If there is a single truth of pediatric emergency medicine, it is that kids love to stuff things into their noses. A particular danger (aside from batteries, covered in a previous pearl) is the magnet.
Specifically, two magnets (as seen with magnet ear and nose rings, frequently worn by children and teens whose pesky parents won't allow piercings), attracted across the nasal septum can cause necrosis and perforation within hours.
Here's how to save yourself (and some noses):
"Ear to sternal notch" positioning has gained wide acceptance in the emergency medicine and anesthesia literature. Most often, this teaching is brought up with respect to obese adult patients whose large body habitus requires the raising of the neck and head to achieve airway alignment.
However, the correct anatomic positioning principle applies to all ages. Specifically, with regard to neonates, a shoulder roll is often placed indiscriminately to put the patient into the now out-dated "sniffing position," usually worsening the view of the airway.
Though this positioning is frequently misused, it can be easily adapted to apply ear to sternal notch positioning to neonates, whose misaligned airway is the result of a large occiput rather than a large torso. In all ages, if you follow these positioning principles, you will improve your view of the airway:
1. Align the ear to the sternal notch
2. Keep the face parallel to the ceiling (do NOT hyperextend the neck, as in the sniffing position)
3. In adults, the head usually needs to be raised (Image 1), while in infants, the torso usually needs to be raised (image 3).
So the magnesium didn't work, and the baby is on the way! You're prepared with everything you need for the delivery from bulb suction to a tripod for Dad's camera... But what is going to special about this baby?
Babies born to mothers who received magnesium therapy for any reason are at risk for hypotonia and severe respiratory depression.
Head injuries in children under 2yo are stress provoking, particularly with regard to when you should be getting a head CT. Luckily, a large (42,412 children, 10,718 <2yo) multi-center trial exists to guide your behavior.
Hyponatremic seizures are a frightening entity. Anticonvulsants don't work well, and will likely cause apnea well before they halt the seizure. Hypertonic saline carries with it the fear of inducing central pontine myelinolysis (CPM) with overly rapid correction of the hyponatremia.
However:
So, you can safely correct hyponatremia rapidly in the setting of seizures. Do it like this:
Give 2-3 mL/kg of 3% NaCl in rapid sequential boluses, until seizures stop. A theoretical maximum dose is 100mL/kg, but recall that only a relatively small correction is required to stop the seizure.
After you've stopped the seizure, correct the hyponatremia slowly, as you would otherwise.
In the past several years it has become common practice to use cuffed tubes for pediatric intubations. However, a recent study suggests that cuff pressures are not as well regulated in pediatric patients, particularly when the patients are quickly intubated prior to aeromedical transport. Cuff pressures >30 cm H2O are associated with tracheal damage, however, up to 41% of pediatric patients transferred had cuff pressures >30 cm H2O, and 30% of those had pressures >60 cm H2O!
So:
Check your cuff pressures in all patients, particularly prior to transport
Cuff pressures must be <30cm H2O
Recall that for years uncuffed tubes were the standard, so as long as effective ventilation is achieved, it is best to err on the low side...
If you work at a facility that routinely transfers out the sickest pediatric patients, you will save their life by securing an airway in this most stressful of circumstances, but careful attention to this seemingly small detail can save your patient from long term complications.
We've all been there. It's 2am, and a 4 week old with a temperature of 38.1 rolls in the door. You grab the LP kit and your "best holder." This person then holds the baby's head and neck flexed with one hand, while the other brings the bottom and legs up to the chest as much as possible...all, usually, without pulse oximetry monitoring.
You may already love ondansetron, but consider using it ORALLY followed by PO hydration in children with vomiting.
The size of the study that showed this: N of just under 35,000.
But don't skimp on dosing. The dose is 0.1 - 0.15mg/kg, and you don't reach a max until 8mg. To put this in perspective, a scrawny 115lb (about 53kg) middle school tennis player would get 8mg, an initial dose often reserved for chemo patients in the adult ED.
Slipped capito-femoral epiphysis (SCFE) is a favorite board exam topic, and typically involves a young early or pre-adolescent obese girl with hip pain and the classic "ice cream falling off the cone" appearance on hip radiographs. However, keep these three pearls in mind when thinking about SCFE:
As RSV season approaches, remember these key points in managing bronchiolitis:
A common debate on the topic of pediatric burns is whether or not blisters should be debrided. ALL PEDIATRIC BURN BLISTERS SHOULD BE DEBRIDED. There are two reasons for this:
1. Without debridement of burn blisters, the depth of a burn cannot be assessed, and such an assessment will certainly affect treatment and disposition.
2. There is conflicting (poor) evidence that blister fluid provides both protective and damaging properties, however, there is excellent evidence that ruptured blisters, or large blisters which are likely to rupture, carry a higher risk of infection if not debrided. Therefore, all blisters should be debrided.
The best method for debriding blisters uses sterile gauze soaked in saline, and it is important to note that pain is almost universally decreased after debridement.
The "1, 2, 3 Ouch!" technique is exactly what it sounds like (count to three with the child, and then wipe quickly, like tearing off a bandage), and works well in older children with smaller burn areas. Sedation may be necessary for extensive debridements, and these children may need to be taken to the OR for debridement under anesthesia. Some burn centers utilize non-operating room anesthesia (NORA) areas for such debridements that may be prolonged or painful, but do not require the full resources of an operating room.
Pediatric Ethanol Ingestion
A young child is brought to you after accidentally drinking a shot of alcohol at a wedding party. Here is what you need to consider:
Current American Burn Association guidelines state that any child with a greater than 10% total body surface area (TBSA) burn should be admitted to a center capable of caring for pediatric burns, rather than being discharged after wound management. However, physician use of TBSA% estimation techniques is variable. An excellent free tool for estimating TBSA is available online, allows for automatic weight based calculation, and allows printing of your diagram. The diagram is available at http://www.sagediagram.com/. More to come...
Once you've made the presumptive diagnosis of cerebral edema in Pediatric DKA (refer to part 1), here's what's next:
Mortality from cerebral edema in DKA is 20-25%, and 15-35% of survivors have permanent disability.
The best strategy is to do your best to avoid cerebral edema in the first place, but if you do recognize it, this is a clinical diagnosis, and you should not delay treatment for radiographic studies.
...more to come.
Congenital hypothyroidism (CH) is almost uniformly identified before symptoms develop because of newborn screening. Though this problem will rarely present to the Emergency Department, it is not uncommon for parents with poor access to care to present to EDs after being notified of an abnormal screen. Here is what you need to know:
So:
Hyperleukocytosis is often seen in acute presentations childhood leukemias, and is defined as a WBC count of greater than 30-50K. Complications usually arise at counts greater than 300, however, keep in mind that automated cell counters may underestimate very high white counts.
Complications include:
Treatment:
The Emergency Department is often the first line in detecting the sexual abuse of a child. Unfortunately, what you do or don't say/ask/test can significantly affect the legal protection of the abused child.
1. Know your region's dedicated sexual abuse center, if one exists. These centers have personnel trained in interviewing and forensic evidence collection. There may be different centers for children of different ages.
2. Know your state laws regarding what is and is not admissible as evidence of sexual abuse. GC/CT urine testing (NAAT), though more sensitive than swab cultures, is not currently admissible as evidence in many states.
3. Withhold prophylactic antibiotic treatment when possible - antibiotics work well, and often eliminate evidence. Withholding antibiotics is acceptable if the child is asymptomatic or only has very mild symptoms.
4. Any sexually transmitted disease in a child warrants further workup and investigation. Primary genital HSV in a young child warrants testing for Gonorrhea and Chlamydia, and appropriate referral as well as police involvement.
5. Finally, if trained personnel is available to conduct the interview of a child, limit the questions you ask the child directly. Any evidence in your note that you may have suggested something to the child in your line of questioning could negate the validity of their testimony.
Ring-removal is a dreaded problem in pediatric hand and finger injuries. Removal can be difficult and time consuming. The relatively recent introduction of Tungsten into the jewelry market has further complicated this problem:
However, it is:
This video explains how. Of course, this works on adults as well.
http://www.youtube.com/watch?v=poM423pewRE
I have no relationship with the copany which made this video - it was simply chosen for its clear explanation of the solution described in this pearl.
