UMEM Educational Pearls - Pediatrics

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: 2/26/2024)
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: 2/26/2024)
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: 2/26/2024)
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: 2/26/2024)
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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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.

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Pseudohyperkalemia can result from the use of small bore IVs, excessive tourniquet time, fist clenching and mechanical stress during collection.  These factors may affect pediatric blood draws. 
 
This was a 5 year retrospective analysis of patients 0-17 years.  187 patients had a hemolyzed sample that showed hyperkalemia.  145 children had repeat testing and only 3 children had true hyperkalemia (2%).  All three of these patients had underlying conditions that would have raised suspicion for hyperkalemia (chronic renal failure and diabetic ketoacidosis).  There were no abnormalities to the BUN or creatinine in the patients without hyperkalemia.
 
Bottom line: This small study suggests that it may not be necessary to obtain repeat blood samples for hyperkalemia in patients with normal BUN and creatinine.  Larger studies are needed before bringing this into mainstream practice.

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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.

 

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Category: Pediatrics

Title: What is the proper ratio of blood products in the bleeding pediatric trauma patient?

Keywords: Pediatric trauma, blood transfusion, ratios (PubMed Search)

Posted: 11/18/2022 by Jenny Guyther, MD (Updated: 2/26/2024)
Click here to contact Jenny Guyther, MD

Research in the pediatric trauma patient has finally shown that crystalloid volume should be limited and blood products should be used early in resuscitation.  Whole blood transfusion is currently being studied.  Studies are also being conducted looking at the proper ratio of blood products for these pediatric trauma patients.
This was a retrospective review of the Trauma Quality Improvement Program.  Patients younger than 18 years old who received at least 1 unit of FFP and PRBCsduring the initial 4 hours of admission were included.  The study looked at 1,233 patients who received FFP:PRBC ratios of 1:1, 1:2, 1:3 and 1:3+ and 24 hour mortality, hospital mortality, complications and 24 hour PRBC requirements.
The 1:1 transfusion group had the lowest 24 mortality and in-hospital mortality.  There was no difference between the groups for complications.  The 1:1 ratio group also had the lowest 24 hour PRBC requirements.  This study did not include those patients who required massive transfusion on arrival. 
Bottom line: FFP:PRBC ratio of 1:1 was associated with increased survival in children.  More studies are needed regarding whole blood and massive transfusion in pediatrics.

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Subcutaneous Fluid Administration for Rehydration

  • An old school technique (described in the 1800’s) that fell out of favor but still has applicability - primarily in pediatrics although it has been explored for use in geriatrics and mass casualty events (due to ease and speed of use)
  • Most appropriate for stable but mildly to moderately dehydrated patients who need rehydration, are not tolerating PO, and in whom an PIV is difficult to establish (this should not replace an IO in a critically ill child)
  • Either a small gauge angiocath or butterfly can be used for access
  • Most common area to access in younger children is between the shoulder blades, although the lateral abdomen, thighs, or outer upper arms can be used as well; the site must have adequate subcutaneous tissue (can test by pinching between the fingers)
  • Subcutaneous catheter placement is generally quite easy, however care should be taken with securing the catheter as there will be expected swelling at the area which can cause dislodgement or discomfort
  • Mild erythema may also occur at the site of administration
  • Injection of hyaluronidase (150 U) at the site being used increases the volume that can be administered as well as speed of absorption (hospitals may carry this product for treatment of severe PIV infiltration events)
  • It is not necessary to have hyaluronidase to utilize subcutaneous fluid administration, but improves efficiency and efficacy
  • Fluids administered should be isotonic and can be administered at 20 mL/kg over an hour – this can be repeated as necessary

 

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Category: Pediatrics

Title: Once intuccesption has been diagnosed, when should reduction occur?

Keywords: intuccesption, air enema, reduction timing (PubMed Search)

Posted: 10/21/2022 by Jenny Guyther, MD (Updated: 2/26/2024)
Click here to contact Jenny Guyther, MD

Once the diagnosis of intussusception is made, there are often delays in 1) getting the patient to a center where reduction can be performed and 2) getting the staff available to perform an air enema, especially during evenings and nights. Previous studies have shown worse outcomes when there is longer than a 24 hour delay in reduction. This was a retrospective single center study looking at 175 cases of intussusception and evaluating the time between the radiology final read of intussusception and the timing of reduction and if enema based reduction was successful. In this group of patients, there was no statistically significant difference in reduction efficacy, requirement for surgical reduction or complication rate (bowel resection or perforation) in the patients studied which included delay intervals up to 8 hours. Successful first attempt reductions ranged from 72-81% in each study group (1hr, 1-3hr, 3-6hr and 6+ hr). The caveat to this study is that there were only 11 patients included in the 6-8 hour group. This study also did not take into account the timing from symptom onset to reduction time. Bottom line: More evidence is needed, but this small study provides evidence that up to 8 hours from radiology diagnosis of intussusception to the 1st reduction attempt was not less efficient compared to those with an attempt in under 1 hour.

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Category: Pediatrics

Title: What Sound Does an ALCAPA Make?

Keywords: pediatric cardiology, ALCAPA (anomalous left coronary artery from the pulmonary artery) (PubMed Search)

Posted: 10/7/2022 by Rachel Wiltjer, DO
Click here to contact Rachel Wiltjer, DO

 

  • Anomalous left coronary artery from the pulmonary artery (ALCAPA) is a rare congenital defect in which there is an altered origin of the left coronary artery (also known as Bland-White-Garland syndrome)
  • Generally asymptomatic at birth, but can present in late infancy, toddlerhood, or later with signs of congestive heart failure, a myocarditis picture, or sudden cardiac death
  • Flow through the left coronary artery is normal at birth due to high pulmonary pressures, but as those pressures drop the blood flow drops as well and may become reversed due to the pressure gradient
  • This can cause chronic myocardial ischemia, the severity of which, is dependent on collateral flow
  • Most patients will also develop mitral regurgitation
  • Cardiomegaly may be seen on CXR (and some patients will present with respiratory symptoms/wheezing)
  • EKG findings include: findings consistent with ischemia (ST changes, q waves – specifically in the anterolateral leads), leftward axis (for age), abnormal R wave progression (loss of R wave amplitude in affected leads)
  • Diagnosis can generally be made with echocardiogram (although not 100% sensitive) and the disease is generally treated with surgical repair

 

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Laryngospasm is defined as the cessation of ventilation despite persistent respiratory effort related to glottic closure.  Complications include hypoxia, bradycardia, and cardiac arrest.  In OR cases, one recent study found the laryngospasm to occur in 0.45/1000 cases.  In these children undergoing general anesthesia, risk factors included current upper respiratory infection, active asthma, airway anomalies, airway procedures, age < 3 months and the use of an LMA.  
Studies of the rates of laryngospasm in pediatric sedation have shown varied incidence, with prevalence between 0.43/1000 to 2.1/1000.  A metaanalysis showed that laryngospasm was more common with a combination of propofol and ketamine.
This study looked at moderate sedation cases where laryngospasm was not relieved with chin repositioning or the use of an airway adjunct.  Over a 7 year study period, 276,832 sedations were examined with 913 patients experiencing laryngospasm (3.3/1000 cases).  About 5% of these patients required intubation.  There were 2 cases of cardiac arrest, one with an underlying cardiac condition and one with a URI who was undergoing an echo.  Both of these patients had multiple agents used for sedation.
The isolated use of IV ketamine had a laryngospasm rate of 1.4/1000 cases.  The highest prevalence occured with propofol + ketamine (6.6/1000), propofol + midazolam + opiate (6.1/1000) and propofol + dexmedetomidine (5.8/1000).
The risk of laryngospasm was associated with a higher ASA status, younger age, presence of a URI, airway procedures, and certain propofol combination regimens.
Bottom line: While the prevalence of laryngospasm remains low during pediatric sedation, risk factors should be taken into consideration and the risk/benefits should be discussed in detail with the families.  Always be prepared for an airway emergency during sedation.

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Category: Pediatrics

Title: Secondary Transmission of SARS-CoV2 with regards to Masking in Schools

Keywords: COVID, kids, masking, school (PubMed Search)

Posted: 8/19/2022 by Jenny Guyther, MD (Updated: 2/26/2024)
Click here to contact Jenny Guyther, MD

This was a multistate, prospective, observational cohort of children and teachers attending in person schools in kindergarden through 12th grade where the school districs had the ability to perform contact tracing and determine primary vs secondary infections.  During the study period (6/21-12/21) 46 districts had universal masking policies and 6 districts had optional masking policies.  

Districts that optionally masked had 3.6x the rate of secondary transmission compared to universally masked school districts.  Optionally masked districts had 26.4 cases of secondary transmission per 100 community acquired cases compared to only 7.3 cases in universally masked districts.

Bottom line: Universial masking was associated with reduced secondary transmission of SARS-CoV2 compared with optional masking policies. 

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  • TXA has been used for pediatric non-traumatic (surgical) bleeding with good evidence
  • Currently used in around 1/3 of pediatric trauma centers based on survey data
  • PED-TRAX (retrospective review of pediatric trauma admissions in a combat zone) showed an association between use of TXA and decreased mortality, with no increase in thromboembolic events
  • Dosing strategies in the literature and in practice have been variable (bolus at variable dosing versus bolus + infusion)
  • The TIC TOC trial was recently completed - a multicenter randomized pilot study looking at 2 dosing strategies of TXA versus placebo which demonstrated feasibility of a larger study and will hopefully serve as a model for further research to determine efficacy as well as ideal dosing

 

Bottom line: There is not clear evidence for efficacy, but trends are positive and the documented rates of adverse effects in this population are low. It is reasonable to give, especially in patients requiring massive transfusion or who are critically ill.

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Category: Pediatrics

Title: The Pediatric Pause - Introducing a Trauma Informed Care Protocol

Keywords: trauma informed care, pediatric resuscitation (PubMed Search)

Posted: 7/15/2022 by Jenny Guyther, MD (Updated: 2/26/2024)
Click here to contact Jenny Guyther, MD

Traumatic injuries are a leading cause of morbidity and mortality in pediatric patients.  Even in the setting of a full recovery, there can be negative psychological sequelae associated with the traumatic events.  The child's perceived risk of death and parental trauma related distress have both been associated with the development of post traumatic stress.
 
Previous studies have suggested the key components of trauma informed pediatric care include: minimizing potentially traumatic aspects of medical care and procedures, providing children and family with basic support and information, addressing child distress such as pain, fear, and loss,  promoting emotional support, screening children and families who might need support and providing anticipatory guidance about adaptive ways of coping.
 
The Pediatric PAUSE was introduced at a pediatric trauma center to help to reduce post traumatic stress.  
 
PAUSE stands for Pain/Privacy, Anxiety/IV access, Urinary Catheter/Rectal Exam/Genital Exam, Support for family or staff and Explain to patient/Engage the PICU team.  The article contains a table with a more detailed outline of the PAUSE.
 
This study evaluated the pediatric PAUSE to see if its implementation would interfere with the timeliness of the ACS/ATLS evaluation.  The PAUSE was inserted after the primary and ABCDE assessment (except in the unstable patient).  The use of this protocol did not prolong time between trauma bay arrival and critical imaging studies.

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  • Use of FAST is less common in pediatric trauma than in adult trauma
  • FAST in pediatric trauma has a lower negative predictive value than in adults
    • 1/3 of pediatric patients with hemoperitoneum on CT will have a negative FAST
    • Lowest sensitivity and specificity is in the under 2 years age group
  • A 2017 randomized clinical trial of ~900 patients showed no difference in clinical care, use of resources, or length of stay in hemodynamically stable children who received FAST + standard trauma evaluation versus standard trauma evaluation alone
  • There may be a role for FAST as a screening in patients with low suspicion for intraabdominal injury in conjunction with labs and physical exam, but this has not been fully explored

Bottom line: A positive FAST warrants further workup and may be helpful in the hemodynamically unstable pediatric trauma patient, but a negative FAST does not exclude intraabdominal injury and evidence for performing FAST in hemodynamically stable pediatric patients is limited.

 

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