UMEM Educational Pearls - Pediatrics

Umbilical Cord Problems

• Delayed Umbilical Separation
  • Normal Time for cord separation = 1 – 8 weeks postnatal age.
  • Common Reasons for Delayed Separation:
    • h/o Neonatal Sepsis and antibiotic administration
    • h/o Prematurity
    • h/o C-Section delivery
    • h/o Low Birth Weight
  • Rare, yet most concerning reason for Delayed Separation:
    • Immuno-Deficiency – Leukocyte Adhesion Deficiency type 1 (LAD-1)
      • Life-threatening
• Omphalitis
  • Infection of the remnant of the umbilical cord
  • More common in developing countries
  • Staph. aureus is most common organism cultured
  • Complication from:
    • Spontaneous Evisceration
    • Necrotizing Fasciiis of scrotum and/or penis
    • Peritonitis
    • Intra-abdominal abscesses
  • Early detection is paramount

Cerebral Edema in Patients with DKA

• Cerebral Edema is a rare, yet catastrophic complication of Pediatric DKA.
  • Occurs in ~1% of episodes of pediatric DKA
  • Mortality rate of 40-90%; 20-40% of survivors have lasting Neuro Sequelae.
• Risk Factors
  • High initial BUN
  • Low paCO2
  • No increase of the sodium during therapy
  • Treatment with bicarbonate
• Diagnosis is made clinically
  • Warning Signs = Headache, Vomitting, Lethargy, Bradycardia, and Hypertension
  • Keep Mannitol (0.25-1.0 grams/kg) at the bedside.  Administer it and stop IVF once you suspect Cerebral Edema.
    
    Glaser N, et al: Risk factors for cerebral edema in children with DKA. NEJM.2001:344:264-9
     

Febrile Seizures

• Diagnosis: Simple vs Complex
  • Simple Febrile Seizure
    • Age = 6mos to 5yrs
    • Single Seizure
    • Generalized
    • Lasting less than 15 minutes
    • Child returns to baseline and has normal neurological exam.
  • Complex Febrile Seizure
    • Same as above, except can be focal seizure or prolonged or with multiple seizures within 24 hours.
    • May indicate a more serious disease process.

• Etiologies:
  • Viral illnesses are the predominant cause of febrile seizures.
    • Human herpes simplex virus 6 (HHSV-6) has been associated with about 20% of pts with first febrile seizures.
  • Shigella gastroenteritis also has been associated.
  • The rate of serious bacterial infections is similar to those found in pt’s with fever without a source

• Key Point:
  • Do NOT forget to work-up the fever as you would for the patient’s age!
  • A lower threshold for performing full-sepsis work-up with LP is advocated in those pt’s less than 12 months of age.
     

Neonate with Red Eye

• Crusty Eye – Not Red
  • Dacryostenosis - nasolacrimal duct obstruction
  • It is the most common cause of tearing in childhood.  
  • No photophobia, corneal is normal
  • Tx  = Warm compresses and gentle massage

• Purulent Conjunctivitis - Ophthalmia neonatorum
  • Chemical (due to prophylactic eye drops) - day 1
  • Gonorrhea –
    • Presents early on (day 2-5)
    • OCULAR EMERGENCY – may cause globe perforation
    • Associated Systemic Infection - meningitis
    • Ceftriaxone (25-50mg/kg) – Treat until Cx’s return.
  • Chlamydia –
    • Longer incubation period (day 5-14)
    • Causes Eyelid Scarring leading to blindness
    • Associated Systemic Infection – Pulmonary
    • Ceftriaxone (25-50mg/kg) + Topical Erythromycin
    • If Culture +, then PO erythromycin to prevent late onset pneumonitis.

Tissue adhesives:

Cyanocrylate Tissue Adhesive is an excellent product to use when repairing linear lacerations.

A few things to remember:

The wound needs to be irrigated as you would any other wound prior to closure.

Gravity works.  Consider where the product may drip to before you apply it (Eyes, Ears, Nose, etc).  

Use Surgi-Lube (or other petroleum product) to create a barrier to limit the flow of the cyanocrylate.

For long lacerations, you may use steri-strips to help approximate edges before applying the tissue adhesive.

What to do if the glue gets out of control and drips onto the eyelids... may also apply to Krazy-Glue:

Use copious irrigation and then Mineral Oil (not acetone or alcohol - which won't go well in the eyes).

Often there will be an associated corneal abrasion... treat it as other corneal abrasion.

Pediatric Back Pain

• Back Pain in PrePubertal Children is rare and often due to serious underlying disorder
  • Infection (diskitis or osteomyelitis)
  • Malignancy
    • Osteoma, Osteoblastoma
    • Histiocytosis X
    • Lymphoma, Leukemia
    • Ewing Sarcoma
    • Neuroblastoma, Spinal Cord Glioma
• Back Pain in adolescent children is more likely to be due to muscular skeletal injury (as with adults)
  • Classified as chronic back pain (greater than 4 weeks duration) in up to 13%

• Red Flags for Serious Underlying Disorders
  • <4yrs of age
  • Back Pain causing functional disability (child not willing to play)
  • Fever
  • Neurologic Abnormality (get the child undressed and do a good neuro exam).
     

Ketamine and RSI for pts p TBI

• Traditionally, Ketamine has been avoided for patients with traumatic brain injury; however, this may be unwarranted…
  • Early after TBI, ICP is not usually elevated.
  • Early after TBI there is a low blood flow state, and Ketamine can increase cerebral blood flow.
  • As long as there is no obstruction to CSF flow, Ketamine will not increase ICP.
• Evidence now states that Ketamine can be neuroprotective because it blocks glutamine because of it NMDA antagonist properties.
• Ketamine also has antiepileptic properties (which improve pediatric TBI outcomes).

• End result, if a patient has TBI and there is no concern for obstruction to CSF drainage, then Ketamine can be a possible option for RSI.
   

Pediatric ITP – Bone Marrow Aspiration

• ITP is an acquired disorder characterized by:
  • thrombocytopenia (platelet < 150)
  • a purpuric rash
  • normal bone marrow
  • the absence of signs of other identifiable causes of thrombocytopenia.

• Therapeutic options include Steroids, IVIG, and Ant-Rh(d)
  • For patients with new Diagnosis, consultation with a hematologist is warranted:
  • Despite the growing number of studies that state there is a low probability of newly diagnosed leukemia presenting as isolated thrombocytopenia, the risk exists.
  • Bone Marrow Bx is the Gold Standard prior to starting steroids currently.
  • Steroids may partially treat a leukemia.
  • Can avoid Bone Marrow Bx if you use IVIG (which needs to be given in consultation with Hematology)
     

Bronchiolitis: Use of RSV rapid testing

• Firstly, know that the sensitivity of the test is ~60% (leaving 40% that have the disease testing falsely negative)
• Secondly, in whom will the result impact your decision?
  • High-risk patient populations (at risk of decompensation or apnea)
    • Premature (especially <34 wks GA)
    • Infants < 2months of age
    • Chronic Lung Disease
    • Congenital Heart Disease
  • Infants undergoing sepsis evaluations
    • The incidence of concominant serious bacterial infection and RSV is low (<1%)
       

Purcell K, Fergie J. Concominant serious bacterial infections in 2396 infans and children hospitalized with respiratory syncytial virus lower respiratory tract infections. Arch pediatr adolesce med. 2002; 156: 322-324.

Pediatric Leukemia/Lymphoma Presentation in the ED

• Pts most commonly present with c/o pallor or decreased activity
• Physical Exam commonly demonstrates pallor, splenomegaly, fever, hepatomegaly, lymphadenopathy, and ecchymoses/petechiae.
• CBC’s and peripheral smears are realiably abnormal
• Patients with solid tumor more commonly present with symptoms related to tumor location (ie Abd pain, Headache, etc.)

Jaffe D, Fleisher G, Grosflam J. Detection of cancer in the pediatric emergency department. Pediatr Emerg Care. 1985 Mar;1(1):11-5.

Child with a Limp

• First classify the limp:
  • Antalgic gait = shortened stance phase of the affected extremity due to PAIN
  • Trendeleburg gait = equal stance phase between involved and uninvolved side, shifted center of gravity; NOT Painful
• Etiologies
  • Painful Limp
    • 1-3 years of age: Septic Joint, Occult Trauma, Neoplasm
    • 4-10 years of age: Septic Joint, Transient Synovitis, Legg-Calve-Perthes Disease, Trauma, neoplasm, Rheumatologic D/O
    • 11 + years of age: SCFE, Rheumatologic D/O, Trauma, (consider AVN in pts with sickle cell disease)
  • Trendelenburg Gait
    • Indicative of underlying hip instability or muscle weakness
    • Think of congential hip dislocation and Neuromuscular Diseases/Disorders

Grossman, Emblad, Plantz. Orthopedic Emergencies in Pediatric Emergency Medicine Board Review.  2nd Edition. 2006. p305.

Child Abuse

• An estimated 2,815,600 children are harmed or endangered by their caretakers annually
• Fractures are among the most common injuries seen in these children and are frequently highly specific for a diagnosis of abuse.
• No fracture is pathognomonic of abuse
• Some are suggestive:
  • Spinal fx
  • Digital fx
  • Complex skull fx
  • Spiral Long Bone fx
  • Scapular fx
  • Sternal fx
  • Metaphyseal fx
  • Periosteal separation
• Some are more specific:
  • Posterior Rib fx
  • Acromioclavicular Fx
  • Multiple fxs of different ages
• Infants < 1 year of age with fractures have a high prevalence of abuse.
  
  C Y Skellern, D O Wood, A Murphy, M Crawford (2000). Non-accidental fractures in infants: Risk of further abuse. Journal of Paediatrics and Child Health 36 (6), 590–592.
  
  K. Nimkin, P. Kleinman. IMAGING OF CHILD ABUSE. Radiologic Clinics of North America, Volume 39, Issue 4, Pages 843-864
   

The Premature Infant Delivered in Your Department

An ode to my final NICU Call… just because you don’t work in a Pediatric ED, doesn’t mean you won’t encounter premature infants.

What do you need to remember when a premature infant is born in your ED (or the ambulance / cab / car)?

• Warm them and keep them warm
  • Cold stress, often overlooked, worsens acidosis and decreases surfactant function.
• Neonatal Respiratory Distress Syndrome manifests as cyanosis, tachypnea, grunting, retractions, and/or respiratory failure.
  • CXR has “ground-glass” appearance and air bronchograms
  • It is due primarily to inadequate surfactant.
  • Early administration of surfactant has proven to improve outcomes
  • Contact a neonatologist ASAP and determine if you have easy access to a surfactant product (it really is an amazing therapy).
  • You administer it down the ETT… you’ve likely intubated them by now.
• Fluids
  • Fluid Boluses are done with normal saline (10ml/kg)
  • Maintenance Fluids should be D5W or D10 (no electrolytes at first!)
• Antibiotics
  • One of the most common reasons for premature delivery is neonatal infections… don’t be stingy, start Amp/Gent (consider acyclovir) and send blood cultures at least.
     

Pierre Robin Syndrome

• The prime features of this condition are a small jaw (micrognathia), cleft palate, and posteriorly positioned tongue.
• In the newborn period, respiratory compromise from obstruction is of greatest concern.
  • Because the tongue is positioned in the back of the mouth, it tends to block the airway and cause respiratory distress.
  • In severe cases, a tracheostomy may be required to provide a stable airway for the patient. (We just had an emergent tracheostomy done in our NICU this month).
• Severity of airway obstruction varies from mild to life-threatening.
  • With only mild distress, attempt to relieve the obstruction by placing the child on his or her stomach; gravity will help to keep the tongue out of the airway.
  • Resuscitation of babies with more severe obstruction may be difficult because the micrognathia and the posteriorly protruded tongue can contribute to inadequate face-mask ventilation and make endotracheal intubation difficult (or impossible).
  • Consider LMA as a bridge to tracheostomy.
  • As soon as you recognize the presence of mirognathia, have someone call pediatric anesthesia and pediatric surgery.

Baraka, A. Laryngeal Mask Airway for Resuscitation of a Newborn with Pierre-Robin Syndrome. Anesthesiology. 83(3):646-647, September 1995.

Proteinuria

• Proteinuria on U/A may suggest underlying renal disease; however, it may be present for benign reasons as well:
  • A very concentrated urine (SG ≥ 1.020)
  • Alkaline urine (pH ≥ 7.5)
  • Presence of mucoproteins
  • Acute illness

• Benign processes almost never produce proteinuria above 1+.
• If proteinuria is detected in the ED in an asymptomatic patient:
  • Have the patient f/u with PMD for repeat u/a within 1-2 weeks
  • Recommend checking a first morning urine sample and urine protein: creatinine ratio (to rule out orthostatic/transient proteinuria).

• If proteinuria persists or is evident on first morning urine sample, then a renal biopsy may be indicated.
• Chemistry panels, CBC’s, renal ultrasound, and 24-hour urine collection rarely change the plan.
   

Chandar J, Gomez-Martin O, del Pozo R, et al. Role of routine urinalysis in asymptomatic pediatric patients.  Clin Pediatr (Phila). 2005; 44:44-48.

Hogg RJ, Portman Rj, Milliner D, Lemley KV, Eddy A, Ingelfinger J. Evaluation and management of proteinuria and nephritic syndrome in children recommendations from a pediatric nephrology panel established at the National Kidney Foundation Conference on Proteinuria, Albuminuria, Risk, Assessment, Detection, and Elimination (PARADE). Pediatrics. 2000; 105: 1242-1249.

Atrial Myxomas:

• Rare primary heart tumor
• Most involve the left side of the heart

• Symptoms may include fatigue, fever, rash, chest pain, syncope, and/or focal neuro deficits
  • Symptomatic emboli occur in 20-45% of pts with atrial myxomas
  • >50% of emboli go to the brain
  • Hemiplegia, aphasia, retinal artery occlusion, embolic “rash” in a child should all raise concern for cardiac source in pediatric pt.
    
    • Embolus from the heart is the most common cause of retinal artery occlusion in pts <40yrs.

• Emboli are most often myxoma tissue and not blood clot (so thrombolytics aren’t of much value)

Majeed Al-Mateen, et al. Cerebral Embolism From Atrial Myxoma in Pediatric Patients. Pediatrics, Aug 2003; 112: e162 - e167.

Rheumatic Fever

• Significant cause of cardiovascular morbidity in developing countries and still present in the USA, although declining in incidence.
• American Heart Association update of the Jones Criteria (1992):
  • Major Criteria
    (1)    Carditis (of any of the layers of the heart)
    (2)    Polyarthritis
    (3)    Subcutaneous Nodules
    (4)    Erythema Marginatum
    (5)    Chorea
  • Minor Criteria
    (1)    Arthralgia (not a criterion if polyarthritis is present)
    (2)    Fever
    (3)    Elevated acute-phase reactants (ESR, CRP)
    (4)    Prolonged P-R interval
• Diagnosis made by presence of TWO MAJOR or ONE MAJOR PLUS TWO MINOR.
• Diagnosis can also be made with presence of chorea and documented strep pharyngitis.

• Acute Management
  • Treat the Infection
    (1)    Penicillin (Pen V for 10 days or Pen G IM)
  • Alleviate Symptoms
    (1)    Salicylates are particularly effective for migratory arthritis
    (2)    High Dose ASA (80-100mg/kg/Day for several weeks, and then taper)
    (3)    NSAIDs for those who cannot tolerate ASA
    (4)    Steroids reserved for moderate to severe carditis.
     

Children s/p Heart Transplantation – Rejection

• Children need heart transplantation for complex congenital heart defects (hypoplastic left heart syndrome is most common) or dilated cardiomyopathies.

• Signs of Acute rejection
  • Chest Pain is uncommon
  • Common presentions: fever, myalgias, and vomiting.
    • ECG may show a decreased R wave amplitude and an increased QRS duration.
  • Labs are most often NOT diagnostic in acute rejection.
    • Troponin and CK levels may or may not be elevated.
    • Elevated LFTs are concerning for right heart failure.
  • Echo – Diastolic dysfunction is the earliest change seen in acute rejection
• Signs of Chronic Rejection
  • Clinical symptoms often related to the accelerated atherosclerosis
  • “Silent” ischemia or infarction – decreased exercise tolerance or malaise
  • Syncope

Woods, WA. Care of the Acutely Ill Pediatric Heart Transplant Recipient. Pediatric Emergency Care. 23(10):721-724, October 2007.

Severe Asthma in Pediatrics (Using “the kitchen sink” when all else fails)

Every effort should be made to avoid intubating an asthmatic pt.  Here are some possible options to consider:

• Atrovent - Multiple doses should be preferred to single doses of anticholinergics. The available evidence only supports their use in school-aged children with severe asthma exacerbation. (reference #1)
• Magnesium - Magnesium sulfate appears to be safe and beneficial in patients who present with severe acute asthma (based on 5 adult and 2 pediatric studies)
• Noninvasive ventilation - The application of NPPV in patients suffering from status asthmaticus, despite some interesting and very promising preliminary results, still remains controversial. (only one trial met criteria.  No pediatric studies)
• Heliox – No good evidence to support its use, but it is relatively safe to use, provided the patient doesn’t need more than 30% FiO2 (70%Helium)
• Ketamine – Cases suggest that for children experiencing severe asthma exacerbations, intravenous ketamine may be an effective temporizing measure to avoid exposing children to the risks associated with mechanical ventilation.
• Singulair - Intravenously administered montelukast, in addition to standard therapy, provided rapid benefits and was well tolerated among patients with acute asthma. (Study population 15yrs – 54yrs).
   

• References:

1. Plotnick LH, Ducharme FM. Combined inhaled anticholinergics and beta2-agonists for initial treatment of acute asthma in children. Cochrane Database of Systematic Reviews 1997, Issue 2. Art. No.: CD000060.
2. Rowe BH, Bretzlaff JA, Bourdon C, Bota GW, Camargo CA Jr. Magnesium sulfate for treating exacerbations of acute asthma in the emergency department. Cochrane Database of Systematic Reviews 1999, Issue 2. Art. No.: CD001490.
3. Ram FSF, Wellington SR, Rowe B, Wedzicha JA. Non-invasive positive pressure ventilation for treatment of respiratory failure due to severe acute exacerbations of asthma. Cochrane Database of Systematic Reviews 2005, Issue 1. Art. No.: CD004360.
4. Rodrigo, GJ. et al. Use of Helium-Oxygen Mixtures in the Treatment of Acute Asthma. Chest. 2003;123:891-896. 2003
5. T. Kent Denmark, Heather A. Crane, Lance Brown. Ketamine to avoid mechanical ventilation in severe pediatric asthma. Journal of Emergency Medicine. Volume 30, Issue 2. pages 163-166
6. James, JM. et al. A RANDOMIZED, CONTROLLED TRIAL OF INTRAVENOUS MONTELUKAST IN ACUTE ASTHMA. PEDIATRICS Vol. 114 No. 2 August 2004, pp. 547

Pediatric Septic Shock

• Sepsis is the most common cause of pediatric deaths worldwide.
• Recognition is paramount!  Delayed Dx = Higher Mortality
  • Hypotension is a late finding. 
  • Look for other signs of End Organ Hypoperfusion
    • Prolonged Cap Refill, Change in MS
    • Tachycardia, Tachypnea
    • Elevated Lactate / unexplained metabolic acidosis
• Management strategy is similar to that of adults
  • Get access (Don’t forget your I/O’s if necessary)!
  • Fluid Resuscitation is the most important aspect of the management
    • Get 20-60ml/kg infused within the first 15 minutes
    • Children with septic shock who get >40ml/kg before the first hour have increased survival compared to those who do not.
      • They may require 60-200ml/kg over the first few hours.
  • Get your Abx on board quickly
  • Currently there are Protocols that are based on the Adult Surviving Sepsis Campaign.

Goldstein B, Giroir B, Randolph A. International pediatric sepsis consensus conference: definitions for sepsis and organ dysfunction in pediatrics.  Pediatr Crit Care Med. 2005 Jan;6(1):2-8.