UMEM Educational Pearls - By Jenny Guyther

Category: Pediatrics

Title: What is the proper ratio of blood products in the bleeding pediatric trauma patient?

Keywords: Pediatric trauma, blood transfusion, ratios (PubMed Search)

Posted: 11/18/2022 by Jenny Guyther, MD (Updated: 11/27/2022)
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Research in the pediatric trauma patient has finally shown that crystalloid volume should be limited and blood products should be used early in resuscitation.  Whole blood transfusion is currently being studied.  Studies are also being conducted looking at the proper ratio of blood products for these pediatric trauma patients.
This was a retrospective review of the Trauma Quality Improvement Program.  Patients younger than 18 years old who received at least 1 unit of FFP and PRBCsduring the initial 4 hours of admission were included.  The study looked at 1,233 patients who received FFP:PRBC ratios of 1:1, 1:2, 1:3 and 1:3+ and 24 hour mortality, hospital mortality, complications and 24 hour PRBC requirements.
The 1:1 transfusion group had the lowest 24 mortality and in-hospital mortality.  There was no difference between the groups for complications.  The 1:1 ratio group also had the lowest 24 hour PRBC requirements.  This study did not include those patients who required massive transfusion on arrival. 
Bottom line: FFP:PRBC ratio of 1:1 was associated with increased survival in children.  More studies are needed regarding whole blood and massive transfusion in pediatrics.

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Category: Pediatrics

Title: Once intuccesption has been diagnosed, when should reduction occur?

Keywords: intuccesption, air enema, reduction timing (PubMed Search)

Posted: 10/21/2022 by Jenny Guyther, MD (Updated: 11/27/2022)
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Once the diagnosis of intussusception is made, there are often delays in 1) getting the patient to a center where reduction can be performed and 2) getting the staff available to perform an air enema, especially during evenings and nights. Previous studies have shown worse outcomes when there is longer than a 24 hour delay in reduction. This was a retrospective single center study looking at 175 cases of intussusception and evaluating the time between the radiology final read of intussusception and the timing of reduction and if enema based reduction was successful. In this group of patients, there was no statistically significant difference in reduction efficacy, requirement for surgical reduction or complication rate (bowel resection or perforation) in the patients studied which included delay intervals up to 8 hours. Successful first attempt reductions ranged from 72-81% in each study group (1hr, 1-3hr, 3-6hr and 6+ hr). The caveat to this study is that there were only 11 patients included in the 6-8 hour group. This study also did not take into account the timing from symptom onset to reduction time. Bottom line: More evidence is needed, but this small study provides evidence that up to 8 hours from radiology diagnosis of intussusception to the 1st reduction attempt was not less efficient compared to those with an attempt in under 1 hour.

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Laryngospasm is defined as the cessation of ventilation despite persistent respiratory effort related to glottic closure.  Complications include hypoxia, bradycardia, and cardiac arrest.  In OR cases, one recent study found the laryngospasm to occur in 0.45/1000 cases.  In these children undergoing general anesthesia, risk factors included current upper respiratory infection, active asthma, airway anomalies, airway procedures, age < 3 months and the use of an LMA.  
Studies of the rates of laryngospasm in pediatric sedation have shown varied incidence, with prevalence between 0.43/1000 to 2.1/1000.  A metaanalysis showed that laryngospasm was more common with a combination of propofol and ketamine.
This study looked at moderate sedation cases where laryngospasm was not relieved with chin repositioning or the use of an airway adjunct.  Over a 7 year study period, 276,832 sedations were examined with 913 patients experiencing laryngospasm (3.3/1000 cases).  About 5% of these patients required intubation.  There were 2 cases of cardiac arrest, one with an underlying cardiac condition and one with a URI who was undergoing an echo.  Both of these patients had multiple agents used for sedation.
The isolated use of IV ketamine had a laryngospasm rate of 1.4/1000 cases.  The highest prevalence occured with propofol + ketamine (6.6/1000), propofol + midazolam + opiate (6.1/1000) and propofol + dexmedetomidine (5.8/1000).
The risk of laryngospasm was associated with a higher ASA status, younger age, presence of a URI, airway procedures, and certain propofol combination regimens.
Bottom line: While the prevalence of laryngospasm remains low during pediatric sedation, risk factors should be taken into consideration and the risk/benefits should be discussed in detail with the families.  Always be prepared for an airway emergency during sedation.

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Category: Pediatrics

Title: Secondary Transmission of SARS-CoV2 with regards to Masking in Schools

Keywords: COVID, kids, masking, school (PubMed Search)

Posted: 8/19/2022 by Jenny Guyther, MD (Updated: 11/27/2022)
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This was a multistate, prospective, observational cohort of children and teachers attending in person schools in kindergarden through 12th grade where the school districs had the ability to perform contact tracing and determine primary vs secondary infections.  During the study period (6/21-12/21) 46 districts had universal masking policies and 6 districts had optional masking policies.  

Districts that optionally masked had 3.6x the rate of secondary transmission compared to universally masked school districts.  Optionally masked districts had 26.4 cases of secondary transmission per 100 community acquired cases compared to only 7.3 cases in universally masked districts.

Bottom line: Universial masking was associated with reduced secondary transmission of SARS-CoV2 compared with optional masking policies. 

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Category: Pediatrics

Title: The Pediatric Pause - Introducing a Trauma Informed Care Protocol

Keywords: trauma informed care, pediatric resuscitation (PubMed Search)

Posted: 7/15/2022 by Jenny Guyther, MD (Updated: 11/27/2022)
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Traumatic injuries are a leading cause of morbidity and mortality in pediatric patients.  Even in the setting of a full recovery, there can be negative psychological sequelae associated with the traumatic events.  The child's perceived risk of death and parental trauma related distress have both been associated with the development of post traumatic stress.
 
Previous studies have suggested the key components of trauma informed pediatric care include: minimizing potentially traumatic aspects of medical care and procedures, providing children and family with basic support and information, addressing child distress such as pain, fear, and loss,  promoting emotional support, screening children and families who might need support and providing anticipatory guidance about adaptive ways of coping.
 
The Pediatric PAUSE was introduced at a pediatric trauma center to help to reduce post traumatic stress.  
 
PAUSE stands for Pain/Privacy, Anxiety/IV access, Urinary Catheter/Rectal Exam/Genital Exam, Support for family or staff and Explain to patient/Engage the PICU team.  The article contains a table with a more detailed outline of the PAUSE.
 
This study evaluated the pediatric PAUSE to see if its implementation would interfere with the timeliness of the ACS/ATLS evaluation.  The PAUSE was inserted after the primary and ABCDE assessment (except in the unstable patient).  The use of this protocol did not prolong time between trauma bay arrival and critical imaging studies.

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Category: Pediatrics

Title: What is the ideal length of treatment for pediatric community acquired pneumonia?

Keywords: PNA, pediatrics, duration of treatment (PubMed Search)

Posted: 6/17/2022 by Jenny Guyther, MD (Updated: 11/27/2022)
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This was a randomized placebo controlled trial looking at 380 pediatric patients aged 6 months to 5 years who were diagnosed with nonsevere CAP and who showed early clinical improvement.  On day 6, one patient group was switched to a placebo while the other group continued with the antibiotics.
 
In this small study population, 5 days of a penicillin based antibiotic had a similar clinical response and antibiotic associated adverse effect profile compared to a 10 day course.  A 5 day course also reduced antibiotic exposure resistance compared to a 10 day course.  

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Category: Pediatrics

Title: Post fracture pain management in children.

Keywords: motrin, narcotics, oxycodone, fracture care (PubMed Search)

Posted: 5/20/2022 by Jenny Guyther, MD (Updated: 11/27/2022)
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This was a prospective study done in a pediatric emergency department where 329 children ages 4-16 years with isolated fractures were included.  After casting, children were prescribed either ibuprofen or oxycodone.  Pain score and activity level were followed by phone for 6 weeks.  The reduction in pain was comparable for motrin and oxycodone.  However, the children who received motrin experienced less side effects and quicker return to baseline activities compared to oxycodone.
Bottom line: Ibuprofen is a safe and effective option for fracture related pain and has fewer adverse effects compared to oxycodone.

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In 2013, the Pediatric Emergency Care Applied Research Network developed a prediction rule to identify patients who were at low risk of requiring acute intervention after blunt abdominal trauma.  Interventions included laparotomy, embolization, blood transfusion or IV fluids for more than 2 nights with pancreatic or bowel injuries.
If ALL of the following are true, the patient is considered very low risk (0.1%) of needing an acute abdominal intervention:  
- No evidence of abdominal wall trauma or seat belt sign
- GCS 14 or 15
- No abdominal tenderness
- No thoracic wall trauma
- No abdominal pain
- No decreased breath sounds
- No vomiting
 
This prediction rule was externally validated in 2018 showing a sensitivity of 99%.  This rule should be used to decrease the rate of CT scans of the abdomen following blunt trauma.

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In emergency departments in the US, the diagnosis of pneumonia is often made on chest xray.  In the outpatient setting, national guidelines focus on the clinical diagnosis of pneumonia and recommend against radiographs.  This study aimed to develop and validate a clinical tool that could be used to determine the risk of radiographic pneumonia.
The criteria in the Pneumonia Risk Score (PRS) evaluate for the presence of fever, rales, and wheeze and take into account age and triage oxygen saturation.  When developing this protocol, the investigators compared the patients who had pneumonia on chest xray with both clinical judgment and the PRS.  The PRS outperformed clinical judgment in predicting which patients would have pneumonia on chest xray.
Children who have a score of 2 or less were unlikely to have pneumonia on chest xray and would qualify for observation without an xray or empiric antibiotics use.  Children who had a score of 5 or greater were likely to have radiographic pneumonia and could be empirically treated with antibiotics. If the PRS score was 6, the specificity was 99.9%
This link https://links.lww.com/INF/E552. takes you to the excel spreadsheet where you can enter the patients clinical data and gives you a present probability of radiographic pneumonia.  (In case the link does not work, it is also found in the supplemental digital content.)
Bottom line: PRS outperforms clinical judgment when determining if pneumonia will be present on the pediatric chest xray.

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This study looked at just over 10,000 children using the National Trauma Data Bank between 2011 and 2012. Patients were divided into two age groups: 0 to 14 years and 15 to 18 years. Primary outcomes were emergency department and inpatient mortality depending on whether they were taken to a pediatric versus adult trauma center. Secondary outcomes included hospital length of stay, complication rate, ICU length of stay and ventilator days.

Children in the 0-14 year age group had lower ED and inpatient mortality when treated at pediatric trauma centers. This age group was also more likely to be discharged home and have fewer ICU and ventilator days when treated at the pediatric trauma centers.

There was no difference in ED mortality or inpatient mortality in the 15 to18 year-old age group to pediatric and adult trauma centers. There were no differences in complication rates in any age group between pediatric and adult trauma centers. 
 
Bottom line: Children aged 0-14 should ideally be evaluated primarily at pediatric trauma centers.

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Category: Pediatrics

Title: Risk factors for severe COVID in children

Keywords: pediatrics, COVID, vaccination, hospitalization (PubMed Search)

Posted: 1/21/2022 by Jenny Guyther, MD
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This recently published study was conducted from May 2020 to May 2021 and included 3106 hospitalized pediatric patients with COVID 19 over 14 states.  2293 children were admitted due to their COVID symptoms.  30% of these patients had severe COVID (ICU admission, mechanical ventilation or death) and 0.5% died.
32.5% of admitted patients were younger than 2 years.  More than half of the patients had at least one medical condition.  The most common underlying conditions were obesity, chronic lung disease, neurologic disorders, cardiovascular disease and blood disorders.
Although this data was collected prior to the US presence of both the delta and omnicron variants and public availability of vaccination in 5-11 year olds, this study has identified children at potentially higher risk of severe COVID who may benefit from prevention efforts that include vaccination. 

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Category: Pediatrics

Title: The dangers of monkey bars

Keywords: orthopedics, upper extremity fractures, playgrounds (PubMed Search)

Posted: 11/19/2021 by Jenny Guyther, MD
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While playgrounds can be enjoyable for children, they are a land mine for possible injuries.  In a study looking at playground safety in Australia, monkey bars were the leading cause of upper extremity fractures.  The fractures caused by monkey bars were also more likely to require reduction or operative fixation.  The risk of fracture significantly increases after a fall above 1.5 meters.  Children ages 5-9 years were the most susceptible to playground falls.
Why does this matter?  Playgrounds have made modifications to prevent other types of injury (such as the modification of the playground surface to prevent head injuries).  Reduction in the height of monkey bars, may reduce or limit the severity of these upper extremity fractures.  

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This was a retrospective, noninferiority analysis looking at patients 14 years old and younger treated for nontraumatic seizures by EMS with a midazolam dose of 0.1 mg/kg (regardless of route).  There were just over 2000 patients with a median age of 6 years included in the study.  Midazolam redosing occurred in 25% of patients who received intranasal midazolam versus only 14% who received midazolam via intramuscular, intravenous, or intraosseous routes.
Bottom line: In the prehospital setting, intranasal midazolam at a dose of 0.1 mg/kg was associated with an increased need to redose compared to other routes.  This dose may be subtherapeutic for intranasal administration.

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Category: Pediatrics

Title: Amusement park safety

Keywords: roller coasters, summer, death (PubMed Search)

Posted: 9/17/2021 by Jenny Guyther, MD
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Over a one year study period, 182 accident events at amusement parks were reported in the news from 38 countries.  51 events involved a fatality. Mechanical rides and roller coasters were involved in 87 events. 
The risk of injury associated with spending a day at an amusement park is very low, but not non-existent.
The high g forces of certain thrill rides (ie roller coasters) can predispose to injury in some children and adolescents with preexisting medical conditions.
Among the conditions that are considered contraindications to exposure to high g force or other thrill rides are Marfan syndrome, Down syndrome, hypermobility-related disorders, coagulation disorders, and many cardiac disorders, particularly ones with rhythm abnormalities.

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Category: Pediatrics

Title: Pediatric heat related car deaths

Keywords: hyperthermia, pediatrics, car (PubMed Search)

Posted: 8/20/2021 by Jenny Guyther, MD (Updated: 11/27/2022)
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- A higher metabolic rate, reduced capacity for sweating, greater thermolability, and a larger body surface-to-volume ratio make infants and young children more susceptible to hyperthermia.

- Temperatures can rise rapidly within enclosed vehicles, reaching maximum temperatures within 5 minutes. In an open area with an ambient temp of 98 F (36.8 C), interior temperatures reach 124-152 F (51 to 67 C) within 15 minutes of closing the car doors.

- Texas leads the country in the numbers of pediatric heatstroke fatalities due to unattended children left in cars, followed by Florida and California.

- Most heatstroke victims (78.2%) were unknowingly left in vehicles by their caregivers.

- Most organizations interested in child safety issues recommend placing a phone, briefcase, or handbag in the back seat when traveling with a child as one way to prevent heatstroke fatalities.

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Category: Pediatrics

Title: Does atropine prevent bradycardia during rapid sequence intubation in pediatric patients?

Keywords: Bradycardia, intubation, RSI, atropine (PubMed Search)

Posted: 7/16/2021 by Jenny Guyther, MD (Updated: 11/27/2022)
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Atropine has historically been used in the pediatric population as a premedication for rapid sequence intubation (RSI) in order to prevent bradycardia.   Recent research indicates that bradycardia that occurs during intubation may be driven by hypoxia as opposed to a vagal response. In 2002, the American Heart Association guidelines recommended pretreatment with atropine for all children younger than 1 year, children receiving succinylcholine, adolescents receiving a second dose of succinylcholine and anyone with bradycardia at the time of induction. The 2015 AHA Pediatric Advanced Life Support guidelines revised the statement on atropine to say that "it may be reasonable for practitioners to use atropine as a premedication in specific emergency intubations when there is higher risk of bradycardia." 
This study retrospectively looked at 62 patients who underwent rapid sequence intubation.  3 patients experienced a bradycardic event during intubation, 1 of which received atropine.  15 patients received atropine for pretreatment. The incidence of bradycardia was similar between those received atropine and those who did not.
Bottom line: Although atropine is generally considered safe, larger studies are needed to determine if there are any specific indications for atropine as a premedication in RSI or if atropine is needed at all for the prevention of bradycardia.

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Category: Pediatrics

Title: Treatment of fingernail avulsion injuries

Keywords: finger injuries, nail bed (PubMed Search)

Posted: 6/18/2021 by Jenny Guyther, MD (Updated: 11/27/2022)
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Traditional management (referred to as "operative management") of a nail avulsion is to replace the nail in the epicanthal fold and suture this in place.  A study was done to see if wound cleaning and placement of a non-adhesive dressing was non inferior to this traditional management.  The primary outcome was the appearance of the new nail at 6 months as determined by 2 separate physicians using a Nail Appearance Score (NAS) and who were blinded to the treatment groups.  The secondary outcomes were patient and parental satisfaction and infection rate.  There were no statistically significant differences in the NAS or patient and parental satisfaction scores between the 2 groups.
Parents were informed of both options and allowed to choose between the treatments.  Patients between 1-16 years with proximal or complete nail bed avulsion injuries were included.
Conclusions: In this small study, non-operative management for fingernail avulsions was not inferior to operative management.

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Category: Pediatrics

Title: Sodium bicarbonate in pediatric cardiac arrests

Keywords: pediatric, cardiac arrest, metabolic acidosis, sodium bicarbonate (PubMed Search)

Posted: 5/21/2021 by Jenny Guyther, MD (Updated: 11/27/2022)
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During cardiac arrest, metabolic acidosis develops because of hypoxia-induced anaerobic metabolism and decreased acid excretion caused by inadequate renal perfusion.  Sodium bicarbonate (SB) administration was considered as a buffer therapy to correct metabolic acidosis.  However,  SB has several side effects such as hypernatremia, metabolic alkalosis, hypocalcemia, hypercapnia, impairment of tissue oxygenation, intracellular acidosis, hyperosmolarity, and increased lactate production.  The 2010 Pediatric Advanced Life Support (PALS) guideline stated that routine administration of SB was not recommended for cardiac arrest except in special resuscitation situations, such as hyperkalemia or certain toxidromes.  An evidence update was conducted in the 2020 Pediatric Life Support (PLS) guideline and the recommendations of 2010 remain valid.  This article was a systematic review and meta-analysis of observational studies of pediatric in hospital cardiac arrests.  The primary outcome was the rate of survival to hospital discharge after in hospital cardiac arrests. The secondary outcomes were the 24-hour survival rate and neurological outcomes.   

 
Bottom line: The result of this study supports current PLS guidelines that “routine administration of SB  is not recommended in pediatric cardiac arrest in the absence of hyperkalemia or sodium channel blocker (eg. tricyclic antidepressant) toxicity”.

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Category: Pediatrics

Title: Pediatric stroke

Keywords: stroke, altered mental status, TPA (PubMed Search)

Posted: 4/16/2021 by Jenny Guyther, MD (Updated: 11/27/2022)
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Stroke diagnosis is often delayed in pediatric patients due to delay in seeking care, misdiagnosis and lack of stroke being included in the initial differential diagnosis. 
Perinatal strokes (occurring between 20 weeks gestation and 28 days of life) are more common than strokes in ages 29 days to 18 years.  The incidence of perinatal stroke is 37/100,000 births and 2.3/100,000 children after 29 days.  Infants age 29 days to < 1 year had the highest rate of stroke outside of perinatal strokes, followed by 15-19 year olds.
The most common risk factors for pediatric strokes include: arteriopathies (such as arterial dissection, moyamoya and vasculitis), cardiac disorders (single ventricle physiology have the highest risk) and infections.  Sickle cell disease and cerebral venous thrombosis are other risk factors for acute ischemic stroke.
Children younger than 6 years were more likely to present with altered mental status or seizures.  Other presentations included facial weakness, speech disturbances, hemiparesis, headache, nausea and vomiting.
There is a pediatric NIH stroke scale that can be used in children at least 2 years old that accounts for developmental differences.
Differential Diagnosis includes (most to least common): migraines, seizures, Bell's palsy, conversion disorder and syncope. Once study found that up to 63% of patients that were suspected of having a stroke, but did not, had another significant disease process that required further evaluation. These other processes included vascular anomalies, seizures, inflammatory disease, metabolic anomalies and drug ingestions.
MRI brain and MRA of the head and neck are gold standard for diagnosis.  If this is not obtainable or would be delayed, then head CT followed by CTA of the head and neck should be obtained.
The treatment of acute ischemic stroke is still not fully researched and much is adopted from adult protocols.   TPA and endovascular thrombectomy are not well established.  There has been a small study of patients treated with TPA, but a subsequent NIH funded trial could not recruit enough patients.  Adult dosing guidelines for TPA have been adopted if TPA is going to be used and should be given within 4.5 hours of symptom onset.  Endovascular therapy should be considered only in patients with persistent, disabling neurological defects and a confirmed large vessel occlusion.  Patient selection is limited by the side of the catheter used.  Patients with confirmed ischemic stroke who do not receive TPA or endovascular therapy should receive antiplatelet therapy.
Cerebral venous thrombosis is treated with anticoagulation.  Hemorrhagic strokes in children are treated similar to adults.
Exchange transfusion is the mainstay of treatment for sickle cell patients with a goal to decrease HbS to < 30%.

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Category: Pediatrics

Title: When should troponin be ordered in a pediatric patient?

Keywords: Chest pain, ischemia, pediatrics, myocarditis (PubMed Search)

Posted: 3/19/2021 by Jenny Guyther, MD (Updated: 11/27/2022)
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Even though acute myocardial ischemia (AMI) does not present as commonly in the pediatric patient as in the adult and the literature is limited, it is reasonable to obtain a troponin when acute cardiac ischemia is suspected based on the history and physical exam. 

Recreational drugs including cocaine, amphetamine, cannabis, Spice, and K2 (cannabis derivatives) have been shown to result in myocardial injury including AMI. Coronary vasospasm secondary to drug use is well documented in the pediatric population. While cocaine use is a known risk factor for coronary vasospasm, the same condition has been reported in pediatric patients after marijuana use.

In a study of pediatric patients with blunt chest trauma, 3 of 4 patients with electrocardiographic or echocardiographic evidence of cardiac injury had elevations in troponin I above 2.0 ng/mL. Cardiac troponins are an accurate tool for screening for cardiac contusion after blunt chest trauma in pediatric patients even with limited data.

Cardiac troponins are also useful in the evaluation for myocarditis. In one study, myocarditis was the most common diagnosis (27%) in pediatric ED patients presenting with chest pain and an increased troponin. Eisenberg et al showed a 100% sensitivity and an 85% specificity for myocarditis using a troponin of 0.01 ng/mL or greater as a cut off.  A normal troponin using this cutoff can be used to exclude myocarditis. Abnormal troponin in the first 72 hours of hospitalization in pediatric patients with viral myocarditis is associated with subsequent need for extracorporeal membrane oxygenation and IVIg.

Bottom line: Troponin can be used in pediatric patients with clinical concern for cardiac ischemia, cardiac contusion and myocarditis

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