Keywords: Trauma, hematuria, kidney injury (PubMed Search)
Keywords: Pediatrics, Bronchiolitis, Respiratory Decompensation, Risk factors (PubMed Search)
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 02 saturations.
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.
Keywords: ARDS, oxygenation index, OI, PALICC, acute lung injury (PubMed Search)
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...
Pediatric Acute Respiratory Distress Syndrome: Consensus Recommendations from the Pediatric Acute Lung Injury Consensus Conference. Pediatric Acute Lung Injury Consensus Conference Group. Pediatr Crit Care Med. 2015 Jun;16(5):428-39
Collaborators: Jouvet P, Thomas NJ, Wilson DF, Erickson S, Khemani R, Zimmerman J, Dahmer M, Flori H, Quasney M, Sapru A, Cheifetz IM, Rimensberger PC, Kneyber M, Tamburro RF, Curley MA, Nadkarni V, Valentine S, Emeriaud G, Newth C, Carroll CL, Essouri S, Dalton H, Macrae D, Lopez-Cruces Y, Quasney M, Santschi M, Watson RS, Bembea M.
Keywords: Sedation, URI, adverse events (PubMed Search)
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.
Data was collected on over 83,000 patients retrospectively from a voluntary database, The Pediatric Sedation Research Consortium. Children with URIs (no fever) who underwent procedural sedation for things such as imaging or hematology/oncology procedures were included. Propofol, dexmedetomidine, ketamine and opiates were the most commonly used agents.
AAEs included wheezing, secretions requiring treatment, cough, stridor, desaturations, obstruction, snoring, laryngospasm, and apnea.
Mallory et al. Upper Respiratory Infections and Airway Adverse Events in Pediatric Procedural Sedation. Pediatrics. 2017; 140 (1): 1-10.
Keywords: VTE, Thrombophilia, Enoxaparin, Children, Thromboembolism (PubMed Search)
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.
With neonates and infants, carefully assess medical history from neonatal period. Umbilical lines? PICC? Broviac? History of these is likely to be the cause.
In children and adolescents, unprovoked VTE is most likely due to inherited thrombophilia, and can be DVT, PE, Portal venous thrombus, etc.
Antithrombin deficiency: The first discovered inherited thrombophilia. The result is a lack of inhibition of coagulation factors – IIa, IXa, Xa, XIIa.
Protein C or/and S deficiency: The result is lack of inhibition of activated Factor V.
Factor V Leiden: Most common inherited thrombophilic defect. Resultant activated Factor V is resistant to normal Protein C and S activity.
Prothrombin Mutation: Second most common inherited thrombophilia. The result is increased levels of prothrombin, which increases the half-life of factor Va.
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.
Van Ommen CH, Nowak-Gottl U. Inherited Thrombophilia in Pediatric Venous Thromboembolic Disease: Why and Who to Treat. Frontiers in Pediatrics. 2017: 5(20).
The Harriet Lane Handbook, 20th edition. Chapter 29: Drug Dosages. 2015
Keywords: allergic reaction, anaphylaxis, auto-injector, epi-pen (PubMed Search)
Anaphylaxis is a life threatening emergency with mortality of up to 2% . Early recognition is imperative and administration of timely Epinephrine is the single most important intervention . 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:
There are no absolute contraindications (including age) for epinephrine in patients with anaphylaxis. Give the initial dose IM into the anterolateral thigh.
1- Bock SA, Muñoz-Furlong A, Sampson HA. Fatalities due to anaphylactic reactions to foods. J Allergy Clin Immunol. 2001 Jan. 107(1):191-3. [Medline].
4- Wood JP, Traub SJ, Lipinski C. Safety of epinephrine for anaphylaxis in the emergency setting. World Journal of Emergency Medicine. 2013;4(4):245-251. doi:10.5847/wjem.j.issn.1920-
Keywords: Febrile seizure, meningitis (PubMed Search)
Febrile seizures occur in children 6 months through 5 year olds. A complex febrile seizure occurs when the seizure is focal, prolonged (> 15 min), or occurs more than once in 24 hours.
The prevalence of bacterial meningitis in children with fever and seizure after the H flu and Strep pneumomoniae vaccine was introduced is 0.6% to 0.8%. The prevalence of bacterial meningitis is 5x higher after a complex than simple seizure.
From the study referenced, those children with complex febrile seizures who had meningitis all had clinical exam findings suggestive of meningitis. More studies are needed to provide definitive guidelines about when lumbar punctures are needed in these patients.
This study was a retrospective review of children aged 6 months to 5 years who had complex febrile seizures in France between 2007-2011.
Children were excluded if they had a simple febrile seizure, history of non-febrile seizure, conditions associated with a higher risk of seizure (cerebral malformations, genetic syndrome, trauma in the previous 24 hours) or predisposing to bacterial meningitis (sickle cell, cancer, immunosuppressive treatments). Outcomes were the diagnosis of bacterial or HSV meningitis at 7 days
The rate of bacterial meningitis was 0.7% (CI 0.2-1.6). There were no cases of HSV meningitis.
69% of the study patients did not have a lumbar puncture, however, follow up was done by repeat exam, phone and review of the meningitis and also death registry if the patient was lost to follow up.
The clinical exam in the 5 children with bacterial meningitis was suggestive of meningitis (irritability, altered mental status, bulging fontanel). In a subgroup of patients without physical exam findings suggestive of meningitis, there were no cases of bacterial meningitis.
Guedji R et al. Do All Children Who Present With a Complex Febrile Seizure Need a Lumbar Puncture? Annals of Emergency Medicine. 2017; 70 (1):52-62.
The answer appears to be ... it depends.
Early Oseltamivir Treatment in Influenza in Children1-3 Years of Age: A Randomized Controlled Trial
A study in 2010 out of Finland by Heinonen, et al showed that if given in the first 12 hours of symptom onset to otherwise healthy pediatric patients between the age of 1-3 years:
- decrease incidence of acute otitis media by 85%
- no difference if given within 24 hours
Among children with influenza A, oseltamivir started within 24 hours of symptom onset
- shortened medium time to resolution of illness by 3.5 days (3.0 versus 6.5) in all children
- shortened median time to resolution of illness by 4.0 days in UNvaccinated children
- Reduced parental work absenteeism by 3 days
* no differences were seen in children with influenza B *
- Single Center study in Finland
- The authors received support from the drug manufacturer
- The sample size of children with confirmed influenza cases with small (influenza A: 79, influenza B: 19)
If you have a patient between the age of 1-3 years with very early symptoms concerning for flu, a positive rapid influenza A test could allow you to cut her symptoms by 3 days, prevent complications, and allow parents to go back to work sooner.
Heinonen S, Silvennoinen H, Lehtinen et al. Early oseltamivir treatment of influenza in children 1-3 years of age: A randomized controlled trial. Clin Infect Dis. 2010;51(8):87-94.
Keywords: CT scans, radiation exposure, pediatrics (PubMed Search)
Ventricular shunt (VP) malfunction can be severe and life-threatening and evaluation has typically included a dry CT brain and a shunt series which includes multiple x-rays of the skull, neck, chest and abdomen. The goal of this study was to decrease the amount of radiation used in the evaluation of these patients since these patients will likely present many times over their lifetime. Several institutions have more towards a rapid cranial MRI, however, this modality may not be readily available.
This multidisciplinary team decreased the CT scan radiation dose from 250mA (the reference mA in the pediatric protocol at this institution) to 150 mA which allows for a balance between reducing radiation exposure and adequate visualization of the ventricular system. They also added single view chest and abdominal x-rays.
The authors found that after implementing this new protocol, there was a reduction in CT radiation doses and number of x-rays ordered with no change in the return rate.
Marchese et al. Reduced Radiation in children presenting to the ED with Suspected Ventricular Shunt Complication. Pediatrics. 2017; 139 (5).
Keywords: overdose, poisoning, veterinary medications (PubMed Search)
Every year in the U.S., preventable poisonings in children result in more than 60,000 ED visits and around 1 million calls to poison centers. Calls relating specifically to pet medication exposure and children have been on the rise.
A recent study in Pediatrics was the first was kind to characterize the epidemiology of such exposures.
This study is a call to arms for an increased effort on the part of public health officials, pharmacists, veterinarians, and physicians to improve patient education to prevent these exposures from occurring.
Summary of major findings:
Most commonly Implicated exposures:
Key contributors to exposure risk:
Take home point: Make sure your pet's medications are appropriately stored for safety!
Methods involved reviewing regional Poison Control Center data from 1999 thruh 2013, during which 1431 calls regarding exposures of children less than or equal to age 19 or exposed to a veterinary medication.
While the authors concluded that most exposures did not result in major adverse outcomes, 14.1% of exposures resulted in at least minor health effects.
A broader range of more highly toxic medications are increasingly being prescribed for animals, including anti-neoplastic drugs such as cyclophosphamide and chlorambucil.
Treatment of chronic health conditions and pets, such as osteoarthritis, hypothyroidism, or anxiety is also increasingly common.
Tomasi S, Roberts KJ, Stull J, Spiller HA, McKenzie LB. Pediatric Exposures to Veterinary Pharmaceuticals. Pediatrics. 2017;139(3)
Keywords: Blunt thoracic trauma, pediatric trauma, chest xray (PubMed Search)
Chest injuries represent the second most common cause of pediatric trauma related death. ATLS guidelines recommend CXR in all blunt trauma patients. Previous studies have suggested a low risk of occult intrathoracic trauma; however, these studies included many children who were sent home.
Predictors of thoracic injury include: abdominal signs or symptoms (OR 7.7), thoracic signs of symptoms (OR 6), abnormal chest auscultation (OR 3.5), oxygen saturation < 95% (OR 3.1), BP < 5% for age (OR 3.7), and femur fracture (OR 2.5).
4.3 % of those found to have thoracic injuries did not have any of the above predictors, but their injuries were diagnosed on CXR. These children did not require trauma related interventions.
Bottom line: There were still a number of children without these predictors that had thoracic injuries, so the authors suggest that chest xray should remain a part of pediatric trauma resuscitation.
This was a retrospective review of children aged 0-17 with blunt trauma requiring trauma team activation who had a chest xray preformed. 483 eligible children were included, all of whom were admitted to the hospital. 108 children had their thoracic injury detected on chest xray, 110 on chest CT and 76 on abdominal CT. Pneumothorax, pulmonary contusion and multiple rib fractures were the most commonly found thoracic injuries. All children also had other injuries.
Weerdenburg et al. Predicting Thoracic Injury in Children with Multi-trauma. Pediatric Emergency Care. Epub ahead of print. 2017.
Keywords: Psychiatric, agitation, pediatric (PubMed Search)
IM ziprasidone (Geodon) has a relatively quick onset of action with a half-life of 2-5 hours. Although commonly used in adults, there has not been a study looking at an effective dose in pediatrics. Based on the study referenced, the suggested pediatric dose of ziprasidone is 0.2 mg/kg (max 20mg).
This is the first study looking at ziprasidone in the pediatric emergency department population. This was a retrospective observational study of children 5-18 years old who were treated with IM ziprasidone. 40 patients received IM ziprasidone in a tertiary care pediatric emergency department between 2007-2015. 2/3 of the patients had ADHD and 1/3 had autism spectrum disorder. Other diagnosis included post-traumatic stress disorder, bipolar disorder and intellectual disabilities.
68% of patients responded to the initial dose. The initial dose was 0.19 +/- 0.1 mg/kg in the responder group and 0.13 +/- 0.06 mg/kg in the non-responder group. Single doses ranged from 2.5 mg to 20 mg total.
No patients had respiratory depression. Two patients had potential extra-pyramidal symptoms, but one was prior to ziprasidone administration and the other patient had baseline facial twitching with no documentation if there was a change after ziprasidone administration.
Nguyen T, Stanton J and Foster R. Intramuscular Ziprasidone Dosing for Acute Agitation in the Pediatric Emergency Department: An observational Study. Journal of Pharmacy Practice 1-4. 2017.
Keywords: analgesics, Ultram, (PubMed Search)
Bottom line: Do not prescribe codeine or tramadol for cough or pain in children and breastfeeding moms.
A summary statement from the American Hospital Association (AHA) is posted below.
FDA RESTRICTS USE OF CODEINE AND TRAMADOL
MEDICINES IN CHILDREN, RECOMMENDS AGAINST USE IN BREASTFEEDING MOTHERS
The Food and Drug Administration (FDA) today announced that it is restricting the use of codeine and tramadol medicines in children, as well as recommending against using codeine and tramadol medicines in breastfeeding mothers due to possible harm to their infants.
Codeine is approved to treat pain and cough, and tramadol is approved to treat pain. These medicines carry serious risks, including slowed or difficult breathing and death, which appear to be a greater risk in children younger than 12 years, and should not be used in these children. These medicines also should be limited in some older children.
The FDA is requiring several changes to the labels of all prescription medicines containing these drugs. These new actions further limit the use of these medicines beyond FDA's 2013 restriction of codeine use in children younger than 18 years to treat pain after surgery to remove the tonsils and/or adenoids. The agency is now adding:
The FDA is urging health care professionals and patients to report side effects involving codeine-and tramadol-containing medicines to the FDA MedWatch program, through its online form.
Keywords: Bronchiolitis, asthma (PubMed Search)
Predictive factors of asthma development in patients diagnosed with bronchiolitis include:
- Male sex (OR 1.3)
- Family history of asthma (OR 1.6)
- Age greater than 5 months at the time of bronchiolitis diagnosis (OR 1.4)
- More than 2 episodes of bronchiolitis (OR 2.4)
- Allergies (OR 1.6)
This was a retrospective study of 1991 children younger than 2 years that presented between 2000-2010 who were diagnosed with bronchiolitis. Primary care records were reviewed 1 year after their visit to the ED to see if the patient had a primary care diagnosis of asthma.
Of the initial study population, 817 patients had received a diagnosis of asthma at 1 year.
Since these patients were only followed up at 1 year, the amount of children who were later diagnosed with asthma may be underestimated.
Waseem et al. Factors Predicting Asthma in children with Acute Bronchiolitis. Pediatric Emergency Care. March 2017. Epub ahead of print.
Keywords: Pediatrics, urinary tract infection, urine concentration (PubMed Search)
A recent study suggests that using a lower cut off value of white blood cells in dilute urine, may have a higher likelihood of detecting a urinary tract infection in children.
In dilute urine (specific gravity < 1.015), the optimal white blood cell cut off point was 3 WBC/hpf (Positive LR 9.9). With higher specific gravities, the optimal cut off was 6 WBC/hpf (Positive LR 10). Positive leukocyte esterase has a high likelihood ratio regardless of the urine concentration.
This was a retrospective study of 2700 infants < 3 months old who were evaluated for urinary tract infections (UTI). The UTI prevalence in this group was 7.8%. A UTI was defined as at least 50,000 colony forming units/mL from a catheterized specimen. Test characteristics looked at white blood cell and leukocyte esterase cut-offs, dichotomized into specific gravities: dilute (<1.015) and concentrated (>/=1.015).
Keywords: pediatric, sepsis, infection, infants, children (PubMed Search)
Sepsis remains the most common cause of death in infants and children worldwide, with pneumonia being the most common cause of pediatric sepsis overall.
Strikingly, however, the mortality rate in pediatric sepsis is significant lower in children (10-20%) as compared to adults (35-50%).
The management of pediatric sepsis has been largely influenced by and extrapolated from studies performed in adults, in part due to difficulties performing clinical trial data in children with critical illness, including sepsis.
A major difference in management of children vs. adults with refractory septic shock with or without refractory hypoxemia from severe respiratory infection is the dramatic survival advantage of children when ECMO rescue therapy is used as compared to adults.
Bottom line: Consider ECMO for refractory pediatric septic shock with respiratory failure – in kids, survival is improved dramatically – consider it early!
For respiratory distress and hypoxia: Infants have a lower FRC and can desaturate very quickly!
Supplemental O2 should be delivered via face mask or nasal cannula or other devices such as high flow nasal cannula or nasopharyngeal CPAP, even if O2 saturation levels appear normal with peripheral monitoring devices
For improved circulation: utilize peripheral IO early
Peripheral IV or IO access can be used for fluid resuscitation, inotrope infusion, and antibiotic delivery when central access is not readily available or obtainable
Initial therapeutic resuscitative end points: hypotension and poor capillary refill may portend imminent cardiovascular collapse!
Antibiotics and source control: Early and aggressive source control is key, just as in adults!
Fluid resuscitation: Support the pump, and fill, but don’t overload the tank!
Inotropes and vasopressors: not just Levo for all!
Extracorporeal Membrane Oxygenation (ECMO)
Consider ECMO for refractory pediatric septic shock with respiratory failure – in kids, survival is improved dramatically – consider it early!
Randolph AG & McCulloh RJ. Pediatric sepsis: important considerations for diagnosing and managing severe infections in infants, children, and adolescents. Virulence. 2014: 1;5(1):179-89. doi: 10.4161/viru.27045.
Keywords: rash, fingertip, bulla, nail disorder (PubMed Search)
2) Cohen R, Levy C, Cohen J, Corrard F, Deberdt P, Béchet S, Bonacorsi S, Bidet P. Diagnostic of group A streptococcal blistering
Keywords: unicameral bone cyst, fracture (PubMed Search)
A 12 year old with arm pain after doing push ups during gym class. What is the diagnosis?
Diagnosis: Pathologic fracture with a unicameral bone cyst
Unicameral bone cysts are benign lesions that mainly affect children and adolescents. On xray the cyst is noted to be a mildly expansile, lytic, thin walled lesion without periosteal reaction. The most common sites are the proximal humerus and femur. These lesions can resolve spontaneously, but there is a risk of pathologic fracture. If fracture is detected, then the fracture site should be treated as any other fracture in the area. These lesions can also be found incidentally in which case they should be referred to orthopedics for outpatient follow up.
Kadhim, M, Thacker M, Kadhim A and Holmes L. Treatment of unicameral bone cyst: systemic review and meta analysis. J Child Orthop. 2014 Mar; 8(2): 171-191.
Mascard E, Gomez-Brouchet A, Lambot K. Bone cysts: Unicameral and aneurysmal bone cyst. Orthop Traumatol Surg Res. 2015 Feb; 101.
Keywords: epinephrine, auto-injector (PubMed Search)
As a follow up to Dr. Winter’s Pearl on Anaphylaxis on 1/24/2017, here’s a handy pearl for pediatric anaphylaxis (part 1).
Anaphylaxis: rapid and potentially life-threatening involvement of at least 2 systems following exposure to an antigen.
Medications (max: adult doses)
Get it?!?! Easy right? Instead of fumbling through an app or reference card during your next case of pediatric anaphylaxis, be a rock star "EM DR" by remembering the “Rule of 2’s”.
(Can't help it...ya'll know I love my mnemonics!!)
Keywords: Nail bed injuries, wound closure (PubMed Search)
More studies are needed, but the existing data shows that medical adhesives may be quicker without impacting cosmetic and functional outcome.
Nail bed injuries occur in 15-24% of children with fingertip injuries.
In 1997, medical adhesive was first used to secure the avulsed nail plate back to the nail bed instead of suturing back into place. By 2008, there were small studies looking at the utility of using medical adhesive to close the laceration of the nail bed. The studies were small, but there was a tendency towards shorter repair times and no difference between pain, cosmetic outcome or function.
A total of 6 articles were included in this review – 2 using histoacryl and 4 using demabond.
Edwards, S, Parkinson L. Is Fixing Pediatric Nail Bed Injuries with Medical Adhesives as Effective as Suturing? A Review of the Literature. Pediatric Emergency Care. 2016.