UMEM Educational Pearls - Pediatrics

  • Stevens-Johnsons like rash and mucositis
  • Most common in children and adolescents, with a mean age of 12 years old
  • More common in males than females, 2:1
  • Prodromal symptoms of cough, fever, and malaise precede
  • Mucositis far out of proportion to body rash, 90% vs 10%
  • Mucositis is primarily oral > ocular > genital in distribution, and can be severe
  • Body rash may involve palms and soles
  • Complications: dehydration, GIB, epiglottitis, blindness, pericardial effusion
  • Testing: PCR nasal wash/BAL; agglutination assays IgM/IgG
  • Treatment: azithromycin and supportive care; occasionally steroids; rarely IVIG
  • Unlike Stevens-Johnsons, prognosis is good.

Takeaways

Fluid overload (defined in this study as (fluid input-output)/weight)) is associated with longer hospital stays, longer treatment duration and oxygen use.

Bottom line: Treat dehydration appropriately but try not to over resuscitate the asthmatic.  Further studies are needed before definitive recommendations are made.

 

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Category: Pediatrics

Title: What is the diagnosis?

Keywords: foreign body, choking (PubMed Search)

Posted: 2/16/2018 by Jenny Guyther, MD
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Question

Patient: 11 month old with trouble breathing and color change after a family member sprayed air freshener.  Symptoms have since resolved.

What are you concerned about in the attached xrays?

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Attachments

11_mo_lung_FB_word.docx (408 Kb)


Category: Pediatrics

Title: Mucositis... when the shoe doesn't fit (submitted by Alexis Salerno, MD)

Keywords: Kawasaki's disease, SJS, TEN, dermatitis (PubMed Search)

Posted: 2/9/2018 by Mimi Lu, MD
Click here to contact Mimi Lu, MD

Question

Case:  5 year old presents to the ED with 2 weeks of fever. She has extensive cracked, bleeding lips and a rash on her hands and feet. She was recently diagnosed with “walking pneumonia” and hand, foot and mouth disease this week. Her pediatrician sent her in for further workup after she was found to have an elevated CRP on outpatient labs. A similar picture appears in the link below:

http://www.eblue.org/cms/attachment/2024057003/2043959646/gr1_lrg.jpg.

What's the diagnosis?

 

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Category: Pediatrics

Title: Name that Belly Pain!

Keywords: Pediatrics, Abdominal Pain (PubMed Search)

Posted: 2/2/2018 by Megan Cobb, MD
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Question

Your patient is an18 months old female with intermittent abdominal pain for the last 4-5 days. She has history of constipation and soy allergy, seen at an outside hospital three days ago for the same. She had an xray and was discharged home with instructions for at home clean out with diagnosis of constipation. 

Mother is bringing her to your ED because the pain is back. The laxatives helped somewhat, but her symptoms have returned. She reports that the patient cries spontaneously, lasting 1-2 minutes, then completely resolves. These episodes happen at multiple times during the day. 

ROS: Decreased appetite and energy, but NO fevers, vomiting, diarrhea, bloody stool, abdominal distension, hematuria, or lethargy. 

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Attachments

Colicky2018.jpg (100 Kb)


Category: Pediatrics

Title: Oral morphine versus ibuprofen in postoperative orthopedic pain in children

Keywords: Pain control in children, opiates, NSAIDS, motrin, orthopedic (PubMed Search)

Posted: 1/19/2018 by Jenny Guyther, MD
Click here to contact Jenny Guyther, MD

This was a randomized superiority trial of 0.5mg/kg of oral morphine every 6 hours to 10 mg/kg of ibuprofen every 6 hours in children 5-17 years old who had minor outpatient orthopedic surgeries.  There were 77 patients in each group.  Primary outcome was pain as rated on the Faces pain scale.  Secondary outcomes were additional analgesic requirements, adverse events, and unplanned visits to the doctor.

Bottom line: Oral morphine was not superior to ibuprofen and both drugs decreased pain with no difference in efficacy.  Morphine was associated with more adverse events.

 

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Tongue laceration is a common injury in children - occurring in the setting of falls and seizures. The most common location is the anterior dorsal portion of the tongue. Priorities are to evaluate for airway compromise (swelling, hematoma, bleeding) and retained foreign bodies (teeth fragments, etc). The vast majority of lacerations DO NOT require repair and do well with routine dental hygiene and antiseptic mouth wash. While there is no clear consensus for indications to repair, considerations include uncontrolled bleeding, airway compromise, wounds greater than 2 cm, and wounds that gape while the tongue is still in the mouth. Use large absorbable sutures (like 4-0 chromic gut). Check out this great video from EM:RAP - https://youtu.be/h14KyO8JlZE

Category: Pediatrics

Title: In NAT, suspicion is key.

Keywords: NAT, non-accidental trauma, abusive head trauma, intra-abdominal injury, burns (PubMed Search)

Posted: 1/6/2018 by Megan Cobb, MD
Click here to contact Megan Cobb, MD

Takeaways

In addition to suspicion of NAT with traumatic brain injury and burns, remember these other high risk injuries and features:

- Duodenal injuries in children <4 y/o 

- Frena injuries in non-ambulating children

- Proximal and midshaft humeral fractures > supracondylar fractures 

- Any bruising on the trunk, ears, neck, or with larger size or pattern  

- Delay in seeking care, inconsistent history, mechanism inconsistent with developmental age, and blame of a sibling or other child inflicting harm are all historical features also high risk. 

 

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Category: Pediatrics

Title: Pediatric Cervical Spine Injuries

Posted: 12/29/2017 by Rose Chasm, MD (Updated: 12/10/2022)
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Children less than 8 years, and especially infants, are more susceptible to upper cervical spine injury.  Moreover, validated decision rules for suspected cervical spine injury imaging have not been proven to be as sensitive or specific for children less than 8 years of age.

The pediatric cervical spine has greater elasticity of the ligamentous structures, while the cartilaginous structures are less calcified. An infant's neck musculature is underdeveloped, with a disproportionally large head.  These factors increase the risk of cervical spine injury, and can make it difficult to properly place protective cervical collars in infants while assessing them for injury. 

In very young children, consider placing padding under the shoulders to prevent abnormal flexion that can occur with placement of a cervical collar, and consider having a lower threshold to image if mechanism history or exam is concerning.

Children are not little adults!  Clinicians must acknowledge the anatomic differences, varying age-related ability to cooperate with examination, pediatric specific injury mechanisms, and decreased reliability of validated decision rules for imaging in children, especially when younger than 8 years old.

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Category: Pediatrics

Title: What is the ideal observation time for a patient with croup who has received racemic epinephrine?

Keywords: Croup, epinephrine, discharge, observation (PubMed Search)

Posted: 12/15/2017 by Jenny Guyther, MD (Updated: 12/10/2022)
Click here to contact Jenny Guyther, MD

The peak age for croup is 6 months to 3 years.  The cornerstone of treatment is corticosteroids, traditionally dexamethasone.  With oral administration, the peak onset is 1-2 hours. Steroids shorten the duration of symptoms, reduce the need for nebulized epinephrine and decrease the need for intubation.

Racemic epinephrine has been used for moderate to severe croup and can show an improvement in patient symptoms for up to 120 minutes.  There is little evidence to suggest how long to observe the patient for recurrence of symptoms after racemic epinephrine was given.  Previous studies have suggested both 2 and 4 hour observation.

299 patients were included in this study.  136 patients were observed for 3.1 to 4 hours.  In the 3.1 to 4 hour group, 21 (7%) failed treatment, 19 of those patients required admission and 2 returned within 24 hours.  No patients who were discharged home after 4 hours returned to the emergency department within 24 hours.

Bottom Line: Consider a 4 hour period of observation after giving racemic epinephrine in order to decrease bounce backs.

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As we are approaching the winter in the northern hemisphere, the number of visits for ear pain or respiratory symptoms are expected to increase.  The occurrence of acute otitis media (AOM) will also increase, but are these two disease processes related?

Drs. Heikkinen and Chonmaitree published a systematic review of previously reported studies regarding the correlation of these two disease processes (1).  As far back as 1990, studies have shown that up to 94% of pediatric patients diagnosed with AOM have concomitant upper respiratory infection (URI) type symptoms at time of diagnosis (2).   The viral infections most commonly associated with AOM are respiratory syncytial virus, influenza virus, and adenovirus (3).

The most commonly taught risk factors for developing AOM include young age, male gender, multiple siblings, day care attendance, and passive smoking.  These factors are also related to the development of upper respiratory symptoms, and the development of AOM should be thought of as a complication of the upper respiratory infection (4). 

Koivunen et al noted the highest incidence of AOM at day 3 after the onset of an URI, and the median time to diagnosis was day 4 (5). If you see a patient in day 2-4 of an URI, who has started to develop an ear effusion, but not clinical AOM, you may want to consider a “Wait-to-see” treatment option if the patient meets treatment criteria (https://em.umaryland.edu/educational_pearls/2049/).

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Category: Pediatrics

Title: Pediatric marijuana ingestion

Keywords: Marijuana, symptoms, overdose (PubMed Search)

Posted: 11/17/2017 by Jenny Guyther, MD (Updated: 12/10/2022)
Click here to contact Jenny Guyther, MD

In the US, there are an estimated 22.2 million users of cannabis based on the 2015 National Survey on Drug Use and Health.  The incidence of unintentional cannabis ingestion has increased in states that have legalized medical and recreational marijuana.  The cited article reviewed of 44 articles involving unintentional cannabis ingestion in children younger than 12 years.

The majority of intoxications were through cannabis resins followed by cookies and joints.

Lethargy was the most common presenting sign followed by ataxia.  Tachycardia, mydriasis and hypotonia were also noted.  Rarer but more serious presentations included respiratory depression and seizures.

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Category: Pediatrics

Title: Pediatric ARDS continued...

Keywords: ARDS, oxygenation index, OI, PALICC, acute lung injury, respiratory distress, PARDS (PubMed Search)

Posted: 10/27/2017 by Mimi Lu, MD
Click here to contact Mimi Lu, MD

Some pediatric practitioners have adopted the oxygenation index (OI) ([FiO2 × mean airway pressure (Paw) × 100]/ PaO2) or oxygen saturation index (OSI) ([FiO2 × Paw × 100]/ SpO2) to assess hypoxemia in children instead of P/F ratios because of the less standardized approach to positive pressure ventilation in children relative to adults. 

OI can be used in pediatric patients to define severity of Acute Respiratory Distress Syndrome (ARDS) in patients receiving invasive mechanical ventilation and assess for potential ECMO treatment. 

In contrast, the P/F ratio should be used to diagnose Pediatric ARDS for patients receiving noninvasive continuous positive airway pressure [CPAP] or bilevel positive airway pressure [BiPAP]) with a minimum CPAP of 5 cm H2O.

Oxygen Index (OI) = FiO2 x MAP x 100
                                 ---------------------
                                         PaO2

  • Mild ARDS: 4 ≤ OI ≤ 8
  • Moderate ARDS: 8 ≤ OI < 16
  • Severe ARDS: OI ≥ 16
  • OI < 25: good outcome
  • OI 25-40: >40% mortality
  • OI > 40: Consider ECMO

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Takeaways

Within the first hour after administration, ondosterone, metoclopramide and bromopride were equally efficacious.  At the 6 hour and 24 hour period after receiving the initial dose of medication, ondansetron was statistically superior to bromopride (not available in the US) and metoclopramide.  There were no reported side effects in the ondansetron group (including diarrhea or sedation).

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Pediatric patients are at a higher risk of blunt renal injury due to multiple anatomic features, include relatively less protective perinephric fat and surrounding musculature, and larger size of the kidneys in relation to the abdomen compared to their adult counterparts (1). For this reason, it is important to keep a high clinical suspicion for renal injury in the pediatric patient with blunt abdominal trauma, particularly in those with lower rib fractures, direct injury, flank ecchymosis and/or tenderness, rapid deceleration injury, or other significant traumatic mechanism (2). Despite the risk of radiation exposure, the preferred imaging modality for the diagnosis of renal injury in pediatric patients is computed tomography (similar to adults). Studies evaluating the utility of renal ultrasound have demonstrated poor sensitivity with a decreased likelihood of diagnosing low-grade injuries. While ultrasound may be a useful screening tool to evaluate for severe injury, it should not be used to rule out traumatic injury (1). Take home point: Keep a high suspicion for renal injury in pediatric patients with blunt abdominal trauma and confirm the diagnosis with computed tomography of the abdomen and pelvis with contrast.

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Category: Pediatrics

Title: Risky Business in Bronchiolitis

Keywords: Pediatrics, Bronchiolitis, Respiratory Decompensation, Risk factors (PubMed Search)

Posted: 10/6/2017 by Megan Cobb, MD
Click here to contact Megan Cobb, MD

Takeaways

Bronchiolitis season will soon be upon us. Here are some risk factors for children under 2 y/o with bronchiolitis, who may be more likely to suffer respiratory decompensation:

1. Age under 9 months

2. Black race

3. Hypoxia documented in the ED

4. Persisent accessory muscle use. 

Bottom Line: Consider providing respiratory support sooner than later in bronchiolitic infants with risk factors for decompensation. For HFNC, start at 1.5 - 2.0 L/kg/min, and titrate to work of breathing and  0saturations. 

_______________________________________________________________________________

Pathophysiology: Bronchiolitis is a disease process that leads to inflammation of lower airways, causing bronchiolar edema, epithelial hyperplasia, mucus plugging, and air trapping or atelectasis. Common viral causes include RSV, Human Metapneumovirus, Rhinovirus, Influenza, and Parainfluenza. 

Clinical Course: For most strains, the disease course is often 5-7 days with the worst days being 3-5. The disease process can last longer, especially in neonates. The predominant presenting symptoms are often rhinorrhea, low grade fevers, and cough, but apnea can be the primary symptom in younger infants. As a result of increased work of breathing, PO feeding tolerance decreases and leads to dehydration. 

Treatment: Primarily supportive care with suctioning, hydration, supplemental oxygen via standard NC, HFNC, and in severe cases BiPAP, CPAP or intubation. Trial of bronchodilator is often used, but there is no role for repeated bronchodilator use if no benefit is seen in pre and posttreatment respiratory effort. Hypertonic saline is not recommended for routine use in the ED. Corticosteroids have no role for routine use in viral bronchiolitis, either.

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Category: Pediatrics

Title: Pediatric Acute Respiratory Distress Syndrome (ARDS)

Keywords: ARDS, oxygenation index, OI, PALICC, acute lung injury (PubMed Search)

Posted: 9/22/2017 by Mimi Lu, MD (Updated: 10/27/2017)
Click here to contact Mimi Lu, MD

Since the first description of acute respiratory distress syndrome (ARDS), various consensus conferences (including American-European Consensus Conference (AECC) and the Berlin Conference) have produced definitions focused on adult lung injury but have limitations when applied to children. 

This prompted the organization of the Pediatric Acute Lung Injury Consensus Conference (PALICC), comprised of  27 experts, representing 21 academic institutions and eight countries.  The goals of the conference were 1) to define pediatric ARDS (PARDS); 2) to offer recommendations regarding therapeutic support; and 3) to identify priorities for future research in PARDS.

Although there were several recommendations from the group, some notable ones, in contrast to the Berlin definition focused on adults, include: 1) use the Oxygenation Index (or, if an arterial blood gas is not available, the Oxygenation Severity Index) rather than the P/F ratio; 2) elimination of the requirement for “bilateral” pulmonary infiltrates (may be unilateral or bilateral) 3) elimination of  specific age criteria for PARDS.

Tune in next month for pearls on management for children with PARDS...

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Takeaways

Elective surgeries with general anesthesia are often cancelled when the child has an upper respiratory tract infection.  What are the adverse events when procedural sedation is used when the child has an upper respiratory tract infection?

Recent and current URIs were associated with an increased frequency of airway adverse events (AAE).  The frequency of AAEs increased from recent URIs, to current URIs with thin secretions to current URIs with thick secretions.   Adverse events not related to the airway were less likely to have a statistically significant difference between the URI and non-URI groups

AAEs for children with no URI was 6.3%.  Children with URI with thick/green secretions had AAEs in 22.2% of cases.  Children with URIs did NOT have a significant increase in the risk of apnea or need for emergent airway intervention.  The rates of AAEs, however, still remains low regardless of URI status.

 

 

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Category: Pediatrics

Title: VTE in Pediatrics

Keywords: VTE, Thrombophilia, Enoxaparin, Children, Thromboembolism (PubMed Search)

Posted: 9/1/2017 by Megan Cobb, MD
Click here to contact Megan Cobb, MD

Background:

There is an increased incidence of venous thromboembolic events (VTE) in pediatrics due to improved diagnosis and survival of children with VTE.

The mortality rate is estimated at 2%.

The most common etiologies vary by age - Central venous catheters in neonates and infants, and inherited thrombophilia in children and adolescents.

Learning Points:

  1. With neonates and infants, carefully assess medical history from neonatal period. Umbilical lines? PICC? Broviac? History of these is likely to be the cause.

  2. In children and adolescents, unprovoked VTE is most likely due to inherited thrombophilia, and can be DVT, PE, Portal venous thrombus, etc.

    1. Antithrombin deficiency: The first discovered inherited thrombophilia. The result is a lack of inhibition of coagulation factors – IIa, IXa, Xa, XIIa.

    2. Protein C or/and S deficiency: The result is lack of inhibition of activated Factor V.

    3. Factor V Leiden: Most common inherited thrombophilic defect. Resultant activated Factor V is resistant to normal Protein C and S activity.

    4. Prothrombin Mutation: Second most common inherited thrombophilia. The result is increased levels of prothrombin, which increases the half-life of factor Va.

  3. Initial treatment of clinically significant VTE can start with enoxaparin (1-1.5 mg/kg q12-24h, while checking Anti-Xa levels 4 hours after administration for therapeutic dosing.)

 

Pearl: Testing for thrombophilia is not always appropriate when diagnosing pediatric patients with their first VTE, but in children and adolescents with first diagnosed, unprovoked VTE, it is worthwhile to send off the initial hypercoaguability work up as this can affect the duration of treatment and need for testing or evaluation. Enoxaparin is a recommended medication to start therapeutic treatment of VTE, even in pediatric patients.

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Category: Pediatrics

Title: What about Anaphylaxis in kids? (submitted by Yitschok Applebaum, MD)

Keywords: allergic reaction, anaphylaxis, auto-injector, epi-pen (PubMed Search)

Posted: 1/27/2017 by Mimi Lu, MD (Emailed: 8/25/2017) (Updated: 8/25/2017)
Click here to contact Mimi Lu, MD

What if you were out in public and a 1 year old child (est 10 kg) suddenly develops anaphylaxis but you only have an epinephrine auto-injector with the “adult” dose of 0.3 mg.  Is it safe to give?

Anaphylaxis is a life threatening emergency with mortality of up to 2% [1]. Early recognition is imperative and administration of timely Epinephrine is the single most important intervention [2]. While providers may be hesitant to administer epinephrine in older patients due to fear of precipitating adverse cardiovascular events, they may also hesitate in younger patients due to fear of overdose. 

Iimmediate administration with any dose available is recommended because:

  • the risks of untreated anaphylaxis are greater than the risk of over-treating with epinephrine.
  • 20% of Anaphylaxis patients require a second dose of Epinephrine [3].
  • The recommended IM dose of 0.01mg /kg was determined arbitrarily.
  • The vast majority of epinephrine overdoses are via IV injection at doses 100 - 1000 fold the recommended  IV dose [4]

Bottom line:

There are no absolute contraindications (including age) for epinephrine in patients with anaphylaxis.  Give the initial dose IM into the anterolateral thigh.

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