UMEM Educational Pearls - By Vikramjit Gill

You just finished assessing a 6 month old in the Pediatric ED who can’t move his right leg.  You suspect child abuse.  You’re ready to order labs, a head CT, ophtho consult, skeletal survey and call Child Protective Services.   While your doing all of this, your medical student asks you, “What exactly are you looking for on the skeletal survey?”

A skeletal survey is mandatory for cases of suspected child abuse in children under the age of 2 years.  Approximately 60% of the fractures seen in abused children are younger than 18 months old.

When you are looking at a skeletal survey, carefully look for the following:

1. Multiple, healing fractures of various ages

2. Rib fractures, especially in the posterior ribs

3. Metaphyseal chip and buckle fractures

4. Spiral fractures in long bones (especially in children that can’t walk)

5. Skull fractures which are not simple and linear

6. Scapula fractures

More to come about child abuse…. 

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Peritoneal dialysis (PD) is a commonly used form of dialysis for pediatric patients with end-stage renal disease, particularly in children less than five years of age.

One well known complication to this mode of dialysis is PD-associated peritonitis.

Children may present with fever, abdominal pain and a cloudy dialysate.

If peritonitis is suspected, obtain sample of dialysate fluid and send for cell count, Gram’s stain and culture.

Cell count in PD-associated peritonitis is usually WBC >100 with >50% neutrophils.

Both gram-positive and gram-negative organisms are involved with PD-associated peritonitis .  Keep both MRSA and Pseudomonas in mind.

In the ED, empiric therapy should cover both gram-positive and gram-negative organisms. Initiate antibiotic therapy with vancomycin and either a third-generation cephalosporin (ceftazidime) or aminoglycoside, respectively.

For PD-associated peritonitis, intraperitoneal (IP) administration of antibiotics is preferred over IV.

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1)      C-A-B for CPR. Now recommended to start compressions immediately instead of the conventional rescue breaths.

2)      Capnography during CPR. Continuous capnography recommended during CPR to guide the resuscitation, especially the effectiveness of chest compressions.

a.     If ETCo2 is less than 10 to 15 mm Hg consistently, focus your efforts on improving chest compressions.

3)      Etomidate for RSI induction.  Okay to use in infants and children, BUT not recommended for pediatric patients in septic shock.  Etomidate was not addressed in 2005 guidelines.

4)      Cuffed ET tubes. Acceptable to use in infants and children.

5)      Limit FiO2 after resuscitation.  Keep O2 sats ≥94%.  Avoid hyperoxia.

6)      Therapeutic hypothermia after cardiac arrest.  Recommendation based off of adult data, no pediatric prospective RCT done on this.  This is beneficial in adolescents with out-of-hospital VF arrest.

a.      Consider therapeutic hypothermia for infants and children.

b.      Cool to 32^oC-34^oC                                      

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