UMEM Educational Pearls - Pediatrics

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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Consider HSV

• Consider HSV as an etiology of fever in a neonate (0-30days) even without a maternal history of HSV or h/o active lesions.
  • In one study, only 12% of neonates dx’d with HSV infections had mothers with a known h/o HSV or active lesions.
• Start Acyclovir empirically in these neonates, especially if the Gram Stain is negative.  Send appropriate HSV PCR and Cx.
  • Only 29% of patients (pediatric and adult) ultimately diagnosed with HSV encephalitis were started on acyclovir in the ED. 
  • Those who were not started on acyclovir in the ED, had a significant delay of appropriate therapy.
  • If you don’t think of it… the admitting team might not either.
     

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Tips for Common Painful Procedures:

• Remember, kids ARE just little adults: they feel pain just like the bigger people!
  • Don't let others convince you not to consider pain management for simple procedures because it is more convenient.

• ORAL SUCROSE
  • Proven to reduce signs of distress in neonate (<1 month) for minor, painful procedures
  • Use in combination with sucking (ie, a pacifier).
  • Dose: 0.1ml of 24% to 2ml of 50% sucrose.

• Topical Lidocaine Creams (LMX 4, EMLA)
  • Use for IV insertion (several studies has proven skilled triage nurses ar able to predict which children will need IVs)
  • Use for Lumbar Puncture!
    • Normally you most likely either ask someone with large muscles to hold the kid or you inject lidocaine, which can obscure your landmarks.
    • Instead, place LMX4 (takes ~20minutes to produce numbness) while you are documenting, getting consent, and setting up your equipment. 
    • This will give good anesthesia and keep the kid comfortable (ie, still) and not distort your landmarks... making you more likely to have success.
    • In neonates, you can also use Oral Sucrose Pacifer for added benefit.

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Hypertension

• Normative BP values are based on Age, Sex, and Height (check Harriet-Lane).
• BP should be measured in all children >3yrs and in selected children <3yrs.

• The younger the child and the higher the BP, the more likely there is a secondary cause. 
• Most common secondary causes:
  • 1st year of life: RenoVascular anomalies and aortic coarctation.
  • Early childhood/school-aged kids: Renal Parenchymal Disease
  • Adolescents: Essential hypertension

• 25% of children that present with HTN requiring emergent management present with hypertensive encephalopathy (ie.  it is a more common presentation of HTN in pediatrics than in adults).
• Initial Work-up:
  • Upper and Lower Extremity BP measurement
  • BMP and U/A – look for renal disease
  • CBC – microangiopathic process c/w HUS?
    
    
     

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Diarrhea and the Petting Zoo

Now that it is Spring Time, trips to the Zoo and to Pools will become more frequent… consider them as potential environmental exposure sites.

Petting Zoos, Farmers Markets and Fairs, and Swimming Pools (especially kiddie swimming pools) are known sources of enteropathogens that can cause diarrhea (sometimes bloody).

• Salmonella (turtles, baby chicks)
• E. Coli (newborn calves)
• Cryptosporidium (farm animals and swimming pools – it is chlorine resistant)

Consider these on your DDx of vomiting/diarrhea.

Ask about these possible exposure sites along with Travel History and Nontraditional Pets.

Sexual Abuse

• The only positive vaginal culture that is DEFINITIVE confirmation of sexual abuse is Neisseria gonorrhea.
  • Vertically transmitted Chlamydia may persist for up to 3 years (does not confirm abuse in children <3yrs)
  • Syphilis may also be present due to vertical transmission (often presents as secondary syphilis)
  • Trichomonas can also be transmitted perinatally and may persist for 6-9 months. 
    • However, it has NOT been found in children >1 year without history of sexual contact.

• Remember that CULTURES need to be sent for GC and Chlamydia.  DNA probes and nonculture methods are NOT recommended in this age group for evaluation of potential sexual abuse.
   

Acute Appendicitis – Delayed Surgery option?

• Appendicitis incidence in children = 4/1000
• The traditional emergent surgical intervention has recently been challenged.
• Three RETROSPECTIVE studies investigated delayed/urgent vs emergent surgical interventions
  • 2 of the three found no significant difference in perforation or complication rates between the 2 groups.
  • 1 found that the emergent group had higher rates of perforation.
• What you need to know:
  • surgeons may base their decisions on these studies, which do have limitations (being that their retrospective)
  • despite the time of day, you should still advocate for patients that are “sick” to go to the OR rather than get antibiotics to “cool off” first.

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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).