Oxycodone v. Codeine for Fracture Pain Management in Children

• When choosing an oral narcotic to give a child for fracture analgesia oxycodone is a better choice than codeine. 
• In this study children were randomized to recieve equianalgesic oral doses of either oxycodone (0.2 mg/kg, max 15 mg) or codeine (2mg/kg, max 120 mg) for forearm fractures
• Children given oxycodone reported a pain score significantly lower than children given codeine
• And children given oxycodone had less itching than those given codeine

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When the Sting REALLY hurts!!

• Anaphylaxis is an acute, potentially life-threatening problem, with multisystemic manifestations.(Remember 2 or more organ systems are required by definition!)
• In Children, foods (Milk, Eggs, Wheat, and Soy (MEWS) are the most common allergens
• But...peanuts and fish are among the most potent!!
• Also children can develop anaphylaxis from the fumes of cooking fish or residual peanut in a candy bar.
• Other common causes are preservatives, medications (antibiotics), insect venom (bee stings!!!!!!)

Remember the dose of Epinephrine is : 

0.01 mg/kg or 0.01 mL/kg of 1:1,000 IM or

0.01 mg/kg IV or 0.1 mL/kg/dose 1:10,000 IV

to the adult dose or 0.3 mg 

Also

Epipen Jr = 0.15 mg (use for < 30 Kg)

Epipen = 0.3 mg (use for > 30 Kg)

To show patients an instructional video click on the referenced link.

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Many things can be fatal with only one pill or sip for a young child.  One teaspoonful of Oil of wintergreen (5ml) contains about 7000 mg of salicylate (the equivalent of about 21 adult aspirin).  It would take only one swallow of Oil of wintergreen to be lethal for a young child.

Other Potential single dose killers for your Pediatric patients:

Alchohols

Methanol
Ethylene glycol
Isopropanol

Antidepressants

Monoamine oxidase inhibitors
Cyclic antidepressants

Antihypertensives

Clonidine
Verapamil
Diltiazem

Antimalarials

Chloroquine
Quinine

Benzocaine

Caustics

Hydrofluoric acid
Ammonia fluoride/bifluoride
Boric acid
Selenious acid
Disk batteries

Herbals

Eucalyptus oil
Pennyroyal oil
Camphor
Oil of wintergreen

Hydrocarbons

Imidazolines

Oxymetazoline
Naphazoline
Xylometazoline
Tetrahydrozoline

Insecticides/Rodenticides/Herbicides

Organophosphates
Carbamates
Lindane
Paraquat
Diquat
Nicotine

Opioids

Diphenoxylate
Methadone
Morphine
Oxycodone
Propoxyphene

Sulfonylureas

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Bladder ultrasound increases catheterization success in pediatric patients

• Next time before you attemt to catheterize a child under 36 months measure the transverse bladder diameter with the ultrasound first. 
• If it is > 2 cm you are much more likely to be successful in obtaining the specimen on the first attempt. 
• 94% when ultrasound measurement was used versus 68% patients who had conventional catheterization.

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In the rush of adrenaline that goes hand in hand with a pediatric intubation often the ETT tip can sometimes be coming out of the little guys toes after passing successfully through the vocal cords, so remember once you get it in and confirm with end-title CO2 detection (capnography or on a monitor) always remember:

Depth of insertion (cm at lip) = 3 x  normal size of ETT

Start at this depth, auscultate bilaterally in the axilla to listen for equal breath sounds, and look for equal chest rise.  If all are good then secure tube and get your chest xray. 

Sever's Disease

• Sever's disease is a painful inflammation of the calcaneal apophysis made worse with activity.
• It is thought to be caused by repetitive trauma to the weaker structure of the apophysis, induced by the pull of the Achilles tendon on its insertion.
• It occurs most frequently in active 10- to 12-year-old boys.
• The pain can limit performance and participation, and if left untreated, the pain can significantly limit even simple activities of daily life.
• Xrays are useful in ruling out other causes of heel pain like fracture or rare tumor but are not diagnostic or prognostic. 
• Treatment consist of rest, nsaids, wearing a half-inch inner-shoe heel lift (at all times during ambulation), a monitored stretching program, and presport and postsport icing. (rarely casting)
• Sever disease is a self-limited condition and will resolve after the growth plate fuses.

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Pyloric Stenosis

• The cause of the hypertrophied pylorus muscle is unknown, but it is usually not present at birth.  Mean onset of symptoms is 2-3 weeks of life, but range can be birth to 5 months with a 4:1 male to female occurrence.
• Clasic presentation is projectile, nonbilious vomiting of last feed which may be immediate or hours later.
• Pyloric Stenosis is the most common reason for abdominal surgery in the first 6 months of life.
• Textbook lab abnormality is a Hypochloremic hypokalemic metabolic alkalosis but this is a later finding and can not be used to rule out the diagnosis.
• Ultrasonography has become the standard imaging technique for diagnosis. It is reliable, highly sensitive, highly specific, and easily performed.
• Muscle wall thickness 3 mm or greater and pyloric channel length 14 mm or greater are considered abnormal in infants younger than 30 days. 
• DDX includes :  Normal Regurgitation (all babies do it!!!), GERD, Milk Intorerance, Obstruction (antral webs, volvulus,intussusception)

PEDIATRIC FEVER + SEIZURE = FEVER

When a child has a fever and a seizure, do the age appropriate workup for a fever and you won't go wrong!!!

•  Intussusception is the telescoping or prolapse of one portion of the bowel into an immediately adjacent segment.
• 90 % occur at the terminal ileum (ie, ileocolic).
• Male-to-female ratio is approximately 3:1.
• Usually seen between 5-9 months of age and 66% of all cases are in the first year of life.
• The classic triad of colicky abdominal pain, vomiting, and red currant jelly stools occurs in only 21% of cases
• Currant jelly stools are observed in only 50% of cases.
• Most patients (75%) without obviously bloody stools have stools that test positive for occult blood.
• If intussusception is strongly suspected, perform a contrast or air  enema without delay.
• Mortality with treatment is 1-3%.
• If untreated, this condition is uniformly fatal in 2-5 days.

Cardiac Involvement in Kawasaki Disease

• 50% can have Myocarditis (tachycardia, decreased ventricular function, arrhythmias, CHF, shock)
• 30% can have Pericarditis In untreated patients;
• 20 – 25% will have Coronary Artery Aneurysm during second and third week of illness Coronary Artery Aneurysms have risk of rupture, thrombosis, or stenosis
• Myocardial Infarction is leading cause of Death due to thrombosis, rupture, or stenosis of a coronary aneurysm
• Treatment with IVIG in the Acute Phase (within 10 days of onset of fever) reduces the risk of coronary artery dilation and aneurysms from 20-25% to < 5 % for coronary dilation and <1 % for giant coronary aneurysm. BUT NOT TO ZERO.

So the Pearl is if you have a pediatric patient with a complaint of Chest Pain, ask if there was any history of Kawasaki Disease and get an EKG ASAP if the answer is yes!

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Pertussis means "violent cough". 

Think of it with prolonged coughing, inspiratory whoop, absolute lymphocytosis, or chronic cough.

Don't Use cough suppressants.

Pertussis can be a life threatening Infection!!  Especially in infants and young children.

Pertussis is a reportable infectious disease in the United States.

Remember to save childrens lives be aggressive with septic shock treatment early!

Do NOT allow long delays at IV attempts before moving to central lines or IOs.

        Goal in the first 0 to 15 minutes from presentation:

• Recognize decreased perfusion and mental status, maintain airway, and obtain access.
• Push 20 ml/kg of Isotonic bolus (up to and over 60 ml/kg) and reassess shock after each.*
• Correct Hypoglycemia and hypocalcemia if present. 

When community ED physicians successfully achieved shock reversal (defined by return of normal systolic blood pressure and capillary refill time) in the first 75 min from arrival there was an associated 96% survival and a > 9-fold increased odds of survival.  Each additional hour of persistent shock was associated with >2-fold increased odds of mortality.

*To push this amount of fluid in an infant or young child it may be easier to use 60 ml syringes for boluses rather than pumps

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Pediatric vascular access can be a challenge especially in a critically ill child.  When placing central lines finding information on what size catheter to use and the depth of insertion can be hard to locate so here are some starters :

Age (yrs)     IJ       SC     Femoral

  0-0.5         3F       3F          3F

  0.5-2         3F       3F         3-4F

  3-6             4F      4F          4-5F

  7-12          4-5F   4-5F      5-8F

Use a single, double, or triple lumen.  (General rule more lumens the better.)

Right IJ and Right SC Depth of insertion:

If Height < 100cm    then   Initial Catheter Depth (cm) = Ht (cm)/10 -1 cm

If Height > 100 cm   then   Initial Catheter Depth (cm) = Ht (cm)/10 -2 cm

These formulas will place 98% of catheters above R atrium.

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Remember in the heat and pressure of a pediatric intubation (if you don't have your Pediatic Qwic Card handy) you can estimate what size blade to use very quickly and successfully by using facial landmarks!!

• Distance from the upper incisor teeth to the angle of the jaw seems to be an excellent clinical landmark for laryngoscope blade length selection for pediatric intubations under 8 years of age 
• Take the blade (excluding the handle insertion block) and place at the upper midline incisor teeth and if the tip is located within 1 cm proximal or distal to the angle of the mandible, oral tracheal intubations are more consistently accomplished on the first attempt!!!     90% on first attempt with correct size blade v. 57% on first attempt if blade too short

And remember to start with a straight blade (Miller, Wisconsin, Guedel, Wis-Hipple etc.) for your patients under 2 years of age because:

• these blades make controlling the tounge and epiglottis easier than curved blades at this age
• and they have a smaller flange profile in the oropharynx so visualization of the vocal cords is clearer

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ALTE and Infections - when to do full septic workups?

Given some recent cases of newborns with ALTEs at UMMS and Wash Co I thought I'd offer the following Pearls:   

• Overall the number of children with bacterial meningitis or bacteremia / sepsis as a cause of the ALTE is very low, much less than 1%
• However there is no data regarding the risk of meningitis in a well-appearing, afebrile infant with an ALTE

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Retropharyngeal Abscess

• Retropharyngeal Abscess is primarily a disease of younger children
• Origin may be medical or traumatic (ie running with popsicle stick in mouth).
• Complications:
  • Airway compromise
  • Sepsis
  • Mediastinal extension or invasion into other local structures
• Presentation:
  • Neck Pain – most common
    • Limitation of neck movement, especially neck extension
    • Torticollis
  • Fever
  • Sore throat
  • Neck mass
  • Respiratory distress, stridor – rarely
• Consider retropharyngeal abscess in pt with fever and limitation of neck mobility even in the absence of respiratory symptoms.
  • Were you considering Meningitis (fever and neck pain) and the LP results are normal? Think of retropharyngeal abscess.
     

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Topical Lidocaine for Acute Otitis Media

• Up to 83% of children with have AOM at least once by their 3rd birthday.
• In 2006, the AAP supported a “wait-and-see” plan for antibiotic prescription
  • Who can you withhold abx on?
    • Older than 6months
    • No severe infections (T>39°C)
    • If yes to both, may hold Abx for 48 hours.
• This approach does not mean “No treatment.”  Pain management is imperative.
  • Oral Analgesics are recommended in all cases.
  • Topical aqueous 2% licocaine eardrops also provide Rapid Pain Relief
    • Randomized, double-blinded, placebo-control study of topical lidocaine vs. placebo (water) demonstrated decreased pain scores at 10, 20, and 30 minutes after administration.
    • These can also be used safely at home for a few days.
       

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Pediatric Burns

• Burn Depth:
  • Avoid the traditional classification of 1st, 2nd, 3rd, and 4th degrees – they are imprecise.
  • Use modern classification:
    • Superficial, superficial partial thickness, deep partial thickness, full thickness, and Deep full thickness.
• Estimation of burn %:
  • Rules of 9 is NOT useful in pediatrics
  • Use the Lund-Browder Chart, which accounts for varying surface area percentiles by age.
  • If Lund-Browder Chart not available, use the area from the patient’s wrist to the tips of the fingers as being equivalent to 1% of his/her BSA.
  • Don’t include superficial burns in calculation of %TBSA burned.
  • Burn depth will often progress… anticipate this, as this will have implications on fluid management.
• Fluid Resuscitation
  • Parkland: Weight (kg) x %TBSA burned x 4ml = 24 hr total volume of Ringer’s Lactate
  • First ½ over the first 8 hours SINCE THE TIME OF THE BURN (not the arrival in the ED)
  • Second ½ over the next 16 hrs.
  • IF THE PT WEIGHS <30kg, this volume needs to be IN ADDITION to the child’s Maintenance fluids
  • Parkland gives you an estimate of the starting fluid requirements, but assessment of the Urine Output allows you to adjust it according to the pt’s needs:
    • Goal Urine Output = 1ml/kg/hr for pts <30kg; 0.5ml/kg/hr for pts >30kgs
    • Be careful not to fluid overload pt: decrease or increase IVF rate accordingly.
       

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Pediatric Accidental Non-Fatal Injuries

• Every 1.5 minutes an infant 0-12 months is evaluated in an ED for nonfatal unintentional injuries
• “Falls” are the leading cause of injuries in all age groups (0-12mos)
  • account for ~51% of ED visits in this group
  • Only 2.6% required hospitalization
• “Drowning” was the least common cause of ED visit (0.2%), but
  • accounts for ~47% of the hospitalizations in this group
• “Poisoning” had a bimodal distribution between 0-12 months
  • more commonly seen in 1-3 mos (likely due to parents or siblings) and
  • also in 7mos to 12 mos (likely because of the kids – age when they put things in mouth)

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Acute Chest Syndrome

• ACS is the leading cause of morbidity and mortality in children and adults with Sickle Cell Disease.
• Definition: ==> A new infiltrate on CXR (excluding atelectasis) PLUS one or more of the following:
  • Tachpnea
  • Fever (>101 degrees F)
  • Chest Pain
  • Cough
  • Wheezing
  • Hypoxemia
• Treatment
  • Bronchodilators
    • Trial of beta-agonists for clinical response is advocated even in those without wheezing.
  • Antibiotics
    • Broad Spectrum: Ceftriaxone PLUS Azithromycin
    • Evidence demonstrates a significant amount of these patients have atypical bacterial infections
    • Vanco is warranted for severe disease unresponsive to therapy
  • Steroids
    • Use for patients with Reactive Airway Disease or severe distress
    • They may cause a rebound of Vaso-occlusive Crisis and need to be tapered.
    • Prednisone 2mg/kg/Day x 5 then taper
  • Pain Control
    • Need to optimize pulmonary toilet by providing adequate pain management, but avoid over-sedation leading to hypoventilation.
    • NSAIDs have proven to be useful in conjunction opiods.
  • Transfusion of PRBCs
    • Simple
      • For pts who have a >10-20% drop from their baseline Hgb
      • For pts who are symptomatic, but not in impending respiratory failure
      • Try not to EXCEED Hgb of 10g/dL post transfusion
    • Exchange
      • For pts with impending respiratory failure
      • For pts with Hgb > 10g/dL and significant symptoms (to avoid hyperviscosity)
    • The decision to transfuse these patients needs to be made in conjunction with the consulting Hematologist.

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