UMEM Educational Pearls - By Jenny Guyther

Category: Pediatrics

Title: Labial adhesions

Keywords: GU anomaly, prepubescent (PubMed Search)

Posted: 10/16/2020 by Jenny Guyther, MD
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A labial adhesion is defined as a thin avascular clear plane, a raphe, between the labia minora. These adhesions which can be caused by minor trauma or infection in the absence of estrogen  can cause varying degrees of obstruction.  

The prevalence is between 0.6% and 5% of females and occurs between 3 months and 3 years of age with a peak between 13 and 23 months.  At least 50% are asymptomatic and found incidentally.  Patient may also have a UTI (20%), postvoid dripping (13%), urinary frequency (7%), or vaginitis (9%).  First-line treatment: estradiol cream 0.01% 1-2x/day for 2-6 weeks. Gentle traction during application of the cream increases the success of separation.  The success rate is between 50% and 89%.  Apply an emollient to reduce recurrence rate.  If there are severe symptoms or medical therapy fails, surgical separation is recommended.

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Category: Pediatrics

Title: Prepubertal Urethral Prolapse

Keywords: prepubertal vaginal bleeding, mass (PubMed Search)

Posted: 9/18/2020 by Jenny Guyther, MD (Updated: 8/17/2022)
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- Urethral prolapse will appear as a protrusion of the distal urethra through the urinary meatus causing a “doughnut” sign.

- Risk factors include trauma, UTI, anatomical differences, and increased intraabdoiminal pressure from cough or constipation.  There is a higher incidence in people of African descent.

- The chief complaint may include urethral mass and vaginal bleeding.

- There is a bimodal age distribution (prepuberty and postmetapause) due to a relative estrogen deficiency.

-Treatment is with estrogen cream and sitz baths for 4- 6 weeks.

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Category: Pediatrics

Title: Imperforate hymen

Keywords: Female GU, abdominal pain, missed period (PubMed Search)

Posted: 8/21/2020 by Jenny Guyther, MD
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Definition: Congenital anomaly where the hymen is completely obstructing the vaginal opening

Demographic: Incidence 0.05-0.1% of females

History:  Most are asymptomatic and diagnosed on physical exam or incidentally when there is lack of menarche. Symptoms in adolescents can include: Abdominal pain (50%), urinary retention (20%), abnormal menstruation (14%), dysuria (10%), frequency, renal failure, UTI and back pain.

Physical exam: bulging, blueish hymenal membrane

Complications: Late detection can lead to infections, fertility problems, endometriosis, hydronephrosis, and rarely renal failure

ED treatment: If abdominal pain is significant or there is urinary obstruction, a urinary foley can be placed.  GYN should be consulted.

Definitive treatment: Hymenectomy, hymenotomy, carbon dioxide laser treatments or foley insertion through the hymen (done by a specialist).

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Category: Pediatrics

Title: Risk factors for pediatric cervical spine injuries

Keywords: MVC, neck injury, neurological injury (PubMed Search)

Posted: 7/24/2020 by Jenny Guyther, MD (Updated: 8/17/2022)
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There is no well validated clinical decision rule similar to NEXUS or the Canadian Cervical Spine rule in children for clearing the cervical spine.  Clinical clearance versus imaging first is a complicated decision.  Certain risk factors may predispose children to injury and should be taken into account when deciding about clinical clearance versus imaging (XR).

High Risk Criteria for Cervical Spine Injury in Pediatrics

Mechanism

 

High risk MVC

              Intrusion > 12 inches at the occupant site

              Intrusion > 18 inches at any site

              Partial or complete ejection

              Death in the same passenger compartment

              Vehicle telemetry consistent with high speed

Fall > 10 feet

Nonaccidental trauma

Diving injury

History

 

Down’s Syndrome

22.q11.2 deletion

Klippel-Fiel syndrome

Physical Exam

 

Altered mental status

Intoxication

Hypotension

Focal neurological exam

Neck pain

Torticollis

             

 

 

 

 

 

 

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Category: Pediatrics

Title: Failure to thrive in children in the ED

Keywords: weight loss, not eating, small, FTT (PubMed Search)

Posted: 6/19/2020 by Jenny Guyther, MD
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Children will often present to the ED with concern for poor feeding or weight loss.  Be concerned about failure to thrive when: 2 or more growth percentile lines are crossed or weight or length is less than the 5th percentile for the patients chronological age.
Make sure to ask about feeding technique, type of formula, frequency of feeds and problems with feeding.
Keep a broad differential in the ED in children with weight concerns including non accidental trauma, congenital heart disease, genetic abnormalities, hyperthyroidism, and gastrointestinal abnormalities.  GI problems include cow's milk protein intolerance, celiac disease, pyloric stenosis and reflux.

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Category: Pediatrics

Title: When does a car seat need to be replaced?

Keywords: seat belt, car seats (PubMed Search)

Posted: 5/15/2020 by Jenny Guyther, MD (Updated: 8/17/2022)
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NHTSA recommends that car seats be replaced following a moderate or severe crash. Car seats do not automatically need to be replaced following a minor crash.

A minor crash is one in which ALL of the following apply:

-The vehicle was able to be driven away from the crash site.
-The vehicle door nearest the car seat was not damaged.
-None of the passengers in the vehicle sustained any injuries in the crash.
-If the vehicle has air bags, the air bags did not deploy during the crash
-There is no visible damage to the car seat.

NEVER use a car seat that has been involved in a moderate to severe crash. Always follow manufacturer's instructions.

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Category: Pediatrics

Title: Teen Driving Education in the Pediatric Emergency Department

Keywords: MVC, anticipatory guidance, seatbelts. (PubMed Search)

Posted: 4/17/2020 by Jenny Guyther, MD (Updated: 8/17/2022)
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The leading cause of death in the US for those aged 16 to 24 years is motor vehicle collisions (MVCs).  Teen drivers are more likely than any other age group to be involved in an MVC that result in injury or fatality.  Texting while driving, nighttime driving, inexperienced driving, and driving under the influence of alcohol or drugs may play a role in these collisions.

Can anticipatory guidance related to safe driving be done in the ED?  YES!

This study implemented a toolkit that contained a copy of the driving law, a sample parent-teen driving contract and statistics on teen driving injuries. Post toolkit questionnaires showed that both teens and their guardians learned new information.

Bottom line: Engage in anticipatory guidance in the ED with teens and their parents about seatbelt use, the dangers of driving under the influence and local driving laws.

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Category: Pediatrics

Title: SARS-CoV-2 Infection in Children

Keywords: pandemic, coronavirus, pediatric (PubMed Search)

Posted: 3/20/2020 by Jenny Guyther, MD (Updated: 8/17/2022)
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New information is coming out each day.  Below is just a sample of some of the recent data in children.
 
SARS-CoV2 Infection in Children - Lu et al
- 1391 Children in China were tested between 1/28-2/26/20. 171 were positive. 
- Fever was present in 41.5 % of infected children at some time during their illness course
- 3 patients required ICU care
- 27 patients did not have any symptoms or pneumonia on chest xray
 
Infant COVID Study - Wei et al
-2 month retrospective review
-9 infants under 1 year tested positive for COVID during this time period
-3/9 asymptomatic, 4/9 fever only, 2/9 mild URI symptoms
 
Children COVID Study - Xai et al
-2 week retrospective review
-20 children, all inpatients 
-12/20 fever (60%), 13/20 cough (65%)
-Coinfection pathogens: influenza A, B, mycoplasma, CMV, RSV 
 
Bottom line: Children appear to be less severely affected than adults and with a different symptom pattern.  Coinfection with other respiratory viral pathogens can occur.

 

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Category: Pediatrics

Title: Epinephrine administration in pediatric prehospital cardiac arrest

Keywords: cardiac arrest, prehospital, epinephrine (PubMed Search)

Posted: 2/21/2020 by Jenny Guyther, MD (Updated: 8/17/2022)
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This was a population based observational study in Japan that enrolled pediatric patients age 8-17 years with out-of-hospital cardiac arrests (OHCA).  The primary end point was 1 month survival and secondary end points were favorable 1 month neurological outcomes and pre-hospital return of spontaneous circulation (ROSC).  In Japan, prehospital administration of epinephrine is allowed in children 8 years and older with appropriate training.
3961 pediatric OHCA were eligible (306 received epinephrine and 3655 patients did not).
There were no differences between the epinephrine and no epinephrine groups in regards to 1 month survival or favorable neurological outcome.  The epinephrine group had a slightly higher likelihood of achieving pre-hospital ROSC.

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Category: Pediatrics

Title: Post tonsillectomy complications

Keywords: ENT, post tonsillectomy bleeding, T and A (PubMed Search)

Posted: 1/17/2020 by Jenny Guyther, MD (Updated: 8/17/2022)
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Tonsillectomy and adenoidectomy (T&A) is the second most common ambulatory surgery performed in the US.  Children younger than 3 years, children with craniofacial disorders or sleep apnea are typically admitted overnight as studies have shown an increase rate of airway or respiratory complications in this population.

The most common late complications include bleeding and dehydration.  Other complications include nausea, respiratory issues and pain.

Post-operatively, the overall 30-day emergency department return rate is up to 13.3%.  Children ages 2 and younger were more likely to present to the ED.  There is significantly higher risk of dehydration for children under 4 years.  Children over the age of 6 had significantly higher bleeding risk and need for reoperation for hemorrhage control.

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Category: Pediatrics

Title: Urinary retention in children

Keywords: Urinary retention, formulas (PubMed Search)

Posted: 12/20/2019 by Jenny Guyther, MD (Updated: 8/17/2022)
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Urinary retention in pediatrics is defined as the inability to void for more than 12 hours in the presence of a palpable bladder or a urine volume greater than expected for age.

Maximum urine volume calculation for age:  (age in years + 2) x 30ml.

Causes of urinary retention include mechanical obstruction, infection, fecal impaction, neurological disorders, gynecological disorders and behavioral problems.

The distribution is bimodal occurring between 3 and 5 years and 10 to 13 years.

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Category: Pediatrics

Title: At what age should I test for strep throat in children?

Keywords: Sore throat, strep throat (PubMed Search)

Posted: 11/15/2019 by Jenny Guyther, MD (Updated: 8/17/2022)
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Streptococcal pharyngitis is common in the pediatric population however in children younger than 3 years, group A streptococcus (GAS) is a rare cause of sore throat and sequela including acute rheumatic fever are very rare.  Inappropriate testing leads to increased healthcare and unnecessary exposure to antibiotics.

The national guidelines published by the Infectious Diseases Society of America do NOT recommend GAS testing in children less than the age of 3 years unless the patient meets clinical criteria and has a home contact with documented GAS.

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Category: Pediatrics

Title: Autism in the ED

Keywords: sedation, autism spectrum disorder (PubMed Search)

Posted: 10/18/2019 by Jenny Guyther, MD
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The emergency department care of a child with autism spectrum disorder (ASD) can be difficult due to problems with communication, social interaction and the patients problems with dealing with change. The often loud, hectic and unfamiliar environment does not help either.  Avoiding triggers, dimming lights, quiet rooms, using distractions and using home electronic devices may help.  Despite these interventions, these children may still require some type of sedation, even to be able to complete a routine exam.  There is not much research on ED sedation practices in this population.
The study cited was a retrospective chart review of 6020 patients with ASD seen over 8 years.  126 patients required sedation.  Laceration repair (24.6%), incision and drainage (17.5%), diagnostic imaging (14.3%) and physical exam (11.9%) were the leading reasons for sedation.  Half of the children received ketamine and half received midazolam.  Adverse effects were seen in 18% of patients with vomiting and desaturations being the most common.  Sedation was inadequate in 4 patients who received midazolam alone.  Physical restraint was used to complete some procedures due to patient resistance.
The use of sedation for painless procedures and exams is likely a consequence of communication impairments and sensory aversions.

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Category: Pediatrics

Title: Pediatric Tibial tubercle avulsion fractures

Keywords: Orthopedics, compartment syndrome (PubMed Search)

Posted: 9/20/2019 by Jenny Guyther, MD (Updated: 8/17/2022)
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-       Tibial tubercle avulsion fractures are rare and pediatrics, accounting for less than 3% of all epiphyseal injuries in children ages 11-17 years. 

-       The typical mechanism is a sudden forceful quadriceps contraction.  Patients present with sudden pain after sprinting or jumping with pain, bruising, deformity or swelling over the tibial tubercle and with a decrease ability to extend the leg. 

-       10 to 20% of cases result in anterior compartment syndrome related to the rupture of the anterior tibial recurrent artery.

-       Although directly measured intra-compartmental pressures can facilitate the diagnosis of compartment syndrome, interpretation of these values can be challenging with healthy children having higher average lower leg compartment pressures than adults.  Treatment of subsequent compartment syndrome is often based on a high index of suspicion.

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Category: Pediatrics

Title: Can an adult tourniquet be used on a pediatric patient?

Keywords: GSW, mass shooting, bleeding (PubMed Search)

Posted: 8/16/2019 by Jenny Guyther, MD (Updated: 8/17/2022)
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Gunshot injuries are a leading cause of morbidity and mortality in the pediatric population.  The Pediatric Trauma Society supports the use of tourniquets in severe extremity trauma.  The Combat Application Tourniquet (CAT) that is commonly used in adults has not been prospectively tested in children.  This study used 60 children ages 6 through 16 years and applied a CAT to the upper arm and thigh while monitoring the peripheral pulse pressure by Doppler.  The CAT was successful in occluding arterial blood flow in all of the upper extremities and in 93% of the lower extremities.

Bottom line: The combat application tourniquet can stop arterial bleeding in the school aged child.

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Category: Pediatrics

Title: Status epilepticus medication management in children

Keywords: Keppra, Dilantin, status epilepticus (PubMed Search)

Posted: 7/20/2019 by Jenny Guyther, MD (Updated: 8/17/2022)
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Takeaways

-Benzodiazepines alone are effective in terminating status epilepticus in 40 to 60% of pediatric patients

-The guidelines for second line agents are based on observational studies and expert opinion

-Adverse effects of phenytoin include hepatotoxicity, pancytopenia, Stevens-Johnson syndrome, extravasation injuries, hypotension and arrhythmias

- Levetiracetam has a reduced risk of serious adverse events, greater compatibility with IV fluids and can be given in 5 minutes versus 20 minutes for phenytoin.

 

Bottom line: In a recent randomized control trial they found that levetiracetam was not superior to phenytoin as a second line agent for management of convulsive status epilepticus in children.  There was no difference between efficacy or safety outcomes between the two groups.

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Category: Pediatrics

Title: When to operate for complicated pediatric appendicitis

Keywords: appendicitis, hospitalization, operative management (PubMed Search)

Posted: 6/21/2019 by Jenny Guyther, MD
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The 30-day adverse event rate is 11% after surgical removal of acute appendicitis.  Some experts believe that acute appendicitis actually consists of 2 types: Uncomplicated appendicitis and complicated appendicitis.  Complicated appendicitis can be broken down into appendicular abscess, appendicular phlegmon, and free perforated appendicitis with generalized peritonitis.
No consensus exists among surgeons regarding the optimal treatment of complicated acute appendicitis in children.  This study hoped to differentiate the complication rates between perforated appendicitis, appendicular abscess, and appendicular phlegmon with regards to early appendectomy versus conservative management.
14 studies were included in this meta-analysis for a total of 1288 patients. 
- Children with appendicular abscess and appendicular phlegmon had fewer complication rates and readmission rates if treated with nonoperative management.  
- Children with free perforated appendicitis showed lower complication rate and readmission rate if treated with operative management.  
- The costs were not significantly different between nonoperative management and operative management.

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Category: Pediatrics

Title: Unintentional pediatric marijuana exposures

Keywords: ingestion, drug overdose, marijuana (PubMed Search)

Posted: 5/17/2019 by Jenny Guyther, MD
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Washington state was one of the first states to legalize recreational marijuana use.  Toxicology call center data was collected on patient's 9 years old and younger with marijuana exposure between July 2010 and July 2016.  There were 161 cases during that time frame and of those 130 occurred after the legalization of recreational marijuana (over a 2.5 year period).  The median age range was 2 years old.  There were increasing cases noted after recreational marijuana was legalized and again after marijuana shops became legal.

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Category: Pediatrics

Title: Measles complications in hospitalized patients

Keywords: Measles, outbreak, complications (PubMed Search)

Posted: 4/19/2019 by Jenny Guyther, MD (Updated: 8/17/2022)
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Measles outbreaks have been reported all over the globe, with the incidence increasing due to low immunization rates.  Italy experienced 5000 cases in 2017. This study was a retrospective multicenter observational study of children less than 18 years hospitalized for clinically and laboratory confirmed measles over a year and a half period from 2016-2017.

There were 263 cases of measles that required hospitalization during this time and 82% developed a complication with 7% having a severe clinical outcome defined by a permanent organ damage need for ICU care or death. A CRP value of greater than 2 mg/dL was associated with a 2-4 fold increased risk of developing complications. 23% developed pneumonia and 9.6% developed respiratory failure.  Hematologic involvement was seen in 48% of patients.  1.2% of hospitalized patients died.

Bottom line: Consider CRP, lipase and CBC at a minimum in your patients with suspected measles who require hospitalization.

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Category: Pediatrics

Title: New pediatric maintenance fluid recommendations

Keywords: Maintenance fluids, D5, NS, hyponatremia (PubMed Search)

Posted: 2/15/2019 by Jenny Guyther, MD (Updated: 8/17/2022)
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Hyponatremia is the most common electrolyte abnormality in hospitalized patients, affecting approximately 15-30% of patients.  Children have historically been given hypotonic maintenance IV fluids based off of theoretical calculations from the 1950s.  Multiple studies have shown complications related to iatrogenic hyponatremia, including increased length of hospital stay, seizures and death.

The American Academy of pediatrics completed a systematic review and developed an updated clinical practice guideline:

Patient's age 28 days to 18 years requiring maintenance IV fluids should receive isotonic solutions with the appropriate amount KCl and dextrose.

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