UMEM Educational Pearls - Pediatrics

Category: Pediatrics

Title: Neonate Resus Review

Keywords: Neonate, Newborn, resuscitation, NRP (PubMed Search)

Posted: 11/3/2023 by Kelsey Johnson, DO (Updated: 7/17/2024)
Click here to contact Kelsey Johnson, DO

Term? Tone? Tantrum?

Immediately after delivery, your initial neonatal assessment should evaluate for:

-       Appearance of full or late pre-term gestation (>34 weeks)

-       Appropriate tone (flexed extremities, not floppy)

-       Good cry and respiratory effort

 

Newborns meeting this criteria should not require resuscitation. They can be placed skin to skin on mother and allowed to breastfeed. Delayed cord clamping for 60 seconds is recommended, as data shows improved neurodevelopmental outcomes and iron stores in first year of life.

 

Neonates not meeting these criteria should be brought to the warmer for resuscitation, with the focus being on:

-       Warm - via radiant warmer. Maintain temps 36.5 C – 37.5 C

-       Dry - Neonates have thin skin and lose heat readily from evaporative loses

-       Stim - tactile stimulation on the head, midline of the back and extremities to provoke a cry and encourage respiratory effort

 

Avoid routinely bulb-suctioning unless there is significant obstructing mucous, as this can increase vagal tone and result in bradycardia. If bulb suctioning is used, first suction the mouth before the nose.

 

Majority of resuscitations do not require additional support, however if heart rate is <100 or there is poor respiratory effort, the physician should initiate PPV.

 

PPV settings:   PIP 20              PEEP 5              FiO2 21%         Rate of 60 breaths per minute

 

Improvement in the neonate’s HR is the primary indicator of effective PPV!

If HR poorly responding (remains <100), ensure appropriate mask size, reposition, suction, and increase PIP (max 35) and FiO2.

 

If HR drops below 60, intubate with uncuffed ETT

-       Prioritize adequate ventilation as this is the highest priority in neonatal resuscitation

-       Initiate compressions at rate of 120/min.

-       Epi dosing is 0.01-0.03 mg/kg q3-5 min

-       ETT size estimation by gestational age:

        25 weeks = 2.5, 30 weeks = 3.0, 35 weeks = 3.5, 40 weeks = 4.0



Category: Pediatrics

Title: Should an ED thoracotomy be performed in pediatrics?

Keywords: trauma arrest, ROSC, blunt, penetrating (PubMed Search)

Posted: 10/20/2023 by Jenny Guyther, MD (Updated: 7/17/2024)
Click here to contact Jenny Guyther, MD

12 pediatric and adult surgeons with pediatric trauma expertise reviewed the literature to form a consensus statement on the indications for ED thoracotomy (EDT) on patients younger than 19 years.  Eleven studies were included for a total of 319 children who underwent EDT.  142 patients had penetrating trauma while 177 sustained blunt trauma.  Survival in the penetrating group was 13.4% and 2.3% in the blunt group.  Many of these patients were 15 and older.  Based on the review of the literature, the group made recommendations:
 
1) In pediatric patients with signs of life (SOL) who present pulseless in the setting of penetrating trauma, EDT was conditionally recommended.
2) In pediatric patients without SOL who present pulseless in the setting of penetrating thoracic trauma EDT was conditionally NOT recommended.  
3)  In pediatric patients with SOL who present pulseless in the setting of penetrating abdominopelvic trauma EDT was conditionally recommended.  
4) In pediatric patients without SOL who present pulseless in the setting of penetrating abdominopelvic trauma EDT was conditionally NOT recommended.  
5) In pediatric patients with SOL who present pulseless in the setting of blunt trauma EDT was conditionally recommended AFTER emergency adjuncts which include ultrasound and thoracostomies.  
6)  In pediatric patients without SOL who present pulseless in the setting of blunt trauma EDT was NOT recommended.  
 
SOL included cardiac electrical activity, respiratory effort, pupillary response, pulses, blood pressure, or extremity movement.
 
Bottom line:  If the pediatric trauma patient presents pulseless, but with SOL, EDT can be considered.  However, evidence is still very limited, especially in children < 15 and these recommendations are conditional.

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- Magnets move through the GI tract at different rates and become lodged in adjacent loops of intestine. Adjacent bowel segments can stick together when the magnets attract each other through the bowel walls which can cause obstruction, perforation, fistula formation, and necrotic bowel.

- Obtain xray to identify ingested metallic object(s)

- Any object lodged in the esophagus should be emergently removed by a pediatric gastroenterologist.

- Once an object is past the stomach and beyond the reach of endoscopy, affected patients need to be watched carefully for signs of obstruction or peritonitis, either occurrence requiring the prompt consultation of a pediatric surgeon.

- Enhancement of magnet movement through the GI  tract may be aided by a laxative such as polyethylene glycol, but there is no clear data that this approach speeds the passage of the magnet. There is no clear guidance on how frequently to obtain abdominal radiographs to determine movement or passage of ingested magnets.

- More frequently lodge in esophagus due to seize and cause electric urn on contact

- Complications include perforation or fistula formation

- Honey or liquid ulcer medication carafate can slow extent of esophageal injury

- Current recommendations from National Button Battery Hotline: caregiver to give 2 teaspoons of honey every 10 minutes while en route to hospital

- Causes caustic contact to vocal cords, which leads to acute laryngospasm 

- Airway compromise, if to occur, occurs rapidly. If after brief obs period, it does not appear, it is very unlikely to be a late occurance. 

- Corrosive on GI tract. pH of detergents range from 7-9. 

- Any child with difficulty swallowing, drooling, stridor, and recurrent vomiting should have GI consulted for endoscopy

Tiki Torch Oil

- Tiki torch oil looks like apple juice (the container looks similar too)

- Lamp oil ingestion (hydrocarbons) can cause excessive drowsiness, lung injury, difficulty breathing

- Preventing accidental tiki torch oil ingestion: NEVER use torch fuels near area where food or drinks are served, keep out of reach and out of sight of young children, and only buy bottle of torch fuels with child-resistant cap and make sure to replace cap securely after every single use

Hydrogen Peroxide

- 35% hydrogen peroxide has become more popular as food-grade or nutraceutical product (food additive purportedly used for medicinal purposes)

- When hydrogen peroxide reacts with HCl in the stomach, it liberates large volumes of oxygen causing immediate frothy emesis and systemic absorption of oxygen. Gastric oxygen, once absorbed, passes through the portal vein to liver causing gas embolisms in liver

- Preferred evaluation of kids with known ingestion and acute vomiting should image by noncontrast limited upper abdominal CT (to reduce radiation exposure) to assess bubble burden. 

- There is no consensus on what is considered a significant air embolism burden that would require hyperbaric treatment

A single tablet of buprenorphine, or a single dissolvable gel strip of its formulation as Suboxone has been lethal to children.

Prescribing intranasal naloxone spray to the family of patients on buprenorphine (and methadone as well) is potentially lifesaving to the patient, should they take too much, but also for children in their homes who may accidentally eat a single tablet or chew on what appears to be a “gummy” product, a dissolvable formulation of Suboxone.

Pediatricians doing anticipatory safety guidance to parents at the 9-month-old to 1-year-old health supervision visit should ask about opiates and medication-assisted therapy present in the home or used by caregivers (especially grandparents) and should offer to write a prescription for naloxone nasal spray 

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Kids eat everything (except perhaps carefully prepared and balanced meals). While button battery ingestions are feared, there is more to worry about. Magnet ingestions – especially rare earth metal magnet ingestions – can lead to high morbidity and mortality.

When more than one magnet (or a magnet and another metallic object) are ingested, they can become stuck together through walls in the GI tract, creating risk for obstruction, erosion, fistula formation, and perforation. Sharp metallic foreign objects can be particularly dangerous as they can do much damage while being moved around by the magnet.  

If there is concern for magnet ingestion, care should be taken to try to determine the number ingested (if parents have the magnets, you can compare the size of an object on xray to the size of the magnets as it can otherwise sometimes be difficult to differentiate if it is one magnet or more than one stuck together).  

Higher risk features of ingestion include: 

  • Ingestion of a magnet and a sharp metallic object
  • Higher number of magnets ingested
  • A longer interval over which the magnets were ingested
  • Multiple magnets in the esophagus (raises concern for concomitant aspiration)

 

Ingestions should prompt consultation with pediatric GI and surgery when isolated as many will require either endoscopic or surgical removal. This may include need for referral and transfer.  

 

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Category: Pediatrics

Title: Spontaneous Pneumomediastinum in Children: What should I do?

Keywords: Spontaneous Pneumomediastinum, asthma, crepitus, esophagram (PubMed Search)

Posted: 9/15/2023 by Jenny Guyther, MD
Click here to contact Jenny Guyther, MD

Spontaneous pneumomediastinum (SPM) is air within the mediastinum in the absence of trauma.  This occurs more often in males and has 2 age peaks: children younger than 6 years as a result of lower respiratory tract infections and adolescents due to asthma exacerbations.  Typical symptoms include chest pain, subcutaneous emphysema and shortness of breath, but can also include neck pain, dysphagia, pneumopericardium, and pneumorrhachis (air in the spinal cord).   SPM has been seen in patients with a history of asthma, current influenza infection and hyperventilation with anxiety, but many have no known precipitating factor. 
The diagnosis of SPM is typically made on CXR.  The literature is mixed on the utility of CT scans, esophagrams, esophagoscopy and bronchoscopy.  This study looked at 179 pediatric patients who were diagnosed with SPM.  No patients were found to have an esophageal injury.  Also, CT scans did not provide additional information or change management based on what was seen on the chest xray.
The author's concluded that CT scans and esophagrams can be avoided unless there is a specific esophageal concern.  Management should be guided based on the patient's symptoms.

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The literature is not completely new regarding the use of intranasal dexmedetomidine for pediatric sedation, with several articles confirming noninferiority to benzodiazepines. It is a potent a2- adrenergic receptor agonist, which allows for sedation without analgesic properties. It can be considered for patients who are undergoing PAINLESS procedures. A recent article gave further clarification for dosing considerations when selecting this option. This study assessed varying weight-based doses and found the best effect with doses of 3 to 4 mcg/kg  

 

Importantly, there is limited data that suggests this may result in longer discharge, duration of procedure and total time in the department compared to other sedation methods. Additionally, this option is not always readily available and approved for pediatric patients in every hospital.  

 

Overall, Dexmedetomidine may be an excellent option for painless procedures, such as CT imaging or even MRI based on the literature, when available. 

 

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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. 

Image

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!)

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Category: Pediatrics

Title: Pediatric drowning what are the risk factors?

Keywords: Drowning, near drowning, CXR (PubMed Search)

Posted: 8/18/2023 by Jenny Guyther, MD (Updated: 7/17/2024)
Click here to contact Jenny Guyther, MD

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

Title: Should blood cultures be drawn in a child with fever and lower extremity pain?

Keywords: fever, limp, bacteremia, osteomyelitis, septic joint (PubMed Search)

Posted: 7/21/2023 by Jenny Guyther, MD (Updated: 7/17/2024)
Click here to contact Jenny Guyther, MD

This was a cross sectional review of 698 patients ages 1 year to 18 years who presented to a tertiary care center with fever of at least 38 degrees centigrade and non traumatic acute lower extremity pain. This hospital was located in the North East of the United States. Lower extremity pain was defined as an antalgic gait by report or on exam, inability or refusal to bear weight or reported bone or joint pain in the verbal patient within the past 14 days.
Blood cultures were available for review in 510 patients.  Blood cultures were positive in 70 of them (13.7%).  Pathogens included MSSA, MRSA, Strep pyogenes and Salmonella.  Significant predictors of bacteremia included an elevated CRP and localizing exam findings.  
8 blood culture contaminants were identified.  6/8 of these patients had other testing and treatment consistent with osteomyelitis.  
The final diagnosis of the patients with bacteremia included osteomyelitis, septic arthritis, pyomyositis and toxic shock syndrome.
 
 
Bottom line: The prevalence of bacteremia, even in Lyme endemic areas, in healthy children presenting to the ED with fever AND lower extremity pain is high enough to strongly consider obtaining a blood culture with other lab work during the initial evaluation. 

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Category: Pediatrics

Title: Pediatric fever: Is response to antipyretics enough to discharge?

Keywords: Pediatrics, infectious disease, fever, bacteremia (PubMed Search)

Posted: 7/14/2023 by Kathleen Stephanos, MD (Updated: 7/17/2024)
Click here to contact Kathleen Stephanos, MD

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. 

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Burns are common pediatric injuries and usually represent preventable unintentional trauma.
Approximately 10% of children hospitalized with burns are victims of abuse. Thermal burns are the most common type of burn and can result from scalding injuries or contact with objects (irons, radiators, or cigarettes). Features of scald burns that are concerning for inflicted trauma include clear lines of demarcation, uniformity of burn depth and characteristic pattern. Abusive contact burns tend to have distinct margins (branding of the hot object), while accidental contact burns tend to have less distinctive edges
How Kids are Different than Adults: 
- Kids have thinner skin, so time to burn/energy required to cause a burn is less. 
- Kids have increased blood volume relative to their mass, so may need more volume resuscitation compared to adults. 
- Kids are more likely to become hypoglycemic so give glucose in mIVF in kids <20 kgs.
- Risk of airway compromise in kids following inhalation injury is higher due to their smaller airway openings 
Treatment:
- Initial treatment should follow ABCs of resuscitation
- Airway: Airway management should include assessment for presence of airway or inhalation injury, with early intubation if such an injury is suspected. Smoke inhalation may be associated with carbon monoxide toxicity; 100% humidified oxygen should be given if hypoxia or inhalation is suspected.
- Circulation: Parkland's formula
     - Fluid requirements = TBSA burned (%) x weight (kg) x4mL
     - Give ½ of total requirements in 1st 8 hours, then give 2nd half over the next 16 hours. 
     - REMEMBER KIDS HAVE BIG HEADS
          - Rule of 9's for adults: 9% for each arm, 18% for each leg, 9% for head, 18% for front torso, 18% for back torso
          - Rule of 9's for children" 9% for each arm, 14% for each leg, 18% for head, 18% for front torso, 18% for back torso. 
Options for pain management
- fentanyl IN
- morphine IV
- ketamine IV
 Burns you should consider admission
- >6% TBSA
- full thickness burns
- specialty areas: face, eyes, airway, genitalia, palmar crease, sole of foot
- concern for non-accidental injury
- caused by treadmill

 

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Category: Pediatrics

Title: Omphalitis

Keywords: neonatal fever, cellulitis, bacteremia (PubMed Search)

Posted: 6/16/2023 by Jenny Guyther, MD (Updated: 7/17/2024)
Click here to contact Jenny Guyther, MD

Omphalitis is a soft tissue infection involving the umbilicus and surrounding tissues with redness and induration around the umbilical stump.  Risk factors include: prematurity, prolonged rupture of membranes, maternal infection, low birth weight, history of umbilical catheter and home birth.  Pathogens include Staph, Strep and Gram Negative bacteria.  Studies have shown that bacteremia can be present in up to 13% of cases.
Omphalitis most often occurs in infants 8-22 days.  If fever is present, the AAP guidelines for neonatal fever should be followed.  In the well appearing, afebrile infant, blood cultures should be obtained, but CSF studies are not reflexively indicated.  Since urachal anomalies can be present in up to 1/4 of these patients, urine studies should be obtained and an ultrasound can be considered if drainage is present.  A surface culture should be obtained when possible as well.

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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.

 

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This study looked at "low risk" patients who were being transferred from a community hospital to the system quaternary referral center.  Patients were selected by the referral center as low risk (closed fracture requiring reduction, eye problems, minor burns, laceration, ect) for transport by personnel vehicle (POV) regardless of IV status.  The families were then approached for consent.
Patients had to be between 4-17 years, without social concerns, unreliable transportation or communication differences.  
78 patients were eligible with 67 patients electing transport by POV.  All patients arrived safely.  29 patients had IVs in place.  Procedures were in place by the sending facility to secure the IV, educate the parents about IV care and supplies in case of dislodgement were given.  The drive was about 40 minutes.  All IVs were functional on arrival at the referral center and there were no noted complications.
Surveys were given to the patients' families and the results were overall positive.  The one negative point of feedback involved traffic and navigational difficulties.
 
Bottom line: In the appropriately selected patient, safe interfacility transport via POV is possible, even when an IV is in place.

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Category: Pediatrics

Title: Putting the 'Omph' in Omphalitis

Keywords: Pediatrics, infections, neonatal (PubMed Search)

Posted: 5/5/2023 by Rachel Wiltjer, DO (Updated: 7/17/2024)
Click here to contact Rachel Wiltjer, DO

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

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Category: Pediatrics

Title: Ketamine vs opiates for pediatric pain management

Keywords: Ketamine, morphine, fentanyl, pediatrics, EMS, pain control (PubMed Search)

Posted: 4/21/2023 by Jenny Guyther, MD (Updated: 7/17/2024)
Click here to contact Jenny Guyther, MD

Multiple modalities are available for pain control in the pediatric setting.  Ketamine has recently been introduced into the prehospital environment as an alternative to opiates (fentanyl and morphine).  This study examines how ketamine and opiates compare in relation to pain reduction and adverse events.
9223 patients (< 18 years) were included with data from the ESO Collaborative. 190 patients received ketamine (2.1%) and 9033 received opiates (97.9%).  Ketamine was associated with a greater reduction in pain score (-4.4 vs -3.1) compared to opiates and a greater reduction in EMS clinician reported improvement.  Patients in the ketamine group did have a reduction in the GCS by -0.3 points.  There were no patients who required ventilatory support in the ketamine group and one patient who required support in the opiate group. No patients in either group required intubation or died.  This study did not examine medication doses or route.
Bottom line: Both ketamine and opiates are viable pain control options for pediatric patients in the prehospital environment.

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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 

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Category: Pediatrics

Title: Is croup caused by COVID more severe compared to other etiologies?

Keywords: Croup, respiratory distress, stridor, URI (PubMed Search)

Posted: 3/17/2023 by Jenny Guyther, MD (Updated: 7/17/2024)
Click here to contact Jenny Guyther, MD

Patients with croup often present with a "barky" cough, stridor, and trouble breathing, traditionally worse at night.  The mainstay of treatment is a dose of dexamethasone and if there is moderate to severe distress, racemic epinephrine is added.  Croup has typically been caused by viruses, mainly parainfluenza, but influenza, non-COVID coronavirus, adenovirus and RSV have also been shown to cause croup.  
When COVID variant Omicron BA.1 became the dominant strain, the rate of pediatric emergency department visits and hospitalizations due to croup were noted to increase.  This retrospective study of 499 pediatric patients showed that those who tested positive for COVID within one week of presentation had a significantly higher degree of stridor at rest, hypoxia, the need for additional doses of racemic epinephrine, admission to the floor, admission to the intensive care unit and increasing respiratory support.  
Bottom line: Consider testing for COVID in your croup patient who is not responding to traditional therapies.

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Category: Pediatrics

Title: Does purulent eye discharge need to be treated topically in pediatrics?

Keywords: conjunctivitis, pink eye, eye drops (PubMed Search)

Posted: 2/17/2023 by Jenny Guyther, MD (Updated: 7/17/2024)
Click here to contact Jenny Guyther, MD

It is often difficult to clinically differentiate between viral and bacterial conjunctivitis, but previous studies have shown that the vast majority of the discharge is bacterial. Topical antibiotics are often prescribed, but the efficacy of these antibiotics compared to no treatment has not been well studied.
This study included 88 children aged 6 months to 7 years with acute infective conjunctivitis who were randomized to receive moxifloxacin eye drops, placebo eye drops or no intervention.  Acute infective conjunctivitis was defined as conjunctival inflammation, discharge, soreness or swelling of the eyelids.  The clinical cure was significantly shorter in the moxifloxacin group compared to the no intervention group (3.8 vs 5.7 days).  Both moxifloxacin and placebo eye drops had a shorter time to clinical cure compared to placebo suggesting that placebo eye drops may be beneficial due to their washout effect.
Bottom line: Topical antibiotics for acute infective conjunctivitis were associated with significantly shorter recovery times from acute infective conjunctivitis.

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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:

  • If symptoms <48 hours, no severe pain, and fever < 39C and child is 2 years or older (either unilateral or bilateral AOM) OR unilateral AOM with symptoms <48 hours, no severe pain, and fever < 39C and child is 6 months to 2 years
  • If observing, consider either a prescription that parents can fill if symptoms persist or ensure prompt primary care follow up

Initial treatment

High dose amoxicillin (90 mg/kg/day divided BID)

  • If true penicillin allergy, can use cefdinir or cefpodoxime if tolerated or trimethoprim-sulfamethoxazole or a macrolide (e.g. azithromycin) but rates of resistance are higher
  • Cefdinir and azithromycin are the most commonly used  
  • Levofloxacin is also an option for age >8 years

Recurrent Otitis Media

If less than 30 days from initial treatment, presumed to be persistent

  • If previously on amoxicillin, start amoxicillin-clavulanate (extra strength suspension has highest amoxicillin to clavulanate ratio and should be used)
  • If previously on amoxicillin-clavulanate, ceftriaxone either for 3 days or 2 doses 36 hours apart

If greater than 30 days from initial treatment can treat as new episode (so amoxicillin unless previous documented resistant infections)

Duration of Antibiotics

  • Less than 2 years, 10 days
  • 2 years and up, 5-7 days

Other Considerations

  • Amoxicillin-clavulanate should be used as an initial agent if there is concurrent purulent conjunctivitis
  • Children with tympanostomy tubes and purulent otorrhea may be treated with otic fluoroquinolones (with or without dexamethasone), as long as debris does not obstruct entry of antibiotic drops
  • Remember that the otic canal and TM can become red with fever and non-purulent effusion is common with URI
  • Remember to treat pain and fever!

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