Keywords: Sore throat, strep throat (PubMed Search)
Streptococcal pharyngitis is common in the pediatric population however in children younger than 3 years, group A streptococcus (GAS) is a rare cause of sore throat and sequela including acute rheumatic fever are very rare. Inappropriate testing leads to increased healthcare and unnecessary exposure to antibiotics.
The national guidelines published by the Infectious Diseases Society of America do NOT recommend GAS testing in children less than the age of 3 years unless the patient meets clinical criteria and has a home contact with documented GAS.
Ahluwalia et al. Reducing streptococcal testing in patients less than 3 years old in an emergency department. Pediatrics 2019;144:4.
Keywords: lactated ringer, LR, normal saline, NS (PubMed Search)
Bottom line: Balance fluid resuscitation with LR was not associated with improved outcomes compared to NS and pediatric sepsis. Selective LR use necessitates a prospective trial to definitively determine comparative effects among crystalloids.
1. Weiss SL, Keele L, Balanmuth F, Vendetti N, Ross R, Fitzgerald JC, Gerber JS. Crystalloid Fluid Choice and Clinical Outcomes in Pediatric Sepsis: A Matched Retrospective Cohort Study. J Pdatr.207 Mar:182:304-310.
2. Balamuth F, Kittick M, McBride P, Woodford AL, Vestal N, Casper TC, Metheney M, Smith K, Atkin NJ, Baren JM, Dean JM, Kuppermann N, Weiss SL. Pragmatic Pediatric Trial of Balanced versus Normal Saline Fluid in Sepsis: The PRoMPT BOLUS Randomized Controlled Trial Pilot Feasibility Study. Acad Emerg Med. 2019 Jun 10
Keywords: sedation, autism spectrum disorder (PubMed Search)
Brown et al. Procedural sedation in children with autism spectrum disorders in the emergency department. Am J Emerg Med. 2019 Aug;37(8):1404-1408.
Keywords: Orthopedics, compartment syndrome (PubMed Search)
- Tibial tubercle avulsion fractures are rare and pediatrics, accounting for less than 3% of all epiphyseal injuries in children ages 11-17 years.
- The typical mechanism is a sudden forceful quadriceps contraction. Patients present with sudden pain after sprinting or jumping with pain, bruising, deformity or swelling over the tibial tubercle and with a decrease ability to extend the leg.
- 10 to 20% of cases result in anterior compartment syndrome related to the rupture of the anterior tibial recurrent artery.
- Although directly measured intra-compartmental pressures can facilitate the diagnosis of compartment syndrome, interpretation of these values can be challenging with healthy children having higher average lower leg compartment pressures than adults. Treatment of subsequent compartment syndrome is often based on a high index of suspicion.
Yue et al. Bilateral tibial tubercle avulsion fractures: Pediatric orthopedic injury at high risk for compartment syndrome. The American Journal of Emergency Medicine. Available online May 2019.
Keywords: UTIcalc, SBI, serious bacterial infection, febrile infant, urinary tract infection (PubMed Search)
Question: In febrile children younger than 2 years, what combination of clinical and laboratory variables best predicts the probability of a urinary tract infection?
Given that urinary tract infections (UTI) are the most common source of serious or invasive bacterial infections in young febrile infants, early identification and treatment has the potential to reduce poor outcomes. Wouldn't it be great if there was an easy way to identify patients at highest risk?
Researchers from the Children’s Hospital of Pittsburgh formulated a calculator (UTICalc) that first estimates the probability of urinary tract infection (UTI) based on clinical variables and then updates that probability based on laboratory results.
The UTICalc calculator can be used to guide to tailor testing and treatment in children with suspected urinary tract infection with the hope of improving outcomes for children with UTI by reducing the number of treatment delays.
Go ahead and give it a click!! https://uticalc.pitt.edu/
Shaikh N, Hoberman A, Hum SW, Alberty A, Muniz G, Kurs-Lasky M, Landsittel D, Shope T. Development and Validation of a Calculator for Estimating the Probability of Urinary Tract Infection in Young Febrile Children. JAMA Pediatr. 2018 Jun 1;172(6):550-556.
There is no standardized national reporting of dog bites in the US. Based on the reported figures, it is estimated that 2% of Americans are bitten annually, and children are affected disproportionately. With kids, it's usually the family dog, and occurs at home.
To avoid infection, usually from Pasturella species, many of us were taught never to primarily repair dog bites by suturing, and to always prescribe prophylactic antibiotic coverage with amoxicillin-clavulanate. However, the literature recommends otherwise in certain cases.
Bite wounds to the face and hands should have special considerations. In general, face wounds heal with lower rates of infection, but provide the greatest concern for cosmetic appearance. Hand wounds have notoriously higher rates of infection.
The latest recommendations for dog bites are as follows:
1. All dog bites should be copiously irrigated under high pressure.
2. Dog bites to the face should be primarily repaired when <8 hours old, as infection rates are not significantly different and cosmesis is greatly improved.
3. Injuries to the hands should be left open, unless function is in jeopardy or there are neurovascular concerns.
4. Prophylactic antibiotics do not always have to be prescribed, especially in low risk patients. Examples of high risk patients include, but are not limited to: primarily repaired bites, injuries in the hand, >8 hours old, deep or macerated or multiple bites, and the immunocompromised.
Paschos NK et al. Primary closure versus non-closure of dog bite wounds. A randomised controlled tira. Injury 2014 45(1): 23l7-40
Chen, HH et al. Analysis of Pediatric Facial Dog Bites. Cranomaxillofac Trauma Reconstr. 2013 Dec; 6(4):225-232
Ellis, R; Ellis, C (2014). "Dog and cat bites". American Family Physician. 90 (4): 239–43.
Keywords: NV exam, neurovascular, upper extremity injury, orthopedics, hand, fracture, supracondylar (PubMed Search)
Keywords: GSW, mass shooting, bleeding (PubMed Search)
Gunshot injuries are a leading cause of morbidity and mortality in the pediatric population. The Pediatric Trauma Society supports the use of tourniquets in severe extremity trauma. The Combat Application Tourniquet (CAT) that is commonly used in adults has not been prospectively tested in children. This study used 60 children ages 6 through 16 years and applied a CAT to the upper arm and thigh while monitoring the peripheral pulse pressure by Doppler. The CAT was successful in occluding arterial blood flow in all of the upper extremities and in 93% of the lower extremities.
Bottom line: The combat application tourniquet can stop arterial bleeding in the school aged child.
Harcke et al. Adult tourniquet use for school-age emergencies. Pediatrics. 2109; 143 (6) e:20183447.
Keywords: Keppra, Dilantin, status epilepticus (PubMed Search)
-Benzodiazepines alone are effective in terminating status epilepticus in 40 to 60% of pediatric patients
-The guidelines for second line agents are based on observational studies and expert opinion
-Adverse effects of phenytoin include hepatotoxicity, pancytopenia, Stevens-Johnson syndrome, extravasation injuries, hypotension and arrhythmias
- Levetiracetam has a reduced risk of serious adverse events, greater compatibility with IV fluids and can be given in 5 minutes versus 20 minutes for phenytoin.
Bottom line: In a recent randomized control trial they found that levetiracetam was not superior to phenytoin as a second line agent for management of convulsive status epilepticus in children. There was no difference between efficacy or safety outcomes between the two groups.
Phenytoin is the second line treatment for pediatric convulsive status epilepticus after failure of first-line benzodiazepines but is only effective in approximately 60% of cases. This study was an open label, multicenter, randomized control trial conducted in Australia and New Zealand with children aged 3 months to 16 years with status epilepticus who had failed first-line benzodiazepine treatment. Patients were randomly assigned to to receive 20 mg/kg of phenytoin or 40 mg/kg of levetiracetam with the primary outcome being seizure resolution at 5 minutes
There were 233 children included in the study and seizure activity stopped in 60% of the patients in the phenytoin group and 50% of the patients in the levetiracetam which was not a statistically significant difference.
Dalziel at al. Levetiracetam versus phenytoin for second line treatment of convulsive status epilepticus in children; an open label, multicenter, randomized control trial. The Lancet. Published online April 17, 2019.
Keywords: appendicitis, hospitalization, operative management (PubMed Search)
Fugazzola et al. Early appendectomy versus conservative management and complicated acute appendicitis in children: a meta-analysis. J Pediatr Surg. 2019 Feb 25 S0002-3468 (19)30125-3.
- Prepubertal females are especially susceptible to urethral prolapse
- Can present incidentally is a painless mass found during bathing or on exam
- More commonly presents as urogenital bleeding, dysuria, or (rarely) urinary retention
- Appears as a partial or circumferential "donut" of bright red, often friable prolapsed mucosa
- Typically occurs in the setting of UTI, cough, or constipation
- Need to rule out complications: UTI, urethral necrosis, and urinary retention
- Medical management start with sitz baths twice daily and addressing causative factors (treatment constipation, UTI, etc.)
- Can add either topical corticosteroid (hydrocortisone) or estrogen (Estrace or Premarin 0.01% twice daily)
- Urology follow-up necessary as many will require surgical resection of prolapsed mucosa
Keywords: ingestion, drug overdose, marijuana (PubMed Search)
Washington state was one of the first states to legalize recreational marijuana use. Toxicology call center data was collected on patient's 9 years old and younger with marijuana exposure between July 2010 and July 2016. There were 161 cases during that time frame and of those 130 occurred after the legalization of recreational marijuana (over a 2.5 year period). The median age range was 2 years old. There were increasing cases noted after recreational marijuana was legalized and again after marijuana shops became legal.
Thomas et al. Unintentional pediatric marijuana exposures prior to and after localization and commercial availability of recreational marijuana in Washington state. J Emerg Med 2019 Mar 4.S0736-4679 (19).
Keywords: Measles, outbreak, complications (PubMed Search)
Measles outbreaks have been reported all over the globe, with the incidence increasing due to low immunization rates. Italy experienced 5000 cases in 2017. This study was a retrospective multicenter observational study of children less than 18 years hospitalized for clinically and laboratory confirmed measles over a year and a half period from 2016-2017.
There were 263 cases of measles that required hospitalization during this time and 82% developed a complication with 7% having a severe clinical outcome defined by a permanent organ damage need for ICU care or death. A CRP value of greater than 2 mg/dL was associated with a 2-4 fold increased risk of developing complications. 23% developed pneumonia and 9.6% developed respiratory failure. Hematologic involvement was seen in 48% of patients. 1.2% of hospitalized patients died.
Bottom line: Consider CRP, lipase and CBC at a minimum in your patients with suspected measles who require hospitalization.
Lo Vecchio A, Krzysztofiak A,
Keywords: closed head injury, concussion, CHI (PubMed Search)
Over 630,000 children visit the ED every year with a diagnosis of concussion
Predictors of persistent post-concussive symptoms (PPCS):
Appromixately 1/3 of pediatric patients will have PPCS lasting over 2 weeks
Likelihood of PPCS increases to >50% in those with risk factors identified in the ED
Every state has a youth concussion law. The basic tenants are a) immediate removal from play b) written clearance from health professional to return to play c) education for athlete, parents, coaches.
Hospitalization for Suicide Ideation or Attempt: 2008-2015. Pediatrics. Pelmons. 2018
Special Considerations in the Pediatric Psychiatric Population. Psychiatric Clinics. Santillanes 2017.
Sarah Edwards, DO. Medical & Program Director. Child and Adolescent Psychiatry. University of Maryland School of Medicine.
Keywords: CCHD, congenital cardiac lesions, congenital heart disease (PubMed Search)
The hyperoxia-hyperventilation test (aka 100% Oxygen Challenge test) is used to differentiate the cause of central cyanosis in the sick neonate. The majority of neonatal cyanosis is caused by either cardiac or respiratory pathology.
Classically the test is performed as follows:
1. An ABG is obtained with the neonate breathing room air
2. The patient is placed on 100% FiO2 for 10 minutes
3. A repeat ABG is performed looking for an increase in PaO2 to >150 mmHg
- If the hypoxia is secondary to a respiratory cause, the PaO2 should increase to >150 mmHg.
- If the hypoxia is secondary to a congenital cardiac lesion (i.e. secondary to a right-to-left cardiac shunt) the PaO2 is not expected to rise significantly.
In practice, many physicians instead use pulse oximetry and monitor the SpO2 pre and post administration of 10 minutes of 100% FiO2.
- If after 10min of 100% FiO2, if SpO2 is not ? 95% (some resources use 85%) then the central cyanosis is likely secondary to intracardiac shunt.
- When this occurs, presume the sick neonate is symptomatic from a congenital cardiac lesion and initiate prostaglandin E-1 (PGE1) at 0.05-0.01 mcg/kg/min. Use caution as PGE1 may cause apnea.
Keywords: Maintenance fluids, D5, NS, hyponatremia (PubMed Search)
Hyponatremia is the most common electrolyte abnormality in hospitalized patients, affecting approximately 15-30% of patients. Children have historically been given hypotonic maintenance IV fluids based off of theoretical calculations from the 1950s. Multiple studies have shown complications related to iatrogenic hyponatremia, including increased length of hospital stay, seizures and death.
The American Academy of pediatrics completed a systematic review and developed an updated clinical practice guideline:
Patient's age 28 days to 18 years requiring maintenance IV fluids should receive isotonic solutions with the appropriate amount KCl and dextrose.
Feld LG, Neuspiel DR, Foster BA, et al. Clinical Practice Guideline: Maintenance Intravenous Fluids in Children. Pediatrics. 2018;142(6):e20183083
Keywords: Post-tonsillectomy, bleeding, airway (PubMed Search)
Post tonsillectomy hemorrhage occurs and 0.1-3% of post tonsillectomy patient's. It occurs typically greater than 24 hours after surgery and up to 4-10 days postoperatively. A survey of otolaryngologists showed that ED management strategies for active bleeding have included direct pressure, clot suction, silver nitrate, topical epinephrine, and thrombin powder.
This article was a case study demonstrating the use of nebulized tranexamic acid (TXA) for post tonsillectomy hemorrhage in a 3-year-old patient. The patient had a copious amount of oral bleeding and had failed treatment with nebulized racemic epinephrine and direct pressure was not an option due to the patient's cooperation and small mouth. 250 mg of IV TXA was given via nebulizer with a flow rate of 8 L. Bleeding stopped 5-7 minutes after completion of the nebulizer. The patient was then taken to the OR for definitive management. No adverse effects were noticed.
TXA in the pediatric population has been shown to decrease surgical blood loss and transfusions in cardiac, spine and craniofacial surgeries. Studies have also been done in pediatric patients with diffuse alveolar hemorrhage using doses of 250 mg for children less than 25 kg and 500 mg for those who are greater than 25 kg.
Bottom line: There are case reports of nebulized TXA use in the pediatric population with no adverse outcomes noted. More research is needed.
Schwarz W, Ruttan T, Bundick K. Nebulized Tranexamic Acid Use for Pediatric Secondary Post-Tonsillectomy Hemorrhage. Annals of Emergency Medicine 2018. Epub ahead of print.
Keywords: ADEM (PubMed Search)
Acute Disseminated Encephalomyelitis (ADEM) is primarily a pediatric disease and can cause a wide variety of neurologic symptoms. As such, should always be in the differential for pediatric patient presenting with vague neurologic symptoms including altered mental status. It is an immune-mediated, demyelinating disease that can affect any part of the CNS; usually preceding a viral illness or rarely, immunizations.
The average age of onset is 5-8 years of age with no gender predilection. It usually has a prodromal. That includes headache, fever, malaise, back pain etc. Neurological symptoms can vary and may present with ataxia, altered mental status, seizures, focal symptoms, behavioral changes or coma.
MRI is the primary modality to diagnose this condition. Other possible indicators may be mild pleocytosis with lymphocyte predominance, and elevated inflammatory markers such as ESR, CRP. These findings, however, are neither sensitive nor specific.
First-line treatment for ADEM is systemic corticosteroids, typically 20-30 mg/kg of methylprednisolone for 2-5 days, followed by oral prednisone 1-2 mg/kg for 1-2 weeks then 3-6-week taper. For steroid refractory cases, IVIG and plasmapheresis may be considered.
ADEM usually has a favorable long-term prognosis in the majority of patients. However, some may experience residual neurological deficits including ataxia, blindness, clumsiness, etc.
Take home points:
Gray, M.P. & Goralick, M.H. (2016). Acute disseminated encephalomyelitis (6th ed, volume 32). Milkwaukee, WI
Keywords: Intubation, ETT, cuffed, airway management (PubMed Search)
Historically uncuffed endotracheal tubes were used in children under the age of 8 years due to concerns for tracheal stenosis. Advances in medicine and monitoring capabilities have resulted in this thinking becoming obsolete. Research is being conducted that is showing the noninferiority of cuffed tubes compared to uncuffed tubes. Multiple other studies are looking into the advantages of cuffed tubes compared to uncuffed tubes.
The referenced study is a meta-analysis of 6 studies which compared cuffed to uncuffed endotracheal tubes in pediatrics. The pooled analysis showed that more patients needed tube changes when they initially had uncuffed tubes placed. There was no difference in intubation duration, reintubation occurrence, post extubation stridor, or racemic epinephrine use between cuffed and uncuffed tubes.
Bottom line: There is no difference in the complication rate between cuffed and uncuffed endotracheal tubes, but uncuffed endotracheal tubes did need to be changed more frequently.
Liang C, Zhang J, Pan G, Li X, Shi T, He W. Cuffed versus uncuffed endotracheal tubes in pediatrics: a meta-analysis. Open Med. 2018; 13:366-373.