Keywords: trauma informed care, pediatric resuscitation (PubMed Search)
Beaulieu-Jones BR, Bingham S, Rhynhart KK, Croitoru DP, Singleton MN, Rutman MS, Baertschiger RM. Incorporating a Trauma-Informed Care Protocol Into Pediatric Trauma Evaluation: The Pediatric PAUSE Does Not Delay Imaging or Disposition. Pediatr Emerg Care. 2022 Jan 1;38(1):e52-e58. doi: 10.1097/PEC.0000000000002278. PMID: 33181796.
Keywords: PNA, pediatrics, duration of treatment (PubMed Search)
Williams DJ, Creech CB, Walter EB, Martin JM, Gerber JS, Newland JG, Howard L, Hofto ME, Staat MA, Oler RE, Tuyishimire B, Conrad TM, Lee MS, Ghazaryan V, Pettigrew MM, Fowler VG Jr, Chambers HF, Zaoutis TE, Evans S, Huskins WC; The DMID 14-0079 Study Team. Short- vs Standard-Course Outpatient Antibiotic Therapy for Community-Acquired Pneumonia in Children: The SCOUT-CAP Randomized Clinical Trial. JAMA Pediatr. 2022 Mar 1;176(3):253-261. doi: 10.1001/jamapediatrics.2021.
Keywords: motrin, narcotics, oxycodone, fracture care (PubMed Search)
Ali et al. An observational cohort study comparing ibuprofen and oxycodone in children with fractures. PLos ONE 16(9): e0257021.
Keywords: abdominal trauma, MVC, CT scans, radiation (PubMed Search)
Fornari M and Lawson S. Pediatric Blunt Abdominal Trauma and Point of Care Ultrasound. Pediatric Emergency Care 2021. 37 (12): 624-629.
Keywords: peds, chest xray, pneumonia. (PubMed Search)
Lipsett, Susan C. MD*,†,‡; Hirsch, Alexander W. MD*,†; Monuteaux, Michael C. ScD*,†; Bachur, Richard G. MD*,†,‡; Neuman, Mark I. MD, MPH*,†,‡ Development of the Novel Pneumonia Risk Score to Predict Radiographic Pneumonia in Children, The Pediatric Infectious Disease Journal: January 2022 - Volume 41 - Issue 1 - p 24-30.
Keywords: pediatric trauma, complications (PubMed Search)
Khalil M, Alawwa G, Pinto F, O'Neill PA. Pediatric Mortality at Pediatric versus Adult Trauma Centers. J Emerg Trauma Shock. 2021 Jul-Sep;14(3):128-135. doi: 10.4103/JETS.JETS_11_20. Epub 2021 Sep 30. PMID: 34759630; PMCID: PMC8527062.
Keywords: pediatrics, COVID, vaccination, hospitalization (PubMed Search)
Woodruff RC, Campbell AP, Taylor CA, et al. Risk Factors for Severe COVID-19 in Children. Pediatrics. 2022;149(1):e2021053418.
Keywords: orthopedics, upper extremity fractures, playgrounds (PubMed Search)
Curnow H and Millar R. Too far to fall: Exploring the relationship between playground equipment and paediatric upper limb fractures. Journal of Pediatrics and Child Health. 2021.
Keywords: seizure, status epilepticus, midazolam (PubMed Search)
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.
Keywords: roller coasters, summer, death (PubMed Search)
Keywords: hyperthermia, pediatrics, car (PubMed Search)
Keywords: Bradycardia, intubation, RSI, atropine (PubMed Search)
Kovacich et al. Incidence of bradycardia and the use of atropine in pediatric rapid sequence intubation in the emergency department. Pediatric emergency care. Published online 2021.
Keywords: finger injuries, nail bed (PubMed Search)
Petruzella F, Easter JS. Pediatric emergency medicine literature 2020. The American Journal of Emergency Medicine. 2021;43:123-133
Keywords: pediatric, cardiac arrest, metabolic acidosis, sodium bicarbonate (PubMed Search)
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.
Chih-Yao Chang, Po-Han Wu, Cheng-Ting Hsiao, Chia-Peng Chang, Yi-Chuan Chen, Kai-Hsiang Wu. Sodium bicarbonate administration during in-hospital pediatric cardiac arrest: a systematic review and meta-analysis. Resuscitation. 2021. Available on line March 1. In Press.
Keywords: stroke, altered mental status, TPA (PubMed Search)
Baldovsky MD, Okada PJ. Pediatric stroke in the emergency department. J Am Coll Emerg Physicians Open. 2020 Oct 6;1(6):1578-1586. doi: 10.1002/emp2.12275. PMID: 33392566; PMCID: PMC7771757.
Keywords: Chest pain, ischemia, pediatrics, myocarditis (PubMed Search)
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
Brown JL, Hirsh DA, Mahle WT. Use of troponin as a screen for chest pain in the pediatric emergency department. Pediatr Cardiol. 2012;33(2):337-342. doi:10.1007/s00246-011-0149-8
Drossner DM, Hirsh DA, Sturm JJ, et al. Cardiac disease in pediatric patients presenting to a pediatric ED with chest pain. Am J Emerg Med. 2011;29(6):632-638. doi:10.1016/j.ajem.2010.01.011
Thankavel PP, Mir A, Ramaciotti C. Elevated troponin levels in previously healthy children: value of diagnostic modalities and the importance of a drug screen. Cardiol Young. 2014;24(2):283-289. doi:10.1017/S1047951113000231
Yolda? T, Örün UA. What is the Significance of Elevated Troponin I in Children and Adolescents? A Diagnostic Approach. Pediatr Cardiol. 2019;40(8):1638-1644. doi:10.1007/s00246-019-02198-w
Adams JE, Dávila-Román VG, Bessey PQ, Blake DP, Ladenson JH, Jaffe AS. Improved detection of cardiac contusion with cardiac troponin I. Am Heart J. 1996;131(2):308-312. doi:10.1016/s0002-8703(96)
Hirsch R, Landt Y, Porter S, et al. Cardiac troponin I in pediatrics: normal values and potential use in the assessment of cardiac injury. J Pediatr. 1997;130(6):872-877. doi:10.1016/s0022-3476(97)
Eisenberg MA, Green-Hopkins I, Alexander ME, Chiang VW. Cardiac troponin T as a screening test for myocarditis in children. Pediatr Emerg Care. 2012;28(11):1173-1178. doi:10.1097/PEC.
Keywords: Congestive heart failure, trouble breathing, basic natriuretic peptide (PubMed Search)
In children with known congenital heart disease, BNP measurements are higher in those patients with heart failure compared to those without heart failure.
The utility of BNP in differentiating a cardiac from pulmonary pathology in patients with respiratory distress has been studied in pediatrics. In one study involving 49 infants with respiratory distress, the patients with a final diagnosis of heart failure had a higher mean BNP concentration than those patients with other causes. Also, there is a suggestion that the relative change in NT proBNP levels may be useful in patients with underlying pulmonary hypertension. However, currently there is not enough literature to support the routine use of BNP or NT proBNP in acute management.
Bottom line: BNP can be useful in your patient with congenital heart disease who is decompensating and may be used in a patient where there is difficulty in differentiating a primary respiratory from cardiac etiology.
Davis GK, Bamforth F, Sarpal A, et al. B-type natriuretic peptide in pediatrics. Clin Biochem. 2006 Jun;39(6):600-5.
Nir A, Lindinger A, Rauh M, et al. NT-pro-B-type natriuretic peptide in infants and children: reference values based on combined data from four studies. Pediatr Cardiol. 2009 Jan;30(1):3-8.
Ten Kate CA, Tibboel D, Kraemer US. B-type natriuretic peptide as a parameter for pulmonary hypertension in children. A systematic review. Eur J Pediatr. 2015 Oct;174(10):1267-75.
Keywords: Infection, sepsis, lactic acid (PubMed Search)
Despite a lack of formal guidelines and evidence, lactate measurement has become a component of many pediatric emergency sepsis quality programs, with one survey showing that up to 68% of responding pediatric emergency medicine providers routinely measured it.
The Surviving Sepsis Campaign, last updated in February 2020, could not make a recommendation on the use of lactate in pediatric patients with suspected shock. The authors did state that lactate levels are often measured during the evaluation of septic shock if the lab can be obtained rapidly. However, lactate levels alone would not be an appropriate screening test.
Weiss SL, Peters MJ, Alhazzani W, et al. Surviving sepsis campaign international guidelines for the management of septic shock and sepsis-associated organ dysfunction in children. Intensive Care Med. 2020;46(Suppl 1):10-67.
Scott HF, Brou L, Deakyne SJet al. Association between early lactate levels and 30-day mortality in clinically suspected sepsis in children. JAMA Pediatr. 2017 Mar 1;171(3):249-255.
Keywords: Procalcitonin, febrile infants, sepsis (PubMed Search)
Young infants (0-90 days) have immature immune systems and are at higher risk for serious bacterial infections, particularly urinary tract infections, bacterial meningitis, and bacteremia. Infants less than 90 days old have an incidence of bacterial infections between 8 to 12.5%, while infants less than or equal to 28 days old have almost a 20% incidence.
Risk-stratification of this group has been a huge focus of research over the past couple of decades to help identify which patients require a full sepsis work-up, particularly in well-appearing infants if a source of fever is identified early. Recent studies have explored the utility of biomarkers in risk stratification in this population. A better ability to discriminate would hopefully decrease unnecessary lumbar punctures, antibiotic use, and hospital admission. Multiple studies have shown procalcitonin is able to outperform CRP for prediction of serious bacterial infections. Kuppermann et al developed a tool to identify low risk febrile infants < 60 days using procalcitonin and ANC. Their prediction rule gave a 97.7% sensitivity, 60% specificity, and 99.6% NPV for serious bacterial infection. There have been several other studies that have looked harder to detect infections such as osteomyelitis or septic arthritis across all pediatric patients and the data has not been as promising.
Bottom line: Procalcitonin shows promise as part of a risk stratification tool in infants younger than 60 days. Other studies have failed to show its relevance as a screening tool for osteomyelitis, septic arthritis, renal abscess or community acquired pneumonia.
Huppler AR, Eickhoff JC, Wald ER. Performance of low-risk criteria in the evaluation of young infants with fever: review of the literature. Pediatrics. 2010;125(2):228-233. doi:10.1542/peds.2009-1070
Schwartz S, Raveh D, Toker O, Segal G, Godovitch N, Schlesinger Y. A week-by-week analysis of the low-risk criteria for serious bacterial infection in febrile neonates. Archives of Disease in Childhood. 2009;94(4):287-292. doi:10.1136/adc.2008.138768
Woll C, Neuman MI, Aronson PL. Management of the Febrile Young Infant: Update for the 21st Century. Pediatr Emerg Care. 2017;33(11):748-753. doi:10.1097/PEC.
Kuppermann N, Dayan PS, Levine DA, et al. A Clinical Prediction Rule to Identify Febrile Infants 60 Days and Younger at Low Risk for Serious Bacterial Infections. JAMA Pediatr. 2019;173(4):342-351. doi:10.1001/jamapediatrics.
Keywords: vaginitis, vaginal discharge (PubMed Search)
To determine if the child is prepubescent, look for the lack of pubic hair, clitoral size, configuration of the hymen, breast development, and axillary hair growth. A Tanner stage of 1 would be consistent with prepuberty.
The proper positioning for the physical exam will allow the child to be comfortable and the examiner to obtain an adequate view including up to one-third of the vagina.
If the child is small enough, they can lay in the parent’s lap. For a larger child, you can have the parent sit in the bed with the patient or stand near the child’s head. Engage child life if available.
The frog leg position with gentle downward and outward traction of the labia at the 5- and 7-o’clock positions provides the optimal view.
The knee to chest position is helpful when further evaluation is needed.
A rectovaginal exam is useful for evaluation of masses or foreign body only and is not routinely needed. Place the examiner’s little finger in the rectum and the other hand on the abdomen and palpate.
The use of a vaginal speculum is rarely needed in prepubertal children; if it is needed, perform the exam under anesthesia.
McCaskill A, Inabinet CF, Tomlin K, Burgis J. Prepubertal Genital Bleeding: Examination and Differential Diagnosis in Pediatric Female Patients. J Emerg Med. 2018 Oct;55(4):e97-e100. doi: 10.1016/j.jemermed.2018.07.
Loveless M, Myint O. Vulvovaginitis- presentation of more common problems in pediatric and adolescent gynecology. Best Pract Res Clin Obstet Gynaecol. 2018 Apr;48:14-27. doi: 10.1016/j.bpobgyn.2017.08.014. Epub 2017 Sep 5. PMID: 28927766.
Manning S. Genital Complaints at the Extremes of Age. Emerg Med Clin North Am. 2019 May;37(2):193-205. doi: 10.1016/j.emc.2019.01.003. PMID: 30940366.