Category: Pediatrics
Keywords: Bradycardia, intubation, RSI, atropine (PubMed Search)
Posted: 7/16/2021 by Jenny Guyther, MD
(Updated: 10/9/2024)
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Kovacich et al. Incidence of bradycardia and the use of atropine in pediatric rapid sequence intubation in the emergency department. Pediatric emergency care. Published online 2021.
Category: Pediatrics
Keywords: finger injuries, nail bed (PubMed Search)
Posted: 6/18/2021 by Jenny Guyther, MD
(Updated: 10/9/2024)
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Petruzella F, Easter JS. Pediatric emergency medicine literature 2020. The American Journal of Emergency Medicine. 2021;43:123-133
Category: Pediatrics
Keywords: pediatric, cardiac arrest, metabolic acidosis, sodium bicarbonate (PubMed Search)
Posted: 5/21/2021 by Jenny Guyther, MD
(Updated: 10/9/2024)
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During cardiac arrest, metabolic acidosis develops because of hypoxia-induced anaerobic metabolism and decreased acid excretion caused by inadequate renal perfusion. Sodium bicarbonate (SB) administration was considered as a buffer therapy to correct metabolic acidosis. However, SB has several side effects such as hypernatremia, metabolic alkalosis, hypocalcemia, hypercapnia, impairment of tissue oxygenation, intracellular acidosis, hyperosmolarity, and increased lactate production. The 2010 Pediatric Advanced Life Support (PALS) guideline stated that routine administration of SB was not recommended for cardiac arrest except in special resuscitation situations, such as hyperkalemia or certain toxidromes. An evidence update was conducted in the 2020 Pediatric Life Support (PLS) guideline and the recommendations of 2010 remain valid. This article was a systematic review and meta-analysis of observational studies of pediatric in hospital cardiac arrests. The primary outcome was the rate of survival to hospital discharge after in hospital cardiac arrests. The secondary outcomes were the 24-hour survival rate and neurological outcomes.
Chih-Yao Chang, Po-Han Wu, Cheng-Ting Hsiao, Chia-Peng Chang, Yi-Chuan Chen, Kai-Hsiang Wu. Sodium bicarbonate administration during in-hospital pediatric cardiac arrest: a systematic review and meta-analysis. Resuscitation. 2021. Available on line March 1. In Press.
Category: Pediatrics
Posted: 4/30/2021 by Rose Chasm, MD
(Updated: 10/9/2024)
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Layden, JE, et al. Pulmonary Illness Related to E-Cigarette Use in Illinois and Wisconsin. New England Journal of Medicine. September 2019.
Centers for Disease Control. Smoking and Tobacco Use. Office of Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion. April 2021.
Category: Pediatrics
Keywords: stroke, altered mental status, TPA (PubMed Search)
Posted: 4/16/2021 by Jenny Guyther, MD
(Updated: 10/9/2024)
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Baldovsky MD, Okada PJ. Pediatric stroke in the emergency department. J Am Coll Emerg Physicians Open. 2020 Oct 6;1(6):1578-1586. doi: 10.1002/emp2.12275. PMID: 33392566; PMCID: PMC7771757.
Category: Pediatrics
Keywords: Chest pain, ischemia, pediatrics, myocarditis (PubMed Search)
Posted: 3/19/2021 by Jenny Guyther, MD
(Updated: 10/9/2024)
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Even though acute myocardial ischemia (AMI) does not present as commonly in the pediatric patient as in the adult and the literature is limited, it is reasonable to obtain a troponin when acute cardiac ischemia is suspected based on the history and physical exam.
Recreational drugs including cocaine, amphetamine, cannabis, Spice, and K2 (cannabis derivatives) have been shown to result in myocardial injury including AMI. Coronary vasospasm secondary to drug use is well documented in the pediatric population. While cocaine use is a known risk factor for coronary vasospasm, the same condition has been reported in pediatric patients after marijuana use.
In a study of pediatric patients with blunt chest trauma, 3 of 4 patients with electrocardiographic or echocardiographic evidence of cardiac injury had elevations in troponin I above 2.0 ng/mL. Cardiac troponins are an accurate tool for screening for cardiac contusion after blunt chest trauma in pediatric patients even with limited data.
Cardiac troponins are also useful in the evaluation for myocarditis. In one study, myocarditis was the most common diagnosis (27%) in pediatric ED patients presenting with chest pain and an increased troponin. Eisenberg et al showed a 100% sensitivity and an 85% specificity for myocarditis using a troponin of 0.01 ng/mL or greater as a cut off. A normal troponin using this cutoff can be used to exclude myocarditis. Abnormal troponin in the first 72 hours of hospitalization in pediatric patients with viral myocarditis is associated with subsequent need for extracorporeal membrane oxygenation and IVIg.
Bottom line: Troponin can be used in pediatric patients with clinical concern for cardiac ischemia, cardiac contusion and myocarditis
Brown JL, Hirsh DA, Mahle WT. Use of troponin as a screen for chest pain in the pediatric emergency department. Pediatr Cardiol. 2012;33(2):337-342. doi:10.1007/s00246-011-0149-8
Drossner DM, Hirsh DA, Sturm JJ, et al. Cardiac disease in pediatric patients presenting to a pediatric ED with chest pain. Am J Emerg Med. 2011;29(6):632-638. doi:10.1016/j.ajem.2010.01.011
Thankavel PP, Mir A, Ramaciotti C. Elevated troponin levels in previously healthy children: value of diagnostic modalities and the importance of a drug screen. Cardiol Young. 2014;24(2):283-289. doi:10.1017/S1047951113000231
Yolda? T, Örün UA. What is the Significance of Elevated Troponin I in Children and Adolescents? A Diagnostic Approach. Pediatr Cardiol. 2019;40(8):1638-1644. doi:10.1007/s00246-019-02198-w
Adams JE, Dávila-Román VG, Bessey PQ, Blake DP, Ladenson JH, Jaffe AS. Improved detection of cardiac contusion with cardiac troponin I. Am Heart J. 1996;131(2):308-312. doi:10.1016/s0002-8703(96)
Hirsch R, Landt Y, Porter S, et al. Cardiac troponin I in pediatrics: normal values and potential use in the assessment of cardiac injury. J Pediatr. 1997;130(6):872-877. doi:10.1016/s0022-3476(97)
Eisenberg MA, Green-Hopkins I, Alexander ME, Chiang VW. Cardiac troponin T as a screening test for myocarditis in children. Pediatr Emerg Care. 2012;28(11):1173-1178. doi:10.1097/PEC.
Category: Pediatrics
Keywords: Congestive heart failure, trouble breathing, basic natriuretic peptide (PubMed Search)
Posted: 2/19/2021 by Jenny Guyther, MD
(Updated: 10/9/2024)
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In children with known congenital heart disease, BNP measurements are higher in those patients with heart failure compared to those without heart failure.
The utility of BNP in differentiating a cardiac from pulmonary pathology in patients with respiratory distress has been studied in pediatrics. In one study involving 49 infants with respiratory distress, the patients with a final diagnosis of heart failure had a higher mean BNP concentration than those patients with other causes. Also, there is a suggestion that the relative change in NT proBNP levels may be useful in patients with underlying pulmonary hypertension. However, currently there is not enough literature to support the routine use of BNP or NT proBNP in acute management.
Bottom line: BNP can be useful in your patient with congenital heart disease who is decompensating and may be used in a patient where there is difficulty in differentiating a primary respiratory from cardiac etiology.
Davis GK, Bamforth F, Sarpal A, et al. B-type natriuretic peptide in pediatrics. Clin Biochem. 2006 Jun;39(6):600-5.
Nir A, Lindinger A, Rauh M, et al. NT-pro-B-type natriuretic peptide in infants and children: reference values based on combined data from four studies. Pediatr Cardiol. 2009 Jan;30(1):3-8.
Ten Kate CA, Tibboel D, Kraemer US. B-type natriuretic peptide as a parameter for pulmonary hypertension in children. A systematic review. Eur J Pediatr. 2015 Oct;174(10):1267-75.
Category: Pediatrics
Keywords: Infection, sepsis, lactic acid (PubMed Search)
Posted: 1/15/2021 by Jenny Guyther, MD
(Updated: 10/9/2024)
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Despite a lack of formal guidelines and evidence, lactate measurement has become a component of many pediatric emergency sepsis quality programs, with one survey showing that up to 68% of responding pediatric emergency medicine providers routinely measured it.
The Surviving Sepsis Campaign, last updated in February 2020, could not make a recommendation on the use of lactate in pediatric patients with suspected shock. The authors did state that lactate levels are often measured during the evaluation of septic shock if the lab can be obtained rapidly. However, lactate levels alone would not be an appropriate screening test.
Weiss SL, Peters MJ, Alhazzani W, et al. Surviving sepsis campaign international guidelines for the management of septic shock and sepsis-associated organ dysfunction in children. Intensive Care Med. 2020;46(Suppl 1):10-67.
Scott HF, Brou L, Deakyne SJet al. Association between early lactate levels and 30-day mortality in clinically suspected sepsis in children. JAMA Pediatr. 2017 Mar 1;171(3):249-255.
Category: Pediatrics
Keywords: Procalcitonin, febrile infants, sepsis (PubMed Search)
Posted: 12/18/2020 by Jenny Guyther, MD
(Updated: 10/9/2024)
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Young infants (0-90 days) have immature immune systems and are at higher risk for serious bacterial infections, particularly urinary tract infections, bacterial meningitis, and bacteremia. Infants less than 90 days old have an incidence of bacterial infections between 8 to 12.5%, while infants less than or equal to 28 days old have almost a 20% incidence.
Risk-stratification of this group has been a huge focus of research over the past couple of decades to help identify which patients require a full sepsis work-up, particularly in well-appearing infants if a source of fever is identified early. Recent studies have explored the utility of biomarkers in risk stratification in this population. A better ability to discriminate would hopefully decrease unnecessary lumbar punctures, antibiotic use, and hospital admission. Multiple studies have shown procalcitonin is able to outperform CRP for prediction of serious bacterial infections. Kuppermann et al developed a tool to identify low risk febrile infants < 60 days using procalcitonin and ANC. Their prediction rule gave a 97.7% sensitivity, 60% specificity, and 99.6% NPV for serious bacterial infection. There have been several other studies that have looked harder to detect infections such as osteomyelitis or septic arthritis across all pediatric patients and the data has not been as promising.
Bottom line: Procalcitonin shows promise as part of a risk stratification tool in infants younger than 60 days. Other studies have failed to show its relevance as a screening tool for osteomyelitis, septic arthritis, renal abscess or community acquired pneumonia.
Huppler AR, Eickhoff JC, Wald ER. Performance of low-risk criteria in the evaluation of young infants with fever: review of the literature. Pediatrics. 2010;125(2):228-233. doi:10.1542/peds.2009-1070
Schwartz S, Raveh D, Toker O, Segal G, Godovitch N, Schlesinger Y. A week-by-week analysis of the low-risk criteria for serious bacterial infection in febrile neonates. Archives of Disease in Childhood. 2009;94(4):287-292. doi:10.1136/adc.2008.138768
Woll C, Neuman MI, Aronson PL. Management of the Febrile Young Infant: Update for the 21st Century. Pediatr Emerg Care. 2017;33(11):748-753. doi:10.1097/PEC.
Kuppermann N, Dayan PS, Levine DA, et al. A Clinical Prediction Rule to Identify Febrile Infants 60 Days and Younger at Low Risk for Serious Bacterial Infections. JAMA Pediatr. 2019;173(4):342-351. doi:10.1001/jamapediatrics.
Category: Pediatrics
Posted: 12/4/2020 by Cathya Olivas Michels, MD
(Updated: 10/9/2024)
Click here to contact Cathya Olivas Michels, MD
Several studies have described factors associated with peri-intubation cardiac arrest in the adult population. Factors such as pre-intubation hypotension, elevated BMI, and elevated shock index (HR/SBP) have been associated with cardiac arrest following intubation in adult ED patients. Given the differences in anatomy and physiology in children, one may expect risk factors for peri-intubation cardiac arrest to differ in children.
A number of studies have examined factors associated with peri-intubation cardiac arrest in the pediatric population, but these have remained limited to the inpatient setting. These studies have found that, in hospitalized and PICU patients, the factors of hemodynamic instability, hypoxemia, history of difficult airway, pre-existing cardiac disease, and higher number of intubation attempts are associated with peri-intubation cardiac arrest. A paucity of literature exists on this airway complication in pediatric ED patients.
Pokrajac et al. provide the first study on risk factors for peri-intubation cardiac arrest in pediatric ED patients. These authors conducted a retrospective nested case-control study of pediatric patients (ages <18 years) who presented to a tertiary children’s hospital in San Diego from 2009-2017. Cases included patients who had a cardiac arrest within 20 minutes after the start of endotracheal intubation. Authors selected a number of predictors to examine, including age-adjusted hemodynamic variables, capillary refill, pulse oximetry, patient characteristics, intubation-related factors, and pre-intubation interventions.
The authors found the following:
- Demographic characteristics:
o Patients with peri-intubation cardiac arrest were significantly younger (<1 year of age), shorter, and more likely to have history of preexisting pulmonary disease.
- Incident characteristics:
o Patients with peri-intubation cardiac arrest were more likely to have:
-Low or unobtainable SBP or DBP
-Delayed capillary refill time
-Low (<92%) or unobtainable pre-intubation SpO2
-More than 1 intubation attempt than controls
-No paralytic or sedative agent prior to intubation
o Patients with peri-intubation cardiac arrest were NOT more likely to have increases in age-adjusted HR or pediatric shock index in comparison to controls.
o The strongest clinical predictor for peri-intubation cardiac arrest was pre-intubation hypoxia or unobtainable SpO2. This fact is supported by children’s increased metabolic rate and thus increased oxygen consumption. This physiologic finding explains the shorter amount of time it takes children to develop acute hypoxia, particularly in the peri-intubation setting.
Bottom line: If planning to intubate a pediatric patient in the ED, keep in mind that pre-intubation systolic or diastolic hypotension, delayed capillary refill time, multiple intubation attempts, and hypoxia in particular may increase the risk for peri-intubation cardiac arrest. Consider providing apneic oxygenation to minimize hypoxemia prior to intubation.
Heffner, A. C., Swords, D. S., Neale, M. N. & Jones, A. E. Incidence and factors associated with cardiac arrest complicating emergency airway management. Resuscitation 84, 1500–1504 (2013).
Hill, K. Cardiac Arrests Associated with Tracheal Intubations in PICUs: A Multicenter Cohort Study. The Journal of Emergency Medicine 51, 617–618 (2016).
Kim, W. Y. et al. Factors Associated with the Occurrence of Cardiac Arrest after Emergency Tracheal Intubation in the Emergency Department. PLoS ONE 9, e112779 (2014).
Pokrajac, N. et al. Risk Factors for Peri-intubation Cardiac Arrest in a Pediatric Emergency Department Pediatric Emergency Care Publish Ahead of Print, (2020).
Category: Pediatrics
Keywords: vaginitis, vaginal discharge (PubMed Search)
Posted: 11/20/2020 by Jenny Guyther, MD
(Updated: 10/9/2024)
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To determine if the child is prepubescent, look for the lack of pubic hair, clitoral size, configuration of the hymen, breast development, and axillary hair growth. A Tanner stage of 1 would be consistent with prepuberty.
The proper positioning for the physical exam will allow the child to be comfortable and the examiner to obtain an adequate view including up to one-third of the vagina.
If the child is small enough, they can lay in the parent’s lap. For a larger child, you can have the parent sit in the bed with the patient or stand near the child’s head. Engage child life if available.
The frog leg position with gentle downward and outward traction of the labia at the 5- and 7-o’clock positions provides the optimal view.
The knee to chest position is helpful when further evaluation is needed.
A rectovaginal exam is useful for evaluation of masses or foreign body only and is not routinely needed. Place the examiner’s little finger in the rectum and the other hand on the abdomen and palpate.
The use of a vaginal speculum is rarely needed in prepubertal children; if it is needed, perform the exam under anesthesia.
McCaskill A, Inabinet CF, Tomlin K, Burgis J. Prepubertal Genital Bleeding: Examination and Differential Diagnosis in Pediatric Female Patients. J Emerg Med. 2018 Oct;55(4):e97-e100. doi: 10.1016/j.jemermed.2018.07.
Loveless M, Myint O. Vulvovaginitis- presentation of more common problems in pediatric and adolescent gynecology. Best Pract Res Clin Obstet Gynaecol. 2018 Apr;48:14-27. doi: 10.1016/j.bpobgyn.2017.08.014. Epub 2017 Sep 5. PMID: 28927766.
Manning S. Genital Complaints at the Extremes of Age. Emerg Med Clin North Am. 2019 May;37(2):193-205. doi: 10.1016/j.emc.2019.01.003. PMID: 30940366.
Category: Pediatrics
Keywords: pain management, ketamine (PubMed Search)
Posted: 11/6/2020 by Prianka Kandhal, MD
Click here to contact Prianka Kandhal, MD
Silva LOJ, Lee JY, Bellolio F, Homme JL, Anderson JL. Intranasal ketamine for acute pain management in children: A systematic review and meta-analysis. American Journal of Emergency Medicine. 2020 (38)1860-1866. doi: 10.1016/j.ajem.2020.05.094
Category: Pediatrics
Posted: 10/31/2020 by Rose Chasm, MD
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The current COVID-19 pandemic and known aerosolized transmission has triggered many ED process changes, including the discouragement of utilizing nebulizers to administer inhaled bronchodilators such as albuterol for concern of spread. Historically, both patients and providers preferred the use of nebulizers as they are easier to use and the belief was that they were more effective than meterd dose inhalers. However, evidence based data has consistently shown that for both adult and pediatric patients that when MDI's are used WITH a spacer:
Albuterol: 2.5 mg nebulizer solution = 3-5 MDI puffs
Albuterol: 5 mg nebulizer solution = 5-10 MDI puffs
Ipratropium: 0.25 mg nebulizer solution = 2 MDI puffs
Ipratropium: 0.5 mg nebulizer solution = 4 MDI puffs
Category: Pediatrics
Keywords: GU anomaly, prepubescent (PubMed Search)
Posted: 10/16/2020 by Jenny Guyther, MD
Click here to contact Jenny Guyther, MD
A labial adhesion is defined as a thin avascular clear plane, a raphe, between the labia minora. These adhesions which can be caused by minor trauma or infection in the absence of estrogen can cause varying degrees of obstruction.
Loveless M, Myint O. Vulvovaginitis- presentation of more common problems in pediatric and adolescent gynecology. Best Pract Res Clin Obstet Gynaecol. 2018 Apr;48:14-27. doi: 10.1016/j.bpobgyn.2017.08.014. Epub 2017 Sep 5. PMID: 28927766.
Bacon JL, Romano ME, Quint EH. Clinical Recommendation: Labial Adhesions. J Pediatr Adolesc Gynecol. 2015 Oct;28(5):405-9. doi: 10.1016/j.jpag.2015.04.010. Epub 2015 Apr 24. PMID: 26162697.
Category: Pediatrics
Keywords: uncomplicated appendicitis (PubMed Search)
Posted: 10/1/2020 by Cathya Olivas Michels, MD
Click here to contact Cathya Olivas Michels, MD
Acute appendicitis is the most common etiology requiring urgent abdominal surgery in children in the United States. Peak incidence occurs in the second decade of life, with male patients being more commonly affected than female patients. Classic manifestations of appendicitis occur in school-aged children and adolescents, but are often absent in younger children. Infants and young children <5 years are more likely to present with nonspecific or atypical findings, resulting in delays in diagnosis and higher rates of perforation.
Diagnosis is aided by clinical factors, lab findings, and ultrasound (+/- CT or MRI if ultrasound is equivocal).
Historically, the standard of care for acute appendicitis has been urgent operative management. However, in the past several years, there has been increasing literature supporting nonoperative management (antibiotics only) in adult patients with acute uncomplicated appendicitis. Additionally, there is a growing body of evidence demonstrating the safety and efficacy of nonoperative management for uncomplicated appendicitis in children.
Hartford and Woodward provide a review of the current literature on the nonoperative management of uncomplicated appendicitis in children. They conclude:
- The majority of recent prospective studies demonstrate early treatment success (0-30 days) of approximately 90% in pediatric patients undergoing nonoperative management.
- Factors associated with failure of nonoperative management in pediatric appendicitis: longer duration of symptoms (>48 hours), younger age (<5 years), and presence of appendicolith.
- Nonoperative management has been associated with
o Lower healthcare costs at 1 year
o Fewer disability days at 1 year
o No significantly different rate of complicated appendicitis
- Most trials to date involve a 24-48 hour initial course of broad spectrum IV antibiotics followed by oral antibiotics for a total of >/= 7 days as nonoperative management. Currently, there is no consensus on antibiotic regimen.
Bottom Line: Given the current evidence, nonoperative management may be a viable treatment option for low risk pediatric patients with uncomplicated appendicitis. The literature is not conclusive, thus we as medical providers in conjunction with our surgical colleagues, should consider numerous factors when discussing treatment options for acute appendicitis with patients and their families.
Hartford, E. A. & Woodward, G. A. Appendectomy or Not? An Update on the Evidence for Antibiotics Only Versus Surgery for the Treatment of Acute Appendicitis in Children. Pediatric Emergency Care 36, 6 (2020).
2.
Minneci, P. C. et al. Association of Nonoperative Management Using Antibiotic Therapy vs Laparoscopic Appendectomy With Treatment Success and Disability Days in Children With Uncomplicated Appendicitis. JAMA 324, 581 (2020).
3.
Minneci, P. C. et al. Effectiveness of Patient Choice in Nonoperative vs Surgical Management of Pediatric Uncomplicated Acute Appendicitis. JAMA Surg 151, 408 (2016).
Category: Pediatrics
Keywords: prepubertal vaginal bleeding, mass (PubMed Search)
Posted: 9/18/2020 by Jenny Guyther, MD
(Updated: 10/9/2024)
Click here to contact Jenny Guyther, MD
- Urethral prolapse will appear as a protrusion of the distal urethra through the urinary meatus causing a “doughnut” sign.
- Risk factors include trauma, UTI, anatomical differences, and increased intraabdoiminal pressure from cough or constipation. There is a higher incidence in people of African descent.
- The chief complaint may include urethral mass and vaginal bleeding.
- There is a bimodal age distribution (prepuberty and postmetapause) due to a relative estrogen deficiency.
-Treatment is with estrogen cream and sitz baths for 4- 6 weeks.
McCaskill A, Inabinet C, Tomlin K et al. Prepubertal Genital Bleeding: Examination and Differential Diagnosis in Pediatric Female Patients. The Journal of Emergency Medicine 2018; 55(4): 97-100.
Category: Pediatrics
Keywords: button battery, pediatrics, esophageal injuries (PubMed Search)
Posted: 9/4/2020 by Prianka Kandhal, MD
Click here to contact Prianka Kandhal, MD
Ingestion of a button battery is a can't-miss diagnosis with a very high risk for causing severe esophageal injury. There are about 3000 button battery ingestions per year, and this is increasing because electronics are becoming more and more prevalent.
Severe damage to the esophagus occurs within 2 hours. On your lateral view, the end with narrowing is the negative end, which triggers a hydrolysis reaction that results in an alkaline caustic injury and, ultimately, liquefactive necrosis.
Children can present with nonspecific symptoms and if the ingestion was not witnessed, they are at high risk for delays in diagnosis. Additionally, in the community setting, there can be further delays in definitive treatment (endoscopic removal) due to difficulty in calling teams in or transporting to other facilities.
Anfang et al. looked into ways to mitigate damage to esophageal tissue. They did an in vitro study on porcine esophageal tissue, measuring the pH with different substances applied. They tried apple juice, orange juice, gatorade, powerade, pure honey, pure maple syrup, and carafate. They then repeated the study in vivo on piglets with button batteries left in the esophagus and ultimately did gross and histological examination of the esophageal tissue.
Honey and carafate demonstrated protective effects both in vitro and in vivo. They neutralized pH changes, decreased full-thickness esophageal injury, and decreased outward extension of injury into deep muscle.
Take Home Point: If a child is found to have a button battery in the esophagus, while definitive management is still emergent endoscopic removal, early and frequent ingestion of honey (outside of the hospital) and Carafate (in the hospital) may help reduce the damage done to the tissue in the interim. The authors recommend 10ml every 10 minutes.
Anfang RR, Jatana KR, Linn RL, et al. pH-Neutralizing Esophageal Irrigations as a Novel Mitigation Strategy for Button Battery Injury. The Laryngoscope. 2019; 129:49-57.
Category: Pediatrics
Keywords: Female GU, abdominal pain, missed period (PubMed Search)
Posted: 8/21/2020 by Jenny Guyther, MD
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Definition: Congenital anomaly where the hymen is completely obstructing the vaginal opening
Demographic: Incidence 0.05-0.1% of females
History: Most are asymptomatic and diagnosed on physical exam or incidentally when there is lack of menarche. Symptoms in adolescents can include: Abdominal pain (50%), urinary retention (20%), abnormal menstruation (14%), dysuria (10%), frequency, renal failure, UTI and back pain.
Physical exam: bulging, blueish hymenal membrane
Complications: Late detection can lead to infections, fertility problems, endometriosis, hydronephrosis, and rarely renal failure
ED treatment: If abdominal pain is significant or there is urinary obstruction, a urinary foley can be placed. GYN should be consulted.
Definitive treatment: Hymenectomy, hymenotomy, carbon dioxide laser treatments or foley insertion through the hymen (done by a specialist).
Lee K, Hong J, Jung H et al. Imperforate Hymen: A Comprehensive Systematic Review. J Clin Med 2019; 8(56): 1-14.
Category: Pediatrics
Keywords: MVC, neck injury, neurological injury (PubMed Search)
Posted: 7/24/2020 by Jenny Guyther, MD
(Updated: 10/9/2024)
Click here to contact Jenny Guyther, MD
There is no well validated clinical decision rule similar to NEXUS or the Canadian Cervical Spine rule in children for clearing the cervical spine. Clinical clearance versus imaging first is a complicated decision. Certain risk factors may predispose children to injury and should be taken into account when deciding about clinical clearance versus imaging (XR).
High Risk Criteria for Cervical Spine Injury in Pediatrics
Mechanism
| High risk MVC Intrusion > 12 inches at the occupant site Intrusion > 18 inches at any site Partial or complete ejection Death in the same passenger compartment Vehicle telemetry consistent with high speed Fall > 10 feet Nonaccidental trauma Diving injury |
History
| Down’s Syndrome 22.q11.2 deletion Klippel-Fiel syndrome |
Physical Exam
| Altered mental status Intoxication Hypotension Focal neurological exam Neck pain Torticollis |
Gopinathan N, Viswanathan V, Crawford A. Cervical Spine Evaluation in Pediatric Trauma: A Review and an Update of Current Concepts. Indian J Orthop 2018;52(5):489-500.
Leonard J, Browne L and Ahmed F et al. Cervical Spine Injury Risk Factors in Children with Blunt Trauma. Pediatrics 2019;144 (1):e20183221.
Kliegman R, Stanton B, St Geme J et al. Nelson Textbook of Pediatrics. 20th edition Vol 1 and 2. 2016. Elsevier. P 549-550, 3299-3300, 3352.
Category: Pediatrics
Posted: 7/3/2020 by Cathya Olivas Michels, MD
Click here to contact Cathya Olivas Michels, MD
Every year, numerous children die of non-exertional heatstroke after being left in motor vehicles in the United States. Per data obtained from the national nonprofit KidsAndCars.org, the average number of pediatric vehicular heatstroke deaths is 39 per year since 1990. In 2018, this number peaked at 54 pediatric deaths. Prior studies show that the interior temperature of a closed vehicle rises quickly within minutes of closing the doors and windows. This rapid change occurs even on days with cooler ambient temperatures (20s °C/70s °F): the interior temperature of a car may still reach 117F within an hour.
Children, particularly infants and toddlers, are at increased risk for heat illness due to several physiologic and developmental factors:
- Unable to escape hot environments or to self-hydrate
- Lack mature thermoregulatory systems
o Have lower rate of sweat production than adults
- Have higher basal metabolic rates than adults
- Have higher body surface area:mass ratio --> absorb heat faster in hot environments
Bottom line: ED providers can be instrumental in giving anticipatory guidance on vehicular heatstroke in children during the warmer seasons:
- Educate caregivers to “Look before you Lock”
- Suggest that the caregiver place a valuable object (phone, employee badge, handbag) in the back seat when traveling with a child
- Remind caregiver of the dangers of intentionally leaving a child in the car for any reason, even during cooler spring/summer days.
A recent retrospective cohort study (Hammett et al.) of 554 pediatric victims (aged <14 years) who died of heatstroke in a motor vehicle was conducted using KidsAndCars.org data. This study is the largest to date to describe this US subset of pediatric fatalities.
Results:
- Nearly half of the cases occurred when the ambient temperature was >90°F. However, 10% cases occurred when the ambient temperature was < 80°F.
- Most incident cases (~40%) occurred in home parking areas > nonresidential parking areas> daycare centers parking.
- The mean victim age was 16.4 months. Most (99%) victims were less than 5 years of age.
- Male children were more common victims (54% cases) than female children.
- Most victims (78%) were left unknowingly in vehicles by their caregivers. For those victims left intentionally in vehicles, caregivers’ reasons for leaving the child in the vehicle were the caregivers’ need to attend work or school or desire to allow the child to keep sleeping.
- A single caregiver was most commonly responsible for leaving the child in the vehicle (89% cases), with the victim’s mother being the most often responsible.
https://www.kidsandcars.org/wp-content/uploads/2020/01/Heatstroke-fact-sheet.pdf
Hammett, D. L., Kennedy, T. M., Selbst, S. M., Rollins, A. & Fennell, J. E. Pediatric Heatstroke Fatalities Caused by Being Left in Motor Vehicles. Pediatric Emergency Care, (2020).
2007031141_Hammett._Pediatric_Heatstroke_Fatalities_Caused_by_Being_Left_in_Cars.pdf (581 Kb)