Category: Pediatrics
Posted: 9/8/2023 by To-Lam Nguyen, MD
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It's back to school season which means back to school injuries!
Scalp lacerations often require suturing or staple closure, but what if you can close the wound without any sharps that scare the kiddos? Consider using the Hair Apposition Technique (HAT)!
What is HAT?
- A very quick and easy technique for superficial scalp laceration closure made by twisting hair on each side of the laceration and sealing the twist with a small dot of glue for primary closure.
When do I consider HAT?
- For linear, superficial lacerations that are <10cm in length
- Laceration has achieved adequate hemostasis
- Patient has hair on both sides of the laceration
What are contraindications to HAT?
- Hair strands are less than 3cm in length
- Laceration is longer than 10cm in length
- Active bleeding from laceration despite hair apposition
- Significant wound tension
- Laceration is highly contaminated
How do I perform HAT?
- Debride wound as you normally wound for any laceration
- Take approximately 5 strands of hair on one side of the laceration and twist them together to make one twisted bundle
- Take approximately 5 strands of hair directly on the other side of the laceration and twist them together to make another twisted bundle
- Then take each bundle and intertwine the two bundles until the wound edges appose.
- Place a drop of glue on the twist
- Repeat along the length of the laceration until laceration is closed
Benefits of HAT:
- Based on a RCT from Singapore that compared suturing to HAT for superficial scalp lacerations that were <10cm, patient's were more satisfied, had less scaring, lower pain scores, shorter procedure tiems, adn less wound breakdown in the HAT group compared to the sutured group.
- A follow up study by the same group also assessed cost-effectievness of HAT compared to suturing (by taking into account staff time, need for staple/suture removal, treatment of complications, materials, etc) and found that HAT saved $28.50 USD when compared to suturing.
Modified hair apposition of scalp wounds- UpToDate
Bottom Line:
- Consider Hair Apposition Technique (HAT) for linear, superficial scalp lacerations, especially in pediatric patients as it is much more well tolerated (can also do this in adults!)
Ong ME. “Cost-effectiveness of hair apposition technique compared with standard suturing in scalp lacerations.” Annals of Emergency Medicine. 2005 Sept; 46(3):237-42.
Trick of the Trade: Hair apposition technique (HAT trick)- https:/www.aliem.com/trick-of-trade-hair-apposition/
Category: Pediatrics
Keywords: Drowning, near drowning, CXR (PubMed Search)
Posted: 8/18/2023 by Jenny Guyther, MD
(Updated: 4/26/2024)
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This was a retrospective study involving several hospitals in Italy. 135 patients who had drowned (the term used in the article) were included. 4.5% of patients died. Most drowning occurred in July and August. The most common comorbidity was epilepsy in about 10% of patients. Several patients were also witnessed to have trauma and syncope. Early resuscitation, either by bystanders or trained professionals, was paramount in survival.
Children who are conscious at presentation and have mild or no respiratory distress have the best prognosis. A well appearing child should be observed for 6-8 hours, given that 98% of children will present with symptoms within the first 7 hours. A chest xray is not indicated in the asymptomatic patient. Patients who are submerged greater than 25 minutes or without ROSC after 30 minutes have a poor prognosis.
Bottom line: Never swim alone and everyone should be trained in bystander CPR.
Category: Pediatrics
Keywords: fever, limp, bacteremia, osteomyelitis, septic joint (PubMed Search)
Posted: 7/21/2023 by Jenny Guyther, MD
(Updated: 4/26/2024)
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El Helou R, Landschaft A, Harper MB, Kimia AA. Bacteremia in Children With Fever and Acute Lower Extremity Pain [published online ahead of print, 2023 Apr 4]. Pediatrics. 2023;e2022059504. doi:10.1542/peds.2022-059504
Category: Pediatrics
Keywords: Pediatrics, infectious disease, fever, bacteremia (PubMed Search)
Posted: 7/14/2023 by Kathleen Stephanos, MD
(Updated: 4/26/2024)
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This study attempts to answer the age old question: What is the importance of fever in pediatric illnesses?
The authors' goal was to assess if response to antipyretics was associated with bacteremia. This article retrospectively reviewed 6,319 febrile children in whom blood cultures were sent and found that 3.8% had bacteremia. They then looked at the fever curve in response to antipyretics for these two groups in the emergency department over 4 hours. The study concluded that patients with bacteremia have a higher rate of persistent fever despite antipyretics. It is important to note the limitations of this study. As this was retrospective, it is unclear what clinical findings resulted in blood cultures being sent - most febrile children did not have any drawn (23,999 were excluded for this reason). They did not assess other vital signs, and did not address other bacterial infections (UTI, cellulitis, meningitis, otitis media, etc). Additionally, while patients with bacteremia did have a higher likelihood of fever, the majority of patients in both groups had fever resolution within 4 hours, and both groups had some children with persistent fevers.
Overall, this does seem to support the decision to consider obtaining further testing in those children with a persistent fever, but also emphasizes the importance of not using fever resolution alone as support for discharge to home or exclusion of bacteremia from the differential.
Baker AH, Monuteaux MC, Michelson KA, Neuman MI. Resolution of Fever in the Pediatric Emergency Department and Bacteremia. Clin Pediatr (Phila). 2023;62(5):474-480.
Category: Pediatrics
Keywords: burns, pediatric (PubMed Search)
Posted: 7/7/2023 by Jenny Guyther, MD
(Updated: 4/26/2024)
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Kliegman, R. M., MD, Stanton, B. F., MD, St Geme, J., MD, & Schor, N. F., MD PhD. (2015). Nelson Textbook of Pediatrics (20th ed.). Elsevier Health Sciences.
Category: Pediatrics
Keywords: neonatal fever, cellulitis, bacteremia (PubMed Search)
Posted: 6/16/2023 by Jenny Guyther, MD
(Updated: 4/26/2024)
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Kaplin, Ron. Clinical Presentation and Approach to Evaluation and Management. Pediatric Emergency Care 2023; 39(3):188-189.
Category: Pediatrics
Keywords: congenital heart disease (PubMed Search)
Posted: 6/2/2023 by Rachel Wiltjer, DO
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Some things are easy, even reflexive, and one of those things is putting oxygen on cyanotic patients. Usually, this is a great thing. Blue = bad. Occasionally, though, blue = baseline and even in those patients who are too blue, you want to keep them closer to purple than pink.
This issue is commonly encountered in certain types of congenital heart disease and as well as through various phases of their repair. These include ductal dependent lesions, those with significant shunts, and single ventricle physiology. Oxygen functions as a pulmonary vasodilator and can increase or change the direction of shunting, directly impacting physiology by causing pulmonary overcirculation, increased strain on the right ventricle, and decreases in systemic circulation.
Helpful Hints:
1) Find out and shoot for the patient’s goal oxygen saturation range (many lesions will be 75%-85%). This may be available from parents, in the EMR, or by calling the child’s cardiac center if they are an established patient.
2) In an undiagnosed neonate with hypoxia and signs of heart failure (crackles, enlarged liver, edema to the sacrum and/or occiput) or if unresponsive to initial trial of oxygen, decrease FiO2 and titrate support (nasal cannula with blender to set FiO2, HFNC, NIPPV, or intubation if necessary) to address respiratory distress as well as evaluation and treatment for ductal dependent lesions.
3) You may still need to use additional FiO2 to obtain reasonable oxygen saturations, but titrate thoughtfully.
Khalil M, Jux C, Rueblinger L, Behrje J, Esmaeili A, Schranz D. Acute therapy of newborns with critical congenital heart disease. Transl Pediatr. 2019 Apr;8(2):114-126.
McMann, K. T, Schelonka R.L. Editorial: Oxygen for cyanotic neonates: Friend or foe? Pediatric Health. 2010 Feb; 4(1): 1-3.
Category: Pediatrics
Keywords: IV, EMS, transfer, pediatrics (PubMed Search)
Posted: 5/19/2023 by Jenny Guyther, MD
(Updated: 4/26/2024)
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Mangus CW, Canares T, Klein BL, et al. Interhospital Transport of Children With Peripheral Venous Catheters by Private Vehicle: A Mixed Methods Assessment. Pediatr Emerg Care. 2022;38(1):e105-e110. doi:10.1097/PEC.
Category: Pediatrics
Keywords: Pediatrics, infections, neonatal (PubMed Search)
Posted: 5/5/2023 by Rachel Wiltjer, DO
(Updated: 4/26/2024)
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Neonatal rashes are common and, usually, benign. There are some skin findings, however, that require early recognition and treatment for best outcomes. One of these concerning etiologies is omphalitis, infection of the umbilical stump and surrounding tissues.
Features of omphalitis may include erythema and induration around the umbilicus, purulent drainage, and potentially systemic illness.
Risk factors include poor cord hygiene, premature or prolonged rupture of membranes, maternal infection, low birth weight, umbilical catheterization, and home birth.
Evaluation includes surface cultures from the site of infection as well as age-appropriate fever workup if patient is febrile. Consider ultrasound to evaluate for urachal anomalies as these can co-exist.
Management is IV antibiotics to cover S. aureus and gram negatives with surgical consultation if there are signs of necrotizing fasciitis or abscess. Some newer literature suggests that patients with omphalitis seen and treated in high-income countries may not be as sick as previously thought (as most data has been obtained in lower income countries where incidence is higher) and there has been a suggestion that there may be a role for oral antibiotics in well appearing, lower risk infants. This deserves further exploration but cannot yet be considered standard of care.
Other umbilical cord findings to consider (when it isn’t omphalitis): patent urachus, granuloma, local irritation, or partial cord separation
Kaplan RL. Omphalitis: Clinical Presentation and Approach to Evaluation and Management. Pediatr Emerg Care. 2023;39(3):188-189.
Category: Pediatrics
Keywords: Ketamine, morphine, fentanyl, pediatrics, EMS, pain control (PubMed Search)
Posted: 4/21/2023 by Jenny Guyther, MD
(Updated: 4/26/2024)
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Frawley J, Goyal A, Gappy R, et al. A Comparison of Prehospital Pediatric Analgesic Use of Ketamine and Opioids [published online ahead of print, 2023 Mar 8]. Prehosp Emerg Care. 2023;1-5. doi:10.1080/10903127.2023.
Category: Pediatrics
Keywords: sedation, anxiolysis, procedure (PubMed Search)
Posted: 4/7/2023 by Rachel Wiltjer, DO
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Background: Intranasal dexmedetomidine has seen usage in the anesthesia and sedation realms over the past few years, with an increasing interest in usage in the ED setting given its generally favorable safety profile and ease of administration. There has been specific interest and consideration in children with autism and neurodevelopmental disorders.
Study: Single center prospective provider study (compared to a retrospective group of patients under 18 who received oral midazolam for indications of agitation or anxiety via chart review) looking at patients 6 months to 18 years of age with an order for intranasal dexmedetomidine. Following use, a provider survey was completed to evaluate indication/rationale for use, satisfaction, comfort with use, and perceived time to onset as well as duration of effect.
Results: 29% of patients receiving IN dexmedetomidine experienced treatment failure compared with 20.7% of patients receiving oral midazolam (not statistically significant). In subgroup analysis, rates of treatment failure were lower for patients diagnosed with autism spectrum disorder receiving IN dexmedetomidine versus oral versed (21.2% versus 66.7%). Length of stay was longer in the IN dexmedetomidine group (6.0 hours versus 4.4 hours). Indication for use had variability between the two groups.
Bottom Line: IN dexmedetomidine may be a reasonable agent to utilize for anxiolysis in pediatric patients, especially those who have previously had paradoxical reactions or poor efficacy of benzodiazepines. It may be specifically useful when effects are desired for a slightly longer time and for non-painful/minimally painful interventions.
Kenneally A, Cummins M, Bailey A, Yackey K, Jones L, Carter C, Dugan A, Baum RA. Intranasal Dexmedetomidine Use in Pediatric Patients for Anxiolysis in the Emergency Department. Pediatr Emerg Care. 2023 Jan 5. Epub ahead of print.
Category: Pediatrics
Keywords: Croup, respiratory distress, stridor, URI (PubMed Search)
Posted: 3/17/2023 by Jenny Guyther, MD
(Updated: 4/26/2024)
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Scribner C, Patel K, Tunik M. Pediatric Croup Due to Omicron Infection Is More Severe Than Non-COVID Croup. Pediatr Emer Care 2022;00.
Category: Pediatrics
Keywords: conjunctivitis, pink eye, eye drops (PubMed Search)
Posted: 2/17/2023 by Jenny Guyther, MD
(Updated: 4/26/2024)
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Honkila et al. Effect of Topical Antibiotics on Duration of Acute Infective Conjunctivitis in Children. JAMA Network Open. 2022;5(10):e2234459.
Category: Pediatrics
Keywords: otitis media, antibiotic (PubMed Search)
Posted: 2/3/2023 by Rachel Wiltjer, DO
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Otitis media is a common pediatric complaint seen in the primary care, urgent care, and ED settings. Recommendations for timing of treatment and deferral of treatment have emerged over the last several years, as have recommendations for regimens for recurrent infections in the age of resistant organisms.
When to consider observation over antibiotics:
Initial treatment
High dose amoxicillin (90 mg/kg/day divided BID)
Recurrent Otitis Media
If less than 30 days from initial treatment, presumed to be persistent
If greater than 30 days from initial treatment can treat as new episode (so amoxicillin unless previous documented resistant infections)
Duration of Antibiotics
Other Considerations
Gaddey HL, Wright MT, Nelson TN. Otitis Media: Rapid Evidence Review. Am Fam Physician. 2019;100(6):350-356.
Rosenfeld RM, Tunkel DE, Schwartz SR, et al. Clinical Practice Guideline: Tympanostomy Tubes in Children (Update). Otolaryngol Head Neck Surg. 2022;166(1_suppl):S1-S55. doi:10.1177/01945998211065662
Category: Pediatrics
Keywords: intubation, supraglottic, BVM (PubMed Search)
Posted: 1/20/2023 by Jenny Guyther, MD
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Should EMS place an advanced airway in out of hospital cardiac arrests? Current studies suggest that advanced airway management is not superior to BVM in pediatric out of hospital cardiac arrest (OHCA).
Pediatric OHCA carries a high mortality rate and those that do survive often have a poor neurologic outcome. This study evaluated BVM vs supraglottic airway (SGA) placement vs endotracheal intubation (ETI) in relation to one month survival and favorable neurological outcomes. SGA and ETI were also grouped together and categorized as advanced airway management (AAM).
This study was conducted using the Pan Asian Resuscitation Outcomes Study Clinical Research Network. 3131 pediatric patients were included. 85% received BVM, 11.8% SGA and 2.6 % ETI. In a matched cohort, one month survival and survival with favorable neurological outcome was higher in the BVM group compared to the AAM group and in the BVM group compared to the SGA group. There was no significant difference noted between the ETI group and BVM group.
Bottom line: In this study, AAM was associated with decreased one month survival and less favorable neurological status in pediatric OHCA.
Tham LP, Fook-Chong S, Binte Ahmad NS, Ho AF, Tanaka H, Shin SD, Ko PC, Wong KD, Jirapong S, Rao GVR, Cai W, Al Qahtani S, Ong MEH; Pan-Asian Resuscitation Outcomes Study Clinical Research Network. Pre-hospital airway management and survival outcomes after paediatric out-of-hospital cardiac arrests. Resuscitation. 2022 Apr 26;176:9-18. doi: 10.1016/j.resuscitation.2022.
Category: Pediatrics
Posted: 12/16/2022 by Jenny Guyther, MD
(Updated: 4/26/2024)
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Kaila et al. Hyperkalemia in a Hemolyzed Sample in Pediatric Patients: Repeat or Do Not Repeat? Pediatric Emergency Care 2022; 00:00-00.
Category: Pediatrics
Keywords: unimmunized, pediatric fever (PubMed Search)
Posted: 12/2/2022 by Rachel Wiltjer, DO
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Childhood vaccination has significantly decreased the incidence of bacterial meningitis and bacteremia in infants and young children, specifically vaccines against H. influenzae and S. pneumoniae, shifting broad workups for these disease and empiric antibiosis to younger age groups as rates declined. In recent years the percentage of unvaccinated and under-vaccinated children has been rising due to multiple factors; now over 1% of children in the US under 2 years of age are unvaccinated. The question becomes, should these children be treated more similarly to young infants as they lack to immunity to these organisms?
Literature on this topic is sparse, although, Finkel, Ospina-Jimenez, et al. reviewed the literature available and proposed an algorithm for well appearing children 3-24 months of age without a clear source and a temperature of >39C (102.2F). Recommendations included UA (to determine possible source) in the following patients: fever > 2 days, prior UTI, female or uncircumcised male <12 months, or male <6 months. They also recommended evaluation with viral panel. If no source was determined, they then recommended CBC and procalcitonin with a CXR for WBC > 20,000/mm3. For WBC >15,000/mm3, ANC >10,000/mm3, absolute band count >1,500/mm3, or procalcitonin >0.5ng/mL they recommended blood culture, ceftriaxone 50 mg/kg, and follow up within 24 hours.
Bottom line: Literature is scarce and practice patterns are likely to evolve as ramifications of decrease in vaccination rates become clearer. The above algorithm is proposed, however covers limited situations and may not be practical in all settings. Clinical judgement should be used in the evaluation and management of these patients. A more conservative approach compared to vaccinated infants is reasonable at this time.
Finkel L, Ospina-Jimenez C, Byers M, Eilbert W. Fever Without Source in Unvaccinated Children Aged 3 to 24 Months: What Workup Is Recommended?. Pediatr Emerg Care. 2021;37(12):e882-e885
Category: Pediatrics
Keywords: Pediatric trauma, blood transfusion, ratios (PubMed Search)
Posted: 11/18/2022 by Jenny Guyther, MD
(Updated: 4/26/2024)
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Akl M, Anand T, Reina R et al. Balanced hemostatic resuscitation for bleeding pediatric trauma patients: A nationwide quantitative analysis of outcomes. Journal of Pediatric Surgery 2022. epub ahead of print.
Category: Pediatrics
Keywords: rehydration, fluid management (PubMed Search)
Posted: 11/4/2022 by Rachel Wiltjer, DO
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Subcutaneous Fluid Administration for Rehydration
Caccialanza R, Constans T, et al. Subcutaneous Infusion of Fluids for Hydration or Nutrition: A Review. Journal of Parenteral and Enteral Nutrition. 2018; 42 (2): 296-307
Spandorfer PR. Subcutaneous Rehydration. Pediatric Emergency Care. 2011; 27 (3):230-236.
Category: Pediatrics
Keywords: intuccesption, air enema, reduction timing (PubMed Search)
Posted: 10/21/2022 by Jenny Guyther, MD
(Updated: 4/26/2024)
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