Board Review
Pediatrics Core Curriculum
Category: Pediatrics
Posted: 10/22/2010 by Rose Chasm, MD
Click here to contact Rose Chasm, MD
Colic
Category: Pediatrics
Keywords: Ondansetron, Oral Rehydration, Therapy, vomiting, pediatrics (PubMed Search)
Posted: 10/15/2010 by Adam Friedlander, MD
(Updated: 10/16/2010)
Click here to contact Adam Friedlander, MD
You may already love ondansetron, but consider using it ORALLY followed by PO hydration in children with vomiting.
The size of the study that showed this: N of just under 35,000.
But don't skimp on dosing. The dose is 0.1 - 0.15mg/kg, and you don't reach a max until 8mg. To put this in perspective, a scrawny 115lb (about 53kg) middle school tennis player would get 8mg, an initial dose often reserved for chemo patients in the adult ED.
Sturm JJ, Hirsh DA, Schweickert A, Massey R, Simon HK. Ondansetron use in the pediatric emergency department and effects on hospitalization and return rates: are we masking alternative diagnoses? Ann Emerg Med. 2010 May;55(5):415-22. Epub 2010 Jan 19.
Category: Pediatrics
Keywords: SCFE, slipped capitofemoral epiphysis (PubMed Search)
Posted: 10/1/2010 by Adam Friedlander, MD
Click here to contact Adam Friedlander, MD
Slipped capito-femoral epiphysis (SCFE) is a favorite board exam topic, and typically involves a young early or pre-adolescent obese girl with hip pain and the classic "ice cream falling off the cone" appearance on hip radiographs. However, keep these three pearls in mind when thinking about SCFE:
Marianne Gausche-Hill, MD, FACEP, Challenging Cases in Pediatric Emergency Medicine, ACEP Scientific Assembly, 2010
Category: Pediatrics
Keywords: Bronchiolitis, RSV (PubMed Search)
Posted: 9/10/2010 by Adam Friedlander, MD
Click here to contact Adam Friedlander, MD
As RSV season approaches, remember these key points in managing bronchiolitis:
Category: Pediatrics
Posted: 8/18/2010 by Rose Chasm, MD
(Emailed: 8/28/2010)
(Updated: 11/2/2024)
Click here to contact Rose Chasm, MD
MedStudy Pediatrics Board Review, Book 4, 1st edit
Category: Pediatrics
Posted: 8/13/2010 by Adam Friedlander, MD
(Updated: 11/2/2024)
Click here to contact Adam Friedlander, MD
A common debate on the topic of pediatric burns is whether or not blisters should be debrided. ALL PEDIATRIC BURN BLISTERS SHOULD BE DEBRIDED. There are two reasons for this:
1. Without debridement of burn blisters, the depth of a burn cannot be assessed, and such an assessment will certainly affect treatment and disposition.
2. There is conflicting (poor) evidence that blister fluid provides both protective and damaging properties, however, there is excellent evidence that ruptured blisters, or large blisters which are likely to rupture, carry a higher risk of infection if not debrided. Therefore, all blisters should be debrided.
The best method for debriding blisters uses sterile gauze soaked in saline, and it is important to note that pain is almost universally decreased after debridement.
The "1, 2, 3 Ouch!" technique is exactly what it sounds like (count to three with the child, and then wipe quickly, like tearing off a bandage), and works well in older children with smaller burn areas. Sedation may be necessary for extensive debridements, and these children may need to be taken to the OR for debridement under anesthesia. Some burn centers utilize non-operating room anesthesia (NORA) areas for such debridements that may be prolonged or painful, but do not require the full resources of an operating room.
Sargent, RL. Management of blisters in the partial-thickness burn: an integrative research review. J Burn Care Res 2006; 27:66.
Alsbjorn, B, Gilbert, P, Hartmann, B, et al. Guidelines for the management of partial-thickness burns in a general hospital or community setting--recommendations of a European working party. Burns 2007; 33:155.
Category: Pediatrics
Keywords: Ethanol, Pediatric, Ingestion (PubMed Search)
Posted: 8/7/2010 by Adam Friedlander, MD
Click here to contact Adam Friedlander, MD
Pediatric Ethanol Ingestion
A young child is brought to you after accidentally drinking a shot of alcohol at a wedding party. Here is what you need to consider:
Category: Pediatrics
Posted: 6/24/2010 by Rose Chasm, MD
(Emailed: 6/26/2010)
(Updated: 11/2/2024)
Click here to contact Rose Chasm, MD
MedStudy Pediatric Board Review, 1st edition
Category: Pediatrics
Keywords: Pediatric Burns, Fire, Injury, Burn Injuries, Sage Diagram, TBSA (PubMed Search)
Posted: 6/11/2010 by Adam Friedlander, MD
(Updated: 11/2/2024)
Click here to contact Adam Friedlander, MD
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...
Category: Pediatrics
Keywords: Pediatrics, Hyperpronation, Radial Head Subluxation, Nursemaid (PubMed Search)
Posted: 5/21/2010 by Reginald Brown, MD
(Updated: 5/22/2010)
Click here to contact Reginald Brown, MD
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.
1005212340_Hyperpronation_technique.jpg (54 Kb)
Category: Pediatrics
Keywords: DKA, diabetic ketoacidosis, Pediatric, Children, Mental Status Change (PubMed Search)
Posted: 5/14/2010 by Adam Friedlander, MD
(Updated: 11/2/2024)
Click here to contact Adam Friedlander, MD
Once you've made the presumptive diagnosis of cerebral edema in Pediatric DKA (refer to part 1), here's what's next:
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.
Category: Pediatrics
Posted: 4/30/2010 by Rose Chasm, MD
(Updated: 11/2/2024)
Click here to contact Rose Chasm, MD
Category: Pediatrics
Posted: 4/23/2010 by Rose Chasm, MD
(Updated: 11/2/2024)
Click here to contact Rose Chasm, MD
Category: Pediatrics
Keywords: Adolescent Consent, EMTALA (PubMed Search)
Posted: 4/16/2010 by Reginald Brown, MD
(Updated: 5/7/2010)
Click here to contact Reginald Brown, MD
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.
Consent for Emergency Medical Services for Children and Adolescnets: Committee on Pediatric Emergency Medicine, Pediatrics VOL 111 No.3 March 20003, pp703-706 reaffirmed 2007.
Levine, S. Adolescent Consent and Confidentiality. Pediatrics in Review. Vol 30 No. 11 pp 457-8. Nov 2009.