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.
Davies, P., and I. Maconochie. “The relationship between body temperature, heart rate and respiratory rate in children.” Emergency Medicine Journal 26.9 (2009): 641-643.
Daymont, Carrie, Christopher P. Bonafide, and Patrick W. Brady. “Heart Rates in Hospitalized Children by Age and Body Temperature.” Pediatrics 135.5 (2015): e1173-e1181.d
The National Institute for Health and Care Excellence. Pediatric Fever Guidelines, 2007 and 2013
Keywords: Foreign bodies, coins, xrays (PubMed Search)
Coins are the most commonly ingested foreign body in the pediatric age group with a peak occurrence in children less than 5 years old. X-rays are considered the gold standard for definitive diagnosis and location of metallic foreign bodies. This study aimed to find a way to decrease radiation exposure by using a metal detector.
19 patients ages 10 months to 14 years with 20 esophageal coins were enrolled in the study. All proximal esophageal coins were detected by the metal detector. 5 patient's failed initial detection of the coin with the metal detector and all of those patients had the coin in the mid or distal esophagus with a depth greater than 7 cm from the skin.
Bottom line: A metal detector may detect proximal esophageal coins. This may have a role in decreasing repeat x-rays.
Aljasser A, Elmaraghy C and Jatana K. Utilization of a handheld metal detector protocol to reduce radiation exposure in pediatric patients with esophageal coins. International Journal of Pediatric Otolaryngology. 2018: 104-108.
Keywords: PECARN, traumatic brain injury, head injury, concussion (PubMed Search)
Keywords: Infection, fever, blood work, CRP (PubMed Search)
Historically, the C-reactive protein (CRP) has been used in the assessment of the febrile child and is the only biomarker recommended by the National Institute for Health and Care Excellence (NICE).
CRP increases 4-6 hours after the onset of inflammation, doubling every 8 hours and peaking at 36-50 hours. It rapidly decreases once the inflammation has resolved.
An elevated CRP alone is not conclusive of a serious bacterial infection (SBI).
A CRP >75 mg/L increased the relative risk of SBI by 5.4.
A CRP <20 mg/L decreased the risk of SBI, but there was still a small subset of children where SBI was present.
In infants < 3 months initial CRP measurements are poorly accurate, but when trended may be useful in deciding when to stop antibiotics (rather then when to start them). A normalizing CRP demonstrated a 100% negative predictive value for excluding invasive bacterial infection.
CRP is not a rule in/rule out test
CRP is not helpful in diagnosing SBI, but serial measurements may be useful in monitoring response to treatment
CRP has a limited role in well appearing children older than 3 months
Dyer EM, Waterfield T, Baynes H. How to use C-reactive protein. Arch Dis Child Educ Pract Ed 2018; 0:1-4.
Keywords: West syndrome, seizures (PubMed Search)
Originally described a Dr. West in 1841 – it is a rare (~1200 cases annually) seizure disorder in young kids, generally less than 1 year old. Very subtle appearance, often with only bending forward or ‘jerking’ of the extremities as opposed to Brief Resolved Unexplained Event (BRUE) or tonic-clonic in description. The spasms can be thought of as a syndrome, where 70% of those have an undiagnosed rare metabolic/genetic disease.
A prompt evaluation, including labs, EEG, MRI, metabolic and genetic studies is vital in helping to establish a diagnosis which can have a profound impact on the patients prognosis. Examples might include Tuberous Sclerosis, Pyridoxine Dependent Seizures among over 50 others.
Bottom line: In pediatric patients less than 1 year old who present to the Emergency Department with a description of spasm-like episodes, consider Infantile Spasms on the differential, and consult your friendly neighborhood Pediatric Neurologist for help in determining a proper disposition.
Keywords: Fever, pain control, ibuprofen, acetaminophen (PubMed Search)
Walsh P, Rothenberg S, Bang H. Safety of ibuprofen and infants younger than 6 months: A retrospective cohort study. PLos ONE 13 (6):e019493.
Keywords: Concussion, minor head injury, traumatic brain injury, mTBI (PubMed Search)
The Centers for Disease Control and Prevention recently released guidelines on the diagnosis and management of mild traumatic brain injury (mTBI**) among children. From 2005-2009, children made almost 3 million ED visits for mTBI. Based on a systemic review of the literature, the guideline includes 19 sets of recommendations on the diagnosis, prognosis, and management/treatment of pediatric mTBI.
1. Do not routinely image patients to diagnose mTBI (utilize clinical decision rules to identify children at low risk and high risk for intracranial injury (ICI), e.g. PECARN)
2. Use validated, age-appropriate symptoms scales to diagnose mTBI
3. Assess evidence-based risk factors for prolonged recovery. No single factor is strongly predictive of outcome.
4. Provide patients with instructions on return to activity customized with their symptoms (see CDC Resources below)
5. Counsel patients to return gradually to non-sports activities after no more than 2-3 days of rest.
A wealth for information and tools for provder and families can be found at:
www.cdc.gov/HEADSUP (including evaluation forms and care plans for providers)
**Although concussion, minor head injury, and mBI are frequently used interchangeably, they have different connotations which allows for misinterpretation and confusion. The guideline recommends the clinical use of the single term mild traumatic brain injury. This is defined as "an acute brain injury resulting from mechanical injury to the head from external physical forces including: (1) 1 or more of the following: Confusion or disorientation, loss of consciousness for 30 minutes or less, posttraumatic amnesia for less than 24 hours, and/or other transient neurologic abnormality such as focal signs, symptoms, or seizure; (2) Glasgow Coma Scale score of 13-15 after 30 minutes post injury or later upon presentation for healthcare
Diagnosis and management of mild traumatic brain injury in children: A systemic review. Lumba-Brown A, Yeates KO, Sarmiento K, Breiding MJ, Haegerich TM, Gioia GA, Turner M, Benzel EC, Suskuer SJ, Giza CC, Joseph M,Broomand C, Weissa B, Gordon W Wright DW, Moser RS, McAvoy K, Ewing-Cobbs L, Duaime AC, Putukian M, Holhouse B, Paulk D, Wade SL, Herig SA, HalsteadM, Keenan H, Choe M, Christia CW, Gusiewic K, Raksin PB, Gregory A, Mucha A, Taylor HG, Callahan JM, DeWtt J, Collins MW, Kirkwood MW, Ragheb J, Ellenbogen RG, Spinks TJ, Ganiats TG, Sabelhaus LJ, Altenhofen K, Hoffman , Getchius T, Gronseh G,Donnell Z, O'Connor RE, Timmons SD JAMA Pediatr 2018 Sept 4.
Bachur, R. Comparison of acute treatment regimens for migraine in the emergency department. Pediatrics.2015;135(2)232-238.
Gelfand, A. Treatment of pediatric migraine in the emregency department. Ped Neuro.2012;47(4)233-241.
Kacperski, J. The optimal management of headaches in chidlren and adolescents. Ther Adv Neuro Disor. 2016;9(1)53-68.
Sheridan, D. Pediatric Migraine: Abortive treatment in the emergency department. Headache. 2014;54(2):235-245.
Keywords: Sedation, NPO time, pediatrics (PubMed Search)
Is there an association between pulmonary aspiration, vomiting or any serious adverse event and the preprocedural fasting time?
The odds ratio of any adverse event did not increase significantly with each additional hour of fasting duration for both solids and liquids.
The guidelines set by the American Society of Anesthesiology for fasting include a minimum of 2 hours for clear liquids, 4 hours for breast milk, 6 hours for formula and light meals and 8 hours for solid meals containing fatty foods or meat.
This was a secondary analysis of a multicenter prospective cohort study of children 0-18 years who received procedural sedation in 6 Canadian pediatric emergency departments from 2010-2015. 6183 children were included with 99.7% meeting ASA 1 or 2 categories. 2974 patients did not meet the American Society of Anesthesiology fasting guidelines for solids and 510 patients did not meet the fasting guidelines for liquids. The overall incidence of adverse events was 11.6%. There were no cases of pulmonary aspiration. There was a total of 717 adverse events. 315 events were vomiting. Oxygen and vomiting were the most common adverse events.
Association of Preprocedural Fasting with Outcomes of Emergency Department Sedation in Children. JAMA Pediatrics. Published online May 18, 2018.
Keywords: Asthma, chest xray (PubMed Search)
Chest xrays (CXRs) may lead to longer length of stay, increased cost, unnecessary radiation exposure, and inappropriate antibiotic use.
CXR in asthma are indicated for:
-severe persistent respiratory distress, room air saturations <91%
- focal findings (localized rales, crackles, decreased breath sounds with or without a documented fever > 38.3) not improving on >11 hours of standard asthma therapy
- concern for pneumomediastinum or pneumothorax
This study tried to use quality improvement measures to decrease the rate of chest xrays in children seen for asthma.
6680 children with billing codes for asthma had 1359 CXRs. Using a clinical practice guideline and then targeted intervention, the group was able to reduce CXR use from 29% to 16%. In subgroup analysis, the CXR use decreased from 21.3% to 12.5% for discharged patients and 53.5% to 31.1% for admitted patients.
The National Asthma Education and Prevention Program has created guidelines to help providers manage acute asthma exacerbations stating that CXRs should be reserved for patients suspected of having an alternate diagnosis such as pneumothorax, pneumomediastinum or congestive heart failure. This does not include the suspicion for associated pneumonia! A study of >14,000 patients with asthma showed that less than 2% also had pneumonia.
The interventions done in this study were:
An electronic asthma order set was created to include “CXR not routinely recommended”
Clinical practice guidelines were reviewed with residents, faculty, nursing, and respiratory therapy at regular intervals
Copies of the clinical practice guidelines were posted in a highly visualized area
CXRs removed from the default order set
Wheezing was removed as an indication for CXR
CXR in asthma are indicated for: severe persistent respiratory distress, room air saturations <91%, focal findings not improving on >11 hours of standard asthma therapy or concern for pneumomediastinum or pneumothorax
Watnick CS, Arnold DH, Latuska RL, O’Connor M, Johnson DP. Successful Chest Radiograph Reduction by Using Quality Improvement Methodology for Children with Asthma. Pediatrics. Published online July 11, 2018.
Keywords: Pediatrics, Migraine, Abdominal Migraine, Headache (PubMed Search)
Abdominal pain in children can be just as frustrating as dizzy in the elderly. Your exam is targeted at quickly ruling out acute pathologies, but then what? The diagnosis is often functional gastrointestinal disorders, like the ever exciting constipation. Abdominal migraine (AM) is an additional entity to consider during your emergency department evaluation.
The following factors are often associated with AM:
- peak incidence at 7 years old
- paroxsymal, periumbilical abdominal pain lasting more than 1 hour
- family history of migraine
- episodes not otherwise explained by known pathology.
AM can be associated with headache, pallor, anorexia, photophobia, and fatigue. There are multiple theories on the pathogenesis, which can be found in the article cited below. If there is a known history, and the patient is presenting with an exacerbation, the treatment protocols for migraine headache may be employed with good success.
AM is increasingly recognized as a source of recurrent abdominal pain in children. If other organic pathologies can be ruled out, this may be an important diagnosis to consider so your patient can get the appropriate follow up and outpatient management.