Next time you have to do a full septic work up on a 2 month old with a fever of 104 F consider giving Ketamine 3mg/kg IM before even starting.  Then you can obtain your cath urine, IV, and LP with a calm pain free patient!!

Ketamine induces a catatonic state that provides sedation, analgesia, and amnesia.  It does not affect pharyngeal-laryngeal reflexes and the patient maintains a patent airway.  This makes it very useful when fasting is not assured.   

Route          Onset          Duration             Dose

  IM            3-5 min         20-30min         3-5 mg/kg

  IV             1 min            5-10 min          1-2 mg/kg

Propofol is an IV hypnotic that is made in a soy-based emulsion containing soybean oil, egg lecithin, and glycerol.  It has a very rapid onset time (10-50 seconds) and a brief duration of action making it ideal for ED sedation.  Children have a more rapid metabolism of propofol than adults.  Propofol has been shown to be safe and effective for Pediatric ED sedation in several studies.  

Pearls on Propofol

• Dosing is 1mg/kg bolus than 0.5 mg/kg IV q 1-2 min until desired sedation occurs
• Due to high lipid concentration can cause pain at injection site in up to 70% of patients.  This can be prevented by applying a rubber tourniquet well above IV site and injecting 0.5 mg/kg of lidocaine 30 seconds before injecting the propofol. 
• Use is contraindicated in those with allergies to Eggs, Soy, or sulfites, or those with mitochondrial disorders
• PRIS (Propofol Infusion Syndrome) was described in 1992 with case reports of children dying due to metabolic acidosis, rhabdomyolysis, and refractory heart failure when receiving high doses (>4mg/kg/h) for >48 hours.  And it is more associated with children < 4 years old. 
• So while safe for pediatric procedural sedation don't use propofol as a drip for intubated children.

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• Bronchiolitis is the most common lower respiratory tract disease in infants, and RSV (Respiratory syncytial virus) bronchiolitis is the leading cause of hospitalization in infants.  It will infect 90% of children by 2 years of life.
• Bronchiolitis "season" in the US is typically December to March but it does occur year round. 
• Pathology is caused by respiratory epithelial cell death that results in inflammation, edema, smooth muscle contraction, bronchoconstriction and mechanical obstruction by cellular debris and mucus plugging.
• History that suggest Bronchiolitis is cough, rhinorrhea, fever
• Most common PE findings are runny nose, tachypnea, wheezing, cough, crackles, use of accessory muscles,  and/or nasal flaring.
• Respiratory distress, dehydration, sepsis, and RSV associated apnea are feared severe complications.
• RSV associated apnea may be the presenting symptom in some infants. 
  • Infants at greatest risk for this are younger (usually < 3 months), hx of prematurity, hx of apnea of prematurity, and those who are early on in the illness.

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SIDS

Sudden infant death syndrome (SIDS) is defined as the sudden death of an infant younger than 1 year that remains unexplained after a thorough case investigation, including the performance of a complete autopsy, examination of the scene of death, and review of the clinical history.

SIDS is the single most common cause of death in infants aged 1 mo to 1 yr

Education is key for prevention of these tragic events:

Following the "Back to Sleep" campaign, federal SIDS researchers have conducted annual surveys to examine how infant sleep practices and SIDS rates have changed.  The rate of prone sleeping for infants decreased from approximately 75% in 1992 to a low of 11.3% in 2002

Since 1992, SIDS rates have fallen approximately 58%. In 2002, the National Center for Health Statistics reported a total of 2295 SIDS deaths nationwide for a SIDS rate in the United States of 0.51 per 1000 live births.

Bed-sharing may lead to compromise of the infants' airway because the infant may be suffocated by soft, loose bedding or a sleeping adult.

Cosleeping on a couch or sofa is associated with an unusually high risk for SIDS and should be avoided.

How do we know if we really need to put all those red eyes sent in from daycare centers and schools on antibiotics? The following study shows us why.

Bacterial Conjunctivitis in Children

• Prospective study in a children’s hospital ED
• Conjunctival swabs for culture were obtained from patients aged 1 mo - 18 yrs presenting with red or pink eye and/or the diagnosis of conjunctivitis
• 111 patients enrolled over one year
• Mean age of 33.2 mos, 55% male
• 87 patients (78%) had positive bacterial cultures
  • Nontypeable H influenzae = 82%
  • S pneumoniae = 16%
  • Staphylococcus aureus = 2.2%
• The combination of a history of gluey or sticky eyelids and the physical finding of mucoid or purulent discharge had a post-test probability of 96% that the infection was bacterial.(So when both these are present you definitely should treat)
• And since the majority of these children (78%) had positive cultures even if they only had a pink eye it is reasonable to use empirical ophthalmic antibiotic therapy in children who present with the complaint of a pink eye.

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With the cooler weather on us all our favorite viral infections will start to appear.  Included in this is the "slapped - cheek disease" Erythema infectiosum. 

Erythema Infectiosum

• An acute viral illness caused by parvovirus B-19
• Usually is seen in the winter and spring months
• Presents with mild fever, itching, headache, and arthralgias
• Usually have an erythematous, erysipeloid rash on the cheeks (slapped look) and a reticular rash (lace-like) on the arms
• No test are needed
• Management is supportive
• Children with chronic hemolytic anemias can develop an aplastic crisis from this infection

Pediatric Discitis is an intervertebral disc infection due to hematogenous spread to vascular channels in cartilage that disappear later in life.  In 1/3 of patients it is caused by S. aureus.

Presenting Features

• age <2.5 years (75%) 
• Refuse or difficult to walk  (56%)
• Back/neck pain (25-45%) ( 100%>3years)
• Hx of fever (28-47%)
• lumbaosacral area (78-82%)
• Mean ESR 39-42
• WBC> 10,500 (50%)
• Abnormal MRI 90-100 %

Management is to exclude more severe disease (osteomylelitis,abscess, tumor) and antibiotic use is debatable.  Remember children this age rarely complain of back pain. 

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Popsicle or cold panniculitis is an inflammation of the subcutaneous fat after prolonged exposure to cold.  It is thought to occur more often in infants and young children because they have a higher percentage of saturated fatty acids than older children and adults.  Pediatric patients may present to you to be evaluated/ruled out for abuse by social workers, schools, or police and if you have the correct history it is easy to dispo quickly.

Clinical Features of Popsicle Panniculitis

• Absence of systemic signs
• Minimal pain, with or without
• Skin is red to purplish, indurated, may have discrete nodules or plaques
• perioral location for popsicles, but may occur at any other area of skin exposure
• resolves in 2-3 weeks without scarring
• hyperpigmentation may persist
• arises within hours to to 1-2 days after exposure to a cold object

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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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