UMEM Educational Pearls - By Sean Fox

Title: Pseudosubluxation

Keywords: Pseudosubluxation, swischuk Line, Hangman's Fracture, Cervical Injury (PubMed Search)

Posted: 8/10/2007 by Sean Fox, MD (Updated: 11/22/2024)
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Pseudosubluxation Refers to the normal mobility of the cervical vertebrae, IN FLEXION, which may appear pathologic Distinguishing between Pseudosubluxation and Pathologic - The displacement should only occur in flexion (Not extension) (1) most pediatric c-spine films are in flexion due to the relatively larger occiput - Swischuk Line (1) Line that is drawn from anterior aspects of C1 to C3 spinous processes (2) This line should be within 2 mm of the anterior aspect of the C2 spinous process - Spinal-Laminar Line (1) The line drawn connecting the lamina of C1, C2, and C3 should remain intact even in flexion If you suspect that the misalignment represents pseudosubluxation, than you can reposition in extension; if it resolves, it is consistent with pseudosubluxation. But be careful, if mechanism warrants it, obtain CT to r/o hangman s fracture instead. Anterior displacement of C2 in children: physiologic or pathologic. LE Swischuk. Radiology. Vol 122(3) 1977. p 759-763.

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0708102139_Swischuck Line.ppt (518 Kb)

Title: Painless Neck Masses

Category: Pediatrics

Keywords: Neck Mass, thyroglossal duct cyst, Second Brachial Cleft Cyst, ectopic Thyroid tissue (PubMed Search)

Posted: 8/3/2007 by Sean Fox, MD (Updated: 11/22/2024)
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Painless Neck Masses Thyroglossal Duct Cyst = most common congenital midline mass ==> Concern that it may be ectopic thyroid tissue ==> Painless ==> Elevates with the tongue during swallowing (It is attached to the base of the tongue) ==> Requires ultrasound. Thyroid Scan if thyroid is abnormal. ==> Tx; Sistrunk procedure excsion of cyst and and mid-portion of the hyoid bone (not removing the portion of the hyoid leads to high rate of recurrence). Second Branchial Cleft Cyst = Most common branchial anomaly (90%) ==> Painless fluctuant mass in the anterior triangle ==> Arise due to failure of the embryonic branchial cleft to obliterate. ==> Ultrasound or CT may be useful to define mass and for pre-operative evaluation. Both are mostly asymptomatic, but may cause symptoms due to compression of local structures. Both may become infected secondarily, at which time they will no longer be painless. Treat with Abx if infected. Surgical excision should be delayed until active infection is resolved.

Title: Hirschsprung Disease

Category: Pediatrics

Keywords: GI, Hirschsrung Disease, Constipation (PubMed Search)

Posted: 7/26/2007 by Sean Fox, MD (Updated: 11/22/2024)
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Hirschsprung Disease Is the absence of parasympathetic ganglion cells in the rectum and colon. May present in neonates or young children. Consider it in any child with constipation, bilious emesis, delayed passage of meconium (after the first 48-72 hrs), abdominal distension, or enterocolitis. Classic physical finding: tight anal sphincter, empty rectal vault, followed by an explosive bowel movement (due to releasing the pressure by loosening the anal sphincter). Definitive Dx made by rectal biopsy. May be complicated by bacterial overgrowth causing enterocolitis.

Title: Nursemaid's Elbow

Category: Pediatrics

Keywords: Nursemaid's Elbow, Radial Head Subluxation (PubMed Search)

Posted: 7/20/2007 by Sean Fox, MD (Updated: 11/22/2024)
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Nursemaid's Elbow PRESENTATION ==> Radial head subluxation is VERY common; most often seen in ages of 1-4 yrs. ==> Arm is held close to the body, elbow flexed and forearm pronated. MANAGEMENT ==> If the history and physical are classic, no X-rays are needed. Obtain x-rays if there is pain to palpation of long bones (rule out Monteggia fx) or the story is not classic. ==> Hold elbow at 90 degrees, then firmly supinate and simultaneously flex the elbow. ==> Place thumb over region of radial head and apply pressure as you supinate. May also need to extend elbow to help screw radial head back in place. POST-REDUCTION ==> Immobilation is not necessary for 1st episode ==> If delayed reduction (>12 hours), place in long arm posterior splint in full supination and elbow @90 degrees http://www.wheelessonline.com/ortho/nursemaids_elbow_radial_head_subluxation

Title: Bronchiolitis

Category: Pediatrics

Keywords: Bronchiolitis, Bronchodilators, Steroids, Supplemental Oxygen (PubMed Search)

Posted: 7/14/2007 by Sean Fox, MD (Updated: 11/22/2024)
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Bronchiolitis The most common lower respiratory infection in infants Diagnosis is based on clinical history and physical. No lab test is useful. Management - Bronchodilators should not be used routinely. They can be continued if the pt has a positive response after a trial. - Corticosteroids have not been found to be of benefit. - Antibiotics should not be used, unless indicated for other reasons. - Ribaviran has not demonstrated any benefit. - Use Supplemental oxygen if the patient is persistently sat'ing <90%. Subcommittee on Diagnosis and Management of Bronchiolitis. Diagnosis and Management of Bronchiolitis. PEDIATRICS Vol. 118 No. 4 October 2006, pp. 1774-1793

Title: Intussusception

Category: Pediatrics

Keywords: Intussusception, Abdominal Pain, bloody stools, vomitting, change in mental status (PubMed Search)

Posted: 7/14/2007 by Sean Fox, MD (Updated: 11/22/2024)
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Intussusception Age: 3months to 6 years, most common among 3-12 months The classic triad: colicky abdominal pain, vomiting, and red currant jelly stools ==> Occurs in only 21% of cases. ==> Currant jelly stools are observed in only 50% of cases. ==> 75% without obviously bloody stools will have positive occult blood. A child vomiting without diarrhea should raise suspicion. Consider it in infant/toddler with change in mental status/lethargy (TIPS AEIOU one of the I s is for Intussusception). Choice of Radiographic Evaluation is often based upon your institutional resources ==> U/S is the modality of choice for imaging, but cannot treat. ==> Air contrast enema (now preferred over saline contrast) is useful for diagnosis and treatment. ==> Both are operator dependent

Title: Acute Otitis Media

Category: Pediatrics

Keywords: Acute Otitis Media, Amoxicillin, insufflation, Delayed treament (PubMed Search)

Posted: 7/14/2007 by Sean Fox, MD (Updated: 11/22/2024)
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Acute Otitis Media Make the Diagnosis Properly ==> Acute Onset of Symptoms ==> Signs of Middle Ear Infection (1) Buldging TM, poor mobility c insufflation, otorrhea, air-fluid level ==> Signs of Middle Ear Inflammation (1) TM erythema or otalgia (that interferes with nl activity) Can you wait on the Abx? ==> Older than 6months ==> No severe infections (T>39 C) ==> If yes to both, may hold Abx for 48 hours. Treat Appropriately ==> High-Dose Amoxicillin (80-90mg/kg/D) is 1st line If the decision is made to observe without antibiotic therapy, the parents can be given a prescription for Abx with instructions to fill it if the child does not improve in 48 to 72 hours, or see the PMD in 2 days. (Spiro, D. Tay, K. Wait-to-see prescription for the treatment of acute otitis media. JAMA 2006, 1235.)

Title: Pediatric Thoracic Trauma

Category: Pediatrics

Keywords: Thoracic, Trauma , Traumatic Asphyxia, Pulmonary Contusion (PubMed Search)

Posted: 7/14/2007 by Sean Fox, MD (Updated: 11/22/2024)
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Pediatric Thoracic Trauma 2nd leading cause of death in Peds Trauma Most injuries in Peds are Blunt Kids are Different ==> More Pliable Chest Walls → Pulm Contusion more likely than rib Fx ==> More Mobile Mediastinum → more susceptible to develop tension ptx ==> More Likely to Hyperventilate → Swallowed Air → compromise Respiratory status ==> Can compensate for significant volume loss with tachycardia Traumatic Asphyxia ==> Primarily in younger children ==> Due to the more pliable chest wall ==> Sudden, severe crushing blow to the chest when the glottis is closed. ==> Petechial Hemorrhages of sclera and skin of the head and upper extremities ==> Neuro deficits and coma due to cerebral edema can occur, although rare Pulmonary Contusion ==> Most Common thoracic Injury in kids ==> Alveolar Hemorrhage, Consolidation, Edema ==> Leads to: (1) V/Q mismatch (2) Decreased Compliance (3) Hypoxemia (4) hypoventilation

Title: Neonatal Resuscitation

Category: Pediatrics

Keywords: Neonatal Resuscitation, Newborn, Transilluminate, Meconoium Aspiration, Zip Lock Bag (PubMed Search)

Posted: 7/14/2007 by Sean Fox, MD (Updated: 11/22/2024)
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Neonatal Resuscitation 3 Key Questions to ask of your pregnant patients: ==> Are you having twins (or more)? ==> When is your due date? ==> What color is the fluid? Magic numbers for Neonatal Resuscitation: ==> HR < 100 (or persistent central cyanosis or apnea) = positive pressure ventilation ==> HR < 60 = chest compressions +/- epinephrine If there is meconium present and ==> The infant is depressed, then use meconium aspirator (aspirate the airway via the ETT) ==> The infant is vigorous, then resuscitate as usual (dry, clear airway, assess circulation/color) When resuscitating an infant who is <28wks GA, do not dry with towels as you would an older neonate, instead ==> Place the child in a food grade polyethylene bag (Zip Lock bag), to prevent heat loss and avoid losing valuable time during the resuscitation. For infants not responding to resuscitation, TRANSILLUMINATE the chest to determine if there is a pneumothorax.

Title: Inborn Errors of Metabolisn

Category: Pediatrics

Keywords: Inborn Errors of Metabolism, Hypoglycemia, organomegaly (PubMed Search)

Posted: 7/14/2007 by Sean Fox, MD (Updated: 11/22/2024)
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Inborn Errors of Metabolism For the child with neurologic abnormalities, vomiting, acidosis, hypoglycemia, organomegaly, or cardiopulmonary arrest remember to consider Inborn Errors of Metabolism (IEM) on your DDx. There are over 300 disorders of the various biochemical pathways, and while the individual incidence for each disorder may be rare, the collective incidence for IEM is 1-2 / 1,000 births. Treat dehydration and hypoglycemia promptly but FIRST, draw EXTRA blood samples (at UMMS, two adult Green Tops and one adult Red Top) in addition to the basic labs. ==> Once you begin therapy to correct the acid/base disturbance, hypoglycemia, and dehydration the abnormal metabolites present in their serum will be reduced and possibly confound the diagnosis. ==> Draw the extra blood, before your give the NS bolus or the Dextrose! ==> Basic Labs (1) ABG, BMP, Ammonia, U/A are helpful immediately (2) CBC, Blood and Urine Cultures (look for concurrent infection, possibly the inciting event) (3) Urine Reducing Substances, serum organic acids, urine and serum amino acids are also useful

Title: ALTE

Category: Pediatrics

Keywords: ALTE , Apparent Life Threatening Events, color change, apnea, SIDS, Seizure (PubMed Search)

Posted: 7/14/2007 by Sean Fox, MD (Updated: 11/22/2024)
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ALTE (Apparent Life Threatening Events) Defined as an episode characterized by some combination of apnea, color change, change in tone, choking, and/or gaging. Vast DDx ==> Get Bedside Glucose Early (should be part of vital signs) ==> Keep Non-accidental Trauma on the list ==> ~50% are classified as Idiopathic Risk Factors associated with Increased Mortality: ==> Sleep Onset ==> Prior Similar Episode ==> Sibling a Victim of SIDS ==> Development of Seizure D/O during monitoring 7.8% of ALTE pt s with a Normal ED evaluation required medical intervention during hospitalization. -Oren, J., D. Kelly, and D.C. Shannon, Identification of a high-risk group for sudden infant death syndrome among infants who were resuscitated for sleep apnea. Pediatrics, 1986. 77(4): p. 495-9. -De Piero, A.D., S.J. Teach, and J.M. Chamberlain, ED evaluation of infants after an apparent life-threatening event. Am J Emerg Med, 2004. 22(2): p. 83-6.

Title: SCIWORA

Category: Pediatrics

Keywords: SCIWORA, Spinal Cord Injury Without Radiographic Abnormality, MRI, steroids (PubMed Search)

Posted: 7/14/2007 by Sean Fox, MD (Updated: 11/22/2024)
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SCIWORA (Spinal Cord Injury Without Radiographic Abnormality) Children <8yrs old can have their spinal cord stretched up to 5cm before rupture. Their cervical spinal columns are more mobile and held together with less stable ligaments allowing for horizontal movement of the vertebrae. The mobility of the spinal column allows for spontaneous reduction of subluxated vertebrae; therefore, CTs and plain radiographs will often appear normal at the time of ED evaluation. Any child with neurologic deficits or a concerning mechanism of injury deserves an MRI to evaluated for SCIWORA. No studies of the utility of steroids in children with spinal cord injury exist; current recommendations are to reserve methylprednisolone for those children who present with persistent or progressive neurologic deficits.

Title: NewBorn Resuscitation

Category: Pediatrics

Keywords: NewBorn Resuscitation, Neonate, Transilluminate, Bradycardia (PubMed Search)

Posted: 7/14/2007 by Sean Fox, MD (Updated: 11/22/2024)
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NewBorn Resuscitation Important numbers to remember: ==> HR <100, start Positive Pressure Ventilation ==> HR <60, start Chest Compressions Bradycardia and Hypotonia are symptoms of Poor Ventilation and Acidosis With an infant who is not responding to resuscitation measures, TRANSILLUMINATE the chest to help detect a pneumothorax.

Title: Kawasaki s Disease

Category: Pediatrics

Keywords: Kawasaki s, Coronary Artery Aneurysm, fever (PubMed Search)

Posted: 7/14/2007 by Sean Fox, MD (Updated: 11/22/2024)
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Kawasaki s In the US, Kawasaki Disease is the leading cause of Acquired Heart Disease in Children (surpassing Acute Rheumatic Fever). ==> 15-25% of untreated pts develop coronary artery aneurysm or ectasia. Diagnosis is a clinical one. ==> 5 days of fever PLUS 4/5 clinical features (rash, inflammation of lips/mouth, bilateral conjunctivitis, edema or erythema of hands/feet, and peeling of fingers/toes). No lab values are diagnostic; however, they can strengthen clinical suspicion. ==> CRP and ESR are usually elevated. Thrombocytosis is also common after 1 week of illness. Symptoms are often transient and require careful history. Considered it in the DDx of every child with fever of at least several days duration, rash, and nonpurulent conjunctivitis, especially in children <1 year old and in adolescents, who often have incomplete Kawasaki Disease and are likely to be missed. Newburger, JW. Diagnosis, Treatment, and Long-Term Management of Kawasaki Disease. Circulation. 2004;110:2747-2771.

Title: Leukokoria

Category: Pediatrics

Keywords: Leukokoria, white pupil, retinoblastoma (PubMed Search)

Posted: 7/14/2007 by Sean Fox, MD (Updated: 11/22/2024)
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Leukokoria The White Pupil Leukokoria is seen in 50-60% of the patients with retinoblastoma Retinoblastoma is the most common intraocular malignancy in children, usually detected in the primary care clinic (which the ED often is now) Median age of diagnosis: unilateral = 24 months; bilateral = 12 months Metastatic disease: direct extension to CNS, hematogenous to bones, lung, and brain When detected early, it is one of the most curable childhood cancers Untreated, almost all will die within 2 years Refer anyone without a normal red reflex to an ophthalmologist within 1 week. WG Wilson, JR Serwint. Retinoblastoma. Pediatrics in Review. 2007;28:37-38 Melamud A, Palekar R, Singh A Retinoblastoma. Am Fam Physician. 2006 Mar 15;73(6):1039-44.

Title: Pediatric Fever / UTI

Category: Pediatrics

Keywords: Fever, UTI, Vesicoureteral Reflux, VCUG (PubMed Search)

Posted: 7/14/2007 by Sean Fox, MD (Updated: 11/22/2024)
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Pediatric Fever / UTI UTI is one of the most frequent bacterial infections in children. ==> Vesicoureteral Reflux is diagnosed in 30-40% of children found to have a febrile UTI. ==> Vesicoureteral Reflux can lead to recurrent UTIs and Renal Scarring, which can then lead to hypertension and renal insufficiency. Instruct newly diagnosed patients and families to f/u with PMD to schedule renal imaging (renal ultrasound and VCUG). American Academy of Pediatrics, Committee on Quality Improvement, Subcommittee on Urinary Tract Infection. Practice parameter: the diagnosis, treatment, and evaluation of the initial urinary tract infection in febrile infants and young children Pediatrics. 2000;105:141.

Title: Syncope

Category: Pediatrics

Keywords: Syncope, Brugada, WPW, Prolonged QTc (PubMed Search)

Posted: 7/14/2007 by Sean Fox, MD (Updated: 11/22/2024)
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Pediatric Syncope 15-25% of children experience at least one syncopal episode by young adulthood Heart Disease has been the attributed etiology in as high as 10-28% of these cases ==> Historical features suggestive of Cardiac etiology (similar to adults): (1) Onset with exertion (2) No prodome or premonitory symptoms; Resulted in bodily injury (3) Incontinence, Seizure-like activity (4) Abnormal Cardiac Structure or previous cardiac surgery (5) Family Hx of unexplained Death or Accidents (MVC) (6) Required CPR (7) Resulted in neurological insult ==> Get the EKG! Look for (1) WPW (2) Prolonged QTc (3) AV blocks (4) BRUGADA Syndrome Yes, even in kids! Johnsrude, C.L., Current approach to pediatric syncope. Pediatr Cardiol, 2000. 21(6): p. 522-31.

Title: Bacterial tracheitis

Category: Pediatrics

Keywords: Bacterial tracheitis, stridor, croup, epiglottitis (PubMed Search)

Posted: 7/14/2007 by Sean Fox, MD (Updated: 11/22/2024)
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Bacterial Tracheitis Considered bacterial tracheitis in a patient who has fever, stridor, and symptoms that do not respond to therapy for croup (racemic epinephrine and steroids). The epidemiology of acute infectious upper airway disease in pediatrics has been altered with immunization against Haemophilus influenza- b and the widespread use of corticosteroids for the treatment of viral croup. Bacterial Tracheitis has replaced epiglottitis and croup as the most common cause of acute respiratory failure. One study found it to be 3 times more likely to cause respiratory failure than croup and epiglotittis combined. The mortality rates had been reported as high as 18% to 40%. Hopkins, A., et al., Changing epidemiology of life-threatening upper airway infections: the reemergence of bacterial tracheitis. Pediatrics, 2006. 118(4): p. 1418-21.