Keywords: unimmunized, pediatric fever (PubMed Search)
Childhood vaccination has significantly decreased the incidence of bacterial meningitis and bacteremia in infants and young children, specifically vaccines against H. influenzae and S. pneumoniae, shifting broad workups for these disease and empiric antibiosis to younger age groups as rates declined. In recent years the percentage of unvaccinated and under-vaccinated children has been rising due to multiple factors; now over 1% of children in the US under 2 years of age are unvaccinated. The question becomes, should these children be treated more similarly to young infants as they lack to immunity to these organisms?
Literature on this topic is sparse, although, Finkel, Ospina-Jimenez, et al. reviewed the literature available and proposed an algorithm for well appearing children 3-24 months of age without a clear source and a temperature of >39C (102.2F). Recommendations included UA (to determine possible source) in the following patients: fever > 2 days, prior UTI, female or uncircumcised male <12 months, or male <6 months. They also recommended evaluation with viral panel. If no source was determined, they then recommended CBC and procalcitonin with a CXR for WBC > 20,000/mm3. For WBC >15,000/mm3, ANC >10,000/mm3, absolute band count >1,500/mm3, or procalcitonin >0.5ng/mL they recommended blood culture, ceftriaxone 50 mg/kg, and follow up within 24 hours.
Bottom line: Literature is scarce and practice patterns are likely to evolve as ramifications of decrease in vaccination rates become clearer. The above algorithm is proposed, however covers limited situations and may not be practical in all settings. Clinical judgement should be used in the evaluation and management of these patients. A more conservative approach compared to vaccinated infants is reasonable at this time.
Finkel L, Ospina-Jimenez C, Byers M, Eilbert W. Fever Without Source in Unvaccinated Children Aged 3 to 24 Months: What Workup Is Recommended?. Pediatr Emerg Care. 2021;37(12):e882-e885
Keywords: DEI, transgender, nonbinary (PubMed Search)
Approximately 1.4 million transgender and gender nonbinary patients live in the United States. Unfortunately, prior research has shown negative experiences with the health system are common after disclosing their trans/NB status. As a result, almost a ¼ report avoiding or delaying needed health care.
This qualitative study interviewed a subset of trans/NB individuals about their experiences visiting emergency departments. Several key themes emerged:
Overall, the study found that clinicians have many opportunities to improve the care of transgender and nonbinary patients, including updating forms, using inclusive language, avoiding medically unnecessary questions, and providing training for staff on trans/NB health.
Allison MK, Marshall SA, Stewart G, Joiner M, Nash C, Stewart MK. Experiences of Transgender and Gender Nonbinary Patients in the Emergency Department and Recommendations for Health Care Policy, Education, and Practice. J Emerg Med. 2021 Oct;61(4):396-405. doi: 10.1016/j.jemermed.2021.04.013. Epub 2021 Jun 25. PMID: 34176685; PMCID: PMC8627922.
Keywords: DEI, Intimate Partner Violence (PubMed Search)
IPV can occur once or over years by a current or former romantic partner. Types of IPV include: Physical and/or Sexual violence, Stalking, and Psychological/Financial aggression (the use of verbal and non-verbal communication to harm mentally or emotionally and to exert control over another partner).
IPV is more prevalent that Aortic Dissection and Pulmonary Embolism combined. Think about how risky it is to NOT recognize IPV.
1:4 women and 1:10 men have been victims of IPV during their lifetime.
1:5 homicide victims are killed by an intimate partner.
Over 50% of female homicide victims are killed by a current or former intimate partner. Patients who have been strangled are 4 times more likely to be killed within a year.
Your Spidey Sense should go off when:
Once patient is identified as a victim:
Keywords: rehydration, fluid management (PubMed Search)
Subcutaneous Fluid Administration for Rehydration
Caccialanza R, Constans T, et al. Subcutaneous Infusion of Fluids for Hydration or Nutrition: A Review. Journal of Parenteral and Enteral Nutrition. 2018; 42 (2): 296-307
Spandorfer PR. Subcutaneous Rehydration. Pediatric Emergency Care. 2011; 27 (3):230-236.
Keywords: pediatric cardiology, ALCAPA (anomalous left coronary artery from the pulmonary artery) (PubMed Search)
Cashen K, Kwiatkowski DM, Riley CM, Buckley J, Sassalos P, Gowda KN, Iliopoulos I, Bakar A, Chiwane S, Badheka A, Moser EAS, Mastropietro CW; Collaborative Research from the Pediatric Cardiac Intensive Care Society (CoRe-PCICS) Investigators. Anomalous Origin of the Left Coronary Artery From the Pulmonary Artery: A Retrospective Multicenter Study. Pediatr Crit Care Med. 2021 Dec 1;22(12):e626-e635.
Hoffman JI. Electrocardiogram of anomalous left coronary artery from the pulmonary artery in infants. Pediatr Cardiol. 2013 Mar;34(3):489-91.
Levitas A1, Krymko H, Ioffe V, Zalzstein E, Broides A. Anomalous Left Coronary Artery From the Pulmonary Artery in Infants and Toddlers Misdiagnosed as Myocarditis. Pediatr Emerg Care. 2016 Apr;32(4):232-4
Keywords: Migrant Health, DEI (PubMed Search)
Approximately 284,000 immigrants reside in Baltimore (10% of the total population). In April 2022, Governor Abbott of Texas began sending migrants from the US southern border to Washington, DC, with Arizona joining soon after. It is important for emergency providers to be aware of these changes and how new disparities may arise.
Mahmoud I, Eley R, Hou XY. Subjective reasons why immigrant patients attend the emergency department. BMC Emerg Med. 2015 Mar 28;15:4.
Maldonado CZ, Rodriguez RM, Torres JR, Flores YS, Lovato LM. Fear of discovery among Latino immigrants presenting to the emergency department. Acad Emerg Med. 2013 Feb;20(2):155-61.
Tarraf W, Vega W, González HM. Emergency department services use among immigrant and non-immigrant groups in the United States. J Immigr Minor Health. 2014 Aug;16(4):595-606.
Keywords: pediatric trauma, tranexamic acid (PubMed Search)
Bottom line: There is not clear evidence for efficacy, but trends are positive and the documented rates of adverse effects in this population are low. It is reasonable to give, especially in patients requiring massive transfusion or who are critically ill.
Eckert MJ, Wertin TM, Tyner SD, et al. Tranexamic acid administration to pediatric trauma patients in a combat setting: the pediatric trauma and tranexamic acid study (PED-TRAX). J Trauma Acute Care Surg. 2014;77(6):852-858.
Hamele M, Aden JK, Borgman MA. Tranexamic acid in pediatric combat trauma requiring massive transfusions and mortality. J Trauma Acute Care Surg. 2020;89(2S Suppl 2):S242-S245.
Nishijima, DK, VanBuren, JM, Linakis, SW, et al. Traumatic injury clinical trial evaluating tranexamic acid in children (TIC-TOC): A pilot randomized trial. Acad Emerg Med. 2022; 29: 862– 873.
Keywords: pediatric trauma, ultrasound, FAST (PubMed Search)
Bottom line: A positive FAST warrants further workup and may be helpful in the hemodynamically unstable pediatric trauma patient, but a negative FAST does not exclude intraabdominal injury and evidence for performing FAST in hemodynamically stable pediatric patients is limited.
Guyther, J. Advances in Pediatric Abdominal Trauma: What’s New is Assessment and Management. Trauma Reports 2016; 17: 1-15.
Holmes JF, Kelley KM, Wootton-Gorges SL, Utter GH, Abramson LP, Rose JS, Tancredi DJ, Kuppermann N. Effect of Abdominal Ultrasound on Clinical Care, Outcomes, and Resource Use Among Children With Blunt Torso Trauma: A Randomized Clinical Trial. JAMA. 2017 Jun 13;317(22):2290-2296.
Keywords: autism spectrum disorder, neurodevelopmental disorder (PubMed Search)
Keywords: inborn error of metabolism (IEM), organic acidemia (PubMed Search)
Laura L. Guilder, Jonathan B. Kronick; Organic Acidemias. Pediatr Rev March 2022; 43 (3): 123–134.
Keywords: bell's palsy, pediatric malignancy (PubMed Search)
Acute facial palsy is common in children and while bell’s palsy is significant proportion, there are other more concerning etiologies that make up a number of cases. A retrospective cohort study of pediatric patients with an ED diagnosis of Bell’s palsy was done using the Pediatric Health Information System and showed an incidence of 0.3% (0.03% in control) for new diagnosis of malignancy within the 60 days following the visit at which bell’s palsy was diagnosed. Younger age increased the risk. There was also a subset of patient’s excluded for diagnosis of bell’s palsy as well as malignancy at the index visit.
These numbers are small but may be clinically significant. They likely do not warrant laboratory or imaging workup as a rule but do make a case for detailed history taking and thorough exam. Consider avoiding steroids which are used commonly but lack high quality data and may undermine later efforts at tissue diagnosis of malignancy or even worsen prognosis.
Walsh PS, Gray JM, Ramgopal S, Lipshaw MJ. Risk of malignancy following emergency department Bell's palsy diagnosis in children. Am J Emerg Med. 2021 Dec 29;53:63-67.
Keywords: peds ortho, calcaneus, stress injury (PubMed Search)
Smith JM, Varacallo M. Sever Disease. [Updated 2021 Jul 18]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK441928/
Keywords: febrile infant, neonatal fever (PubMed Search)
What they are: Clinical practice guidelines put together by an AAP subcommittee over a span of several years based on changing bacteriology and incidence of illness, advances in testing, and evidence that has accumulated
Includes: Healthy infants 8 to 60 days of life with an episode of temperature greater than or equal to 38.0 C who at now at home after being born at home or after discharge from the newborn nursery, born between 37 and 42 weeks, without focal infection on exam (cellulitis, vesicles, etc)
For the well appearing 8-21 day old:
For well appearing 22- 28 day olds:
For well appearing 29-60 day olds:
Pantell, R., Roberts, K., et al. Evaluation and Managment of Well-Appearing Febrile Infants 8 to 60 Days Old. Pediatrics. Aug 2021, 148(2) e2021052228
Keywords: RSV, bronchiolitis (PubMed Search)
CDC. Increased Interseasonal Respiratory Syncytial Virus (RSV) Activity in Parts of the Southern United States. Health Alert Network. Published online June 10, 2021.
Ralston, S., Lieberthal, A., et al. Clinical Practice Guideline: The Diagnosis, Management, and Prevention of Bronchiolitis. Pediatrics. Nov 2014. 134(5) e1474-1502.