Kids eat everything (except perhaps carefully prepared and balanced meals). While button battery ingestions are feared, there is more to worry about. Magnet ingestions – especially rare earth metal magnet ingestions – can lead to high morbidity and mortality.
When more than one magnet (or a magnet and another metallic object) are ingested, they can become stuck together through walls in the GI tract, creating risk for obstruction, erosion, fistula formation, and perforation. Sharp metallic foreign objects can be particularly dangerous as they can do much damage while being moved around by the magnet.
If there is concern for magnet ingestion, care should be taken to try to determine the number ingested (if parents have the magnets, you can compare the size of an object on xray to the size of the magnets as it can otherwise sometimes be difficult to differentiate if it is one magnet or more than one stuck together).
Higher risk features of ingestion include:
Ingestions should prompt consultation with pediatric GI and surgery when isolated as many will require either endoscopic or surgical removal. This may include need for referral and transfer.
The literature is not completely new regarding the use of intranasal dexmedetomidine for pediatric sedation, with several articles confirming noninferiority to benzodiazepines. It is a potent a2- adrenergic receptor agonist, which allows for sedation without analgesic properties. It can be considered for patients who are undergoing PAINLESS procedures. A recent article gave further clarification for dosing considerations when selecting this option. This study assessed varying weight-based doses and found the best effect with doses of 3 to 4 mcg/kg
Importantly, there is limited data that suggests this may result in longer discharge, duration of procedure and total time in the department compared to other sedation methods. Additionally, this option is not always readily available and approved for pediatric patients in every hospital.
Overall, Dexmedetomidine may be an excellent option for painless procedures, such as CT imaging or even MRI based on the literature, when available.
It's back to school season which means back to school injuries!
Scalp lacerations often require suturing or staple closure, but what if you can close the wound without any sharps that scare the kiddos? Consider using the Hair Apposition Technique (HAT)!
What is HAT?
- A very quick and easy technique for superficial scalp laceration closure made by twisting hair on each side of the laceration and sealing the twist with a small dot of glue for primary closure.
When do I consider HAT?
- For linear, superficial lacerations that are <10cm in length
- Laceration has achieved adequate hemostasis
- Patient has hair on both sides of the laceration
What are contraindications to HAT?
- Hair strands are less than 3cm in length
- Laceration is longer than 10cm in length
- Active bleeding from laceration despite hair apposition
- Significant wound tension
- Laceration is highly contaminated
How do I perform HAT?
- Debride wound as you normally wound for any laceration
- Take approximately 5 strands of hair on one side of the laceration and twist them together to make one twisted bundle
- Take approximately 5 strands of hair directly on the other side of the laceration and twist them together to make another twisted bundle
- Then take each bundle and intertwine the two bundles until the wound edges appose.
- Place a drop of glue on the twist
- Repeat along the length of the laceration until laceration is closed
Benefits of HAT:
- Based on a RCT from Singapore that compared suturing to HAT for superficial scalp lacerations that were <10cm, patient's were more satisfied, had less scaring, lower pain scores, shorter procedure tiems, adn less wound breakdown in the HAT group compared to the sutured group.
- A follow up study by the same group also assessed cost-effectievness of HAT compared to suturing (by taking into account staff time, need for staple/suture removal, treatment of complications, materials, etc) and found that HAT saved $28.50 USD when compared to suturing.
Modified hair apposition of scalp wounds- UpToDate
Bottom Line:
- Consider Hair Apposition Technique (HAT) for linear, superficial scalp lacerations, especially in pediatric patients as it is much more well tolerated (can also do this in adults!)
This was a retrospective study involving several hospitals in Italy. 135 patients who had drowned (the term used in the article) were included. 4.5% of patients died. Most drowning occurred in July and August. The most common comorbidity was epilepsy in about 10% of patients. Several patients were also witnessed to have trauma and syncope. Early resuscitation, either by bystanders or trained professionals, was paramount in survival.
Children who are conscious at presentation and have mild or no respiratory distress have the best prognosis. A well appearing child should be observed for 6-8 hours, given that 98% of children will present with symptoms within the first 7 hours. A chest xray is not indicated in the asymptomatic patient. Patients who are submerged greater than 25 minutes or without ROSC after 30 minutes have a poor prognosis.
Bottom line: Never swim alone and everyone should be trained in bystander CPR.
This study attempts to answer the age old question: What is the importance of fever in pediatric illnesses?
The authors' goal was to assess if response to antipyretics was associated with bacteremia. This article retrospectively reviewed 6,319 febrile children in whom blood cultures were sent and found that 3.8% had bacteremia. They then looked at the fever curve in response to antipyretics for these two groups in the emergency department over 4 hours. The study concluded that patients with bacteremia have a higher rate of persistent fever despite antipyretics. It is important to note the limitations of this study. As this was retrospective, it is unclear what clinical findings resulted in blood cultures being sent - most febrile children did not have any drawn (23,999 were excluded for this reason). They did not assess other vital signs, and did not address other bacterial infections (UTI, cellulitis, meningitis, otitis media, etc). Additionally, while patients with bacteremia did have a higher likelihood of fever, the majority of patients in both groups had fever resolution within 4 hours, and both groups had some children with persistent fevers.
Overall, this does seem to support the decision to consider obtaining further testing in those children with a persistent fever, but also emphasizes the importance of not using fever resolution alone as support for discharge to home or exclusion of bacteremia from the differential.
Some things are easy, even reflexive, and one of those things is putting oxygen on cyanotic patients. Usually, this is a great thing. Blue = bad. Occasionally, though, blue = baseline and even in those patients who are too blue, you want to keep them closer to purple than pink.
This issue is commonly encountered in certain types of congenital heart disease and as well as through various phases of their repair. These include ductal dependent lesions, those with significant shunts, and single ventricle physiology. Oxygen functions as a pulmonary vasodilator and can increase or change the direction of shunting, directly impacting physiology by causing pulmonary overcirculation, increased strain on the right ventricle, and decreases in systemic circulation.
Helpful Hints:
1) Find out and shoot for the patient’s goal oxygen saturation range (many lesions will be 75%-85%). This may be available from parents, in the EMR, or by calling the child’s cardiac center if they are an established patient.
2) In an undiagnosed neonate with hypoxia and signs of heart failure (crackles, enlarged liver, edema to the sacrum and/or occiput) or if unresponsive to initial trial of oxygen, decrease FiO2 and titrate support (nasal cannula with blender to set FiO2, HFNC, NIPPV, or intubation if necessary) to address respiratory distress as well as evaluation and treatment for ductal dependent lesions.
3) You may still need to use additional FiO2 to obtain reasonable oxygen saturations, but titrate thoughtfully.
Neonatal rashes are common and, usually, benign. There are some skin findings, however, that require early recognition and treatment for best outcomes. One of these concerning etiologies is omphalitis, infection of the umbilical stump and surrounding tissues.
Features of omphalitis may include erythema and induration around the umbilicus, purulent drainage, and potentially systemic illness.
Risk factors include poor cord hygiene, premature or prolonged rupture of membranes, maternal infection, low birth weight, umbilical catheterization, and home birth.
Evaluation includes surface cultures from the site of infection as well as age-appropriate fever workup if patient is febrile. Consider ultrasound to evaluate for urachal anomalies as these can co-exist.
Management is IV antibiotics to cover S. aureus and gram negatives with surgical consultation if there are signs of necrotizing fasciitis or abscess. Some newer literature suggests that patients with omphalitis seen and treated in high-income countries may not be as sick as previously thought (as most data has been obtained in lower income countries where incidence is higher) and there has been a suggestion that there may be a role for oral antibiotics in well appearing, lower risk infants. This deserves further exploration but cannot yet be considered standard of care.
Other umbilical cord findings to consider (when it isn’t omphalitis): patent urachus, granuloma, local irritation, or partial cord separation
Background: Intranasal dexmedetomidine has seen usage in the anesthesia and sedation realms over the past few years, with an increasing interest in usage in the ED setting given its generally favorable safety profile and ease of administration. There has been specific interest and consideration in children with autism and neurodevelopmental disorders.
Study: Single center prospective provider study (compared to a retrospective group of patients under 18 who received oral midazolam for indications of agitation or anxiety via chart review) looking at patients 6 months to 18 years of age with an order for intranasal dexmedetomidine. Following use, a provider survey was completed to evaluate indication/rationale for use, satisfaction, comfort with use, and perceived time to onset as well as duration of effect.
Results: 29% of patients receiving IN dexmedetomidine experienced treatment failure compared with 20.7% of patients receiving oral midazolam (not statistically significant). In subgroup analysis, rates of treatment failure were lower for patients diagnosed with autism spectrum disorder receiving IN dexmedetomidine versus oral versed (21.2% versus 66.7%). Length of stay was longer in the IN dexmedetomidine group (6.0 hours versus 4.4 hours). Indication for use had variability between the two groups.
Bottom Line: IN dexmedetomidine may be a reasonable agent to utilize for anxiolysis in pediatric patients, especially those who have previously had paradoxical reactions or poor efficacy of benzodiazepines. It may be specifically useful when effects are desired for a slightly longer time and for non-painful/minimally painful interventions.
Otitis media is a common pediatric complaint seen in the primary care, urgent care, and ED settings. Recommendations for timing of treatment and deferral of treatment have emerged over the last several years, as have recommendations for regimens for recurrent infections in the age of resistant organisms.
When to consider observation over antibiotics:
Initial treatment
High dose amoxicillin (90 mg/kg/day divided BID)
Recurrent Otitis Media
If less than 30 days from initial treatment, presumed to be persistent
If greater than 30 days from initial treatment can treat as new episode (so amoxicillin unless previous documented resistant infections)
Duration of Antibiotics
Other Considerations
Should EMS place an advanced airway in out of hospital cardiac arrests? Current studies suggest that advanced airway management is not superior to BVM in pediatric out of hospital cardiac arrest (OHCA).
Pediatric OHCA carries a high mortality rate and those that do survive often have a poor neurologic outcome. This study evaluated BVM vs supraglottic airway (SGA) placement vs endotracheal intubation (ETI) in relation to one month survival and favorable neurological outcomes. SGA and ETI were also grouped together and categorized as advanced airway management (AAM).
This study was conducted using the Pan Asian Resuscitation Outcomes Study Clinical Research Network. 3131 pediatric patients were included. 85% received BVM, 11.8% SGA and 2.6 % ETI. In a matched cohort, one month survival and survival with favorable neurological outcome was higher in the BVM group compared to the AAM group and in the BVM group compared to the SGA group. There was no significant difference noted between the ETI group and BVM group.
Bottom line: In this study, AAM was associated with decreased one month survival and less favorable neurological status in pediatric OHCA.
Childhood vaccination has significantly decreased the incidence of bacterial meningitis and bacteremia in infants and young children, specifically vaccines against H. influenzae and S. pneumoniae, shifting broad workups for these disease and empiric antibiosis to younger age groups as rates declined. In recent years the percentage of unvaccinated and under-vaccinated children has been rising due to multiple factors; now over 1% of children in the US under 2 years of age are unvaccinated. The question becomes, should these children be treated more similarly to young infants as they lack to immunity to these organisms?
Literature on this topic is sparse, although, Finkel, Ospina-Jimenez, et al. reviewed the literature available and proposed an algorithm for well appearing children 3-24 months of age without a clear source and a temperature of >39C (102.2F). Recommendations included UA (to determine possible source) in the following patients: fever > 2 days, prior UTI, female or uncircumcised male <12 months, or male <6 months. They also recommended evaluation with viral panel. If no source was determined, they then recommended CBC and procalcitonin with a CXR for WBC > 20,000/mm3. For WBC >15,000/mm3, ANC >10,000/mm3, absolute band count >1,500/mm3, or procalcitonin >0.5ng/mL they recommended blood culture, ceftriaxone 50 mg/kg, and follow up within 24 hours.
Bottom line: Literature is scarce and practice patterns are likely to evolve as ramifications of decrease in vaccination rates become clearer. The above algorithm is proposed, however covers limited situations and may not be practical in all settings. Clinical judgement should be used in the evaluation and management of these patients. A more conservative approach compared to vaccinated infants is reasonable at this time.
