UMEM Educational Pearls - Pediatrics

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).
     

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.