UMEM Educational Pearls - By Jenny Guyther

Category: Pediatrics

Title: TXA use in pediatric patients for post tonsillectomy bleeding

Keywords: Post-tonsillectomy, bleeding, airway (PubMed Search)

Posted: 1/18/2019 by Jenny Guyther, MD (Updated: 8/17/2022)
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Post tonsillectomy hemorrhage occurs and 0.1-3% of post tonsillectomy patient's.  It occurs typically greater than 24 hours after surgery and up to 4-10 days postoperatively.  A survey of otolaryngologists showed that ED management strategies for active bleeding have included direct pressure, clot suction, silver nitrate, topical epinephrine, and thrombin powder.

This article was a case study demonstrating the use of nebulized tranexamic acid (TXA) for post tonsillectomy hemorrhage in a 3-year-old patient.  The patient had a copious amount of oral bleeding and had failed treatment with nebulized racemic epinephrine and direct pressure was not an option due to the patient's cooperation and small mouth.  250 mg of IV TXA was given via nebulizer with a flow rate of 8 L.  Bleeding stopped 5-7 minutes after completion of the nebulizer.  The patient was then taken to the OR for definitive management.  No adverse effects were noticed.

TXA in the pediatric population has been shown to decrease surgical blood loss and transfusions in cardiac, spine and craniofacial surgeries.  Studies have also been done in pediatric patients with diffuse alveolar hemorrhage using doses of 250 mg for children less than 25 kg and 500 mg for those who are greater than 25 kg.

Bottom line: There are case reports of nebulized TXA use in the pediatric population with no adverse outcomes noted.  More research is needed.

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Category: Pediatrics

Title: Pediatric intubation: Cuffed or uncuffed tubes?

Keywords: Intubation, ETT, cuffed, airway management (PubMed Search)

Posted: 12/21/2018 by Jenny Guyther, MD (Updated: 8/17/2022)
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Historically uncuffed endotracheal tubes were used in children under the age of 8 years due to concerns for tracheal stenosis.  Advances in medicine and monitoring capabilities have resulted in this thinking becoming obsolete.  Research is being conducted that is showing the noninferiority of cuffed tubes compared to uncuffed tubes.  Multiple other studies are looking into the advantages of cuffed tubes compared to uncuffed tubes.

The referenced study is a meta-analysis of 6 studies which compared cuffed to uncuffed endotracheal tubes in pediatrics.  The pooled analysis showed that more patients needed tube changes when they initially had uncuffed tubes placed.  There was no difference in intubation duration, reintubation occurrence, post extubation stridor, or racemic epinephrine use between cuffed and uncuffed tubes.

Bottom line: There is no difference in the complication rate between cuffed and uncuffed endotracheal tubes, but uncuffed endotracheal tubes did need to be changed more frequently.

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Category: Pediatrics

Title: Metal detector use for esophageal coins

Keywords: Foreign bodies, coins, xrays (PubMed Search)

Posted: 11/16/2018 by Jenny Guyther, MD (Updated: 8/17/2022)
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Coins are the most commonly ingested foreign body in the pediatric age group with a peak occurrence in children less than 5 years old.  X-rays are considered the gold standard for definitive diagnosis and location of metallic foreign bodies.  This study aimed to find a way to decrease radiation exposure by using a metal detector.

19 patients ages 10 months to 14 years with 20 esophageal coins were enrolled in the study.  All proximal esophageal coins were detected by the metal detector.  5 patient's failed initial detection of the coin with the metal detector and all of those patients had the coin in the mid or distal esophagus with a depth greater than 7 cm from the skin.

Bottom line: A metal detector may detect proximal esophageal coins.  This may have a role in decreasing repeat x-rays.

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Category: Pediatrics

Title: How to use the C-reactive protein in pediatrics

Keywords: Infection, fever, blood work, CRP (PubMed Search)

Posted: 10/19/2018 by Jenny Guyther, MD (Updated: 8/17/2022)
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Historically, the C-reactive protein (CRP) has been used in the assessment of the febrile child and is the only biomarker recommended by the National Institute for Health and Care Excellence (NICE).

CRP increases 4-6 hours after the onset of inflammation, doubling every 8 hours and peaking at 36-50 hours.  It rapidly decreases once the inflammation has resolved.

An elevated CRP alone is not conclusive of a serious bacterial infection (SBI).

A CRP >75 mg/L increased the relative risk of SBI by 5.4.

A CRP <20 mg/L decreased the risk of SBI, but there was still a small subset of children where SBI was present.

In infants < 3 months initial CRP measurements are poorly accurate, but when trended may be useful in deciding when to stop antibiotics (rather then when to start them).  A normalizing CRP demonstrated a 100% negative predictive value for excluding invasive bacterial infection.

Bottom line:

CRP is not a rule in/rule out test

CRP is not helpful in diagnosing SBI, but serial measurements may be useful in monitoring response to treatment

CRP has a limited role in well appearing children older than 3 months

 

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Category: Pediatrics

Title: Ibuprofen use and infants

Keywords: Fever, pain control, ibuprofen, acetaminophen (PubMed Search)

Posted: 9/21/2018 by Jenny Guyther, MD
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Ibuprofen is an effective antipyretic and analgesic and children.  In the US, ibuprofen is not used in children less than 6 months due to safety concerns involving adverse GI effects, risk of renal failure, increased risk of necrotizing infections and Rey syndrome.   The British National Formulary, however, does provide dosing guidance for infants aged 1-3 months.
This study was a retrospective review looking at infant's age less than 6 months who were prescribed ibuprofen or acetaminophen.  The rate of adverse GI and renal events were compared between both the ibuprofen and acetaminophen group. 
GI adverse events were mild including vomiting, moderate with abdominal pain and gastritis. Renal adverse events included acute or chronic renal failure.
GI and renal adverse events were not higher in infants younger than 6 months who are prescribed ibuprofen compared to those age 6-12 months.  Adverse events were increased in children younger than 6 months to her prescribed Motrin compared to acetaminophen alone.
Bottom line: Remain cautious about adverse GI and renal events in children age less than 6 months when using ibuprofen compared to acetaminophen.  However, there is no difference in adverse events when ibuprofen is used in children younger than 6 months compared with those older than 6 months.

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Is there an association between pulmonary aspiration, vomiting or any serious adverse event and the preprocedural fasting time?

The odds ratio of any adverse event did not increase significantly with each additional hour of fasting duration for both solids and liquids. 

The guidelines set by the American Society of Anesthesiology for fasting include a minimum of 2 hours for clear liquids, 4 hours for breast milk, 6 hours for formula and light meals and 8 hours for solid meals containing fatty foods or meat.

This was a secondary analysis of a multicenter prospective cohort study of children 0-18 years who received procedural sedation in 6 Canadian pediatric emergency departments from 2010-2015.  6183 children were included with 99.7% meeting ASA 1 or 2 categories.  2974 patients did not meet the American Society of Anesthesiology fasting guidelines for solids and 510 patients did not meet the fasting guidelines for liquids.  The overall incidence of adverse events was 11.6%.  There were no cases of pulmonary aspiration.  There was a total of 717 adverse events.  315 events were vomiting.  Oxygen and vomiting were the most common adverse events. 

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Category: Pediatrics

Title: When do I get a chest xray in a child with asthma?

Keywords: Asthma, chest xray (PubMed Search)

Posted: 7/20/2018 by Jenny Guyther, MD (Updated: 8/17/2022)
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Takeaways

Chest xrays (CXRs) may lead to longer length of stay, increased cost, unnecessary radiation exposure, and inappropriate antibiotic use.

CXR in asthma are indicated for:

-severe persistent respiratory distress, room air saturations <91%

- focal findings (localized rales, crackles, decreased breath sounds with or without a documented fever > 38.3) not improving on >11 hours of standard asthma therapy

- concern for pneumomediastinum or pneumothorax

 

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Category: Pediatrics

Title: Occult bacteremia in infants

Keywords: Fever, infants, blood culture (PubMed Search)

Posted: 6/15/2018 by Jenny Guyther, MD
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Takeaways

The rate of occult bacteremia in infants 3 months to 24 months with a temperature higher than 40.5C was slightly higher when compared to those with a temperature higher than 39C.

363 infants (3 months to 24 months) with a fever > 40.5C who were well appearing were evaluated in this study.  4 were diagnosed with occult bacteremia (1.1%).  3 of these were caused by S. pneumoniae and 2 were fully immunized.

A larger sample size is needed to see if reconditions to include empiric blood cultures on this subgroup of patients is warrented.

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Category: Pediatrics

Title: Development of an algorithm for battery ingestion

Keywords: Button batteries, removal (PubMed Search)

Posted: 5/18/2018 by Jenny Guyther, MD (Updated: 8/17/2022)
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Takeaways

There were 180 battery ingestions over a 5 year period at two tertiary care children’s hospital.  The median age was 3.8 years (0.7 to 18 years).  The most common symptoms were abdominal pain (17%), and nausea and vomiting (14%).  X-rays detected the location in 94% of patients.

Based on these patients, a treatment algorithm was developed (See attached).  Prospective validation is needed.

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Attachments

battery_algorithm.docx (123 Kb)


Category: Pediatrics

Title: Epidural hematoma formation after pediatric lumbar puncture

Keywords: Infant fever, lumbar puncture, risks, ultrasound (PubMed Search)

Posted: 4/20/2018 by Jenny Guyther, MD (Updated: 8/17/2022)
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Unsuccessful lumbar punctures (LP) may lead to epidural hematoma (EH) formation at the site of needle insertion which may affect subsequent attempts and lead to no success or a grossly bloody sample.  There is no standard definition of a traumatic LP based on CSF red blood cell counts.  Gross blood may also be obtained by interrupting the vascular structures outside the spinal canal which would not result in EH formation.

This was a prospective study of children younger than 6 months who had an LP at a single children’s hospital.  Post LP ultrasounds were completed by the investigating team and interpreted by a pediatric radiologist. 74  patients were included in the study.  31% of the patients had evidence of a post LP EH.  17% fully effaced the thecal sac which would likely preclude future success at that anatomic site.  25% of patients where the clinician did not feel there was a traumatic attempt had evidence of an EH.The study was not powered to determine the risk factors for EH formation.  The study also did not look at any other consequences to EH.

Key points: Point of care ultrasound to evaluate EH and bleeding at the failed LP site my provide useful information for a location of subsequent attempts.  Also US to evaluate for bleeding in the spinal canal may help with interpretation of the CSF when a large number of red blood cells are present.  

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Takeaways

Fluid overload (defined in this study as (fluid input-output)/weight)) is associated with longer hospital stays, longer treatment duration and oxygen use.

Bottom line: Treat dehydration appropriately but try not to over resuscitate the asthmatic.  Further studies are needed before definitive recommendations are made.

 

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Category: Pediatrics

Title: What is the diagnosis?

Keywords: foreign body, choking (PubMed Search)

Posted: 2/16/2018 by Jenny Guyther, MD
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Question

Patient: 11 month old with trouble breathing and color change after a family member sprayed air freshener.  Symptoms have since resolved.

What are you concerned about in the attached xrays?

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Attachments

11_mo_lung_FB_word.docx (408 Kb)


Category: Pediatrics

Title: Oral morphine versus ibuprofen in postoperative orthopedic pain in children

Keywords: Pain control in children, opiates, NSAIDS, motrin, orthopedic (PubMed Search)

Posted: 1/19/2018 by Jenny Guyther, MD
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This was a randomized superiority trial of 0.5mg/kg of oral morphine every 6 hours to 10 mg/kg of ibuprofen every 6 hours in children 5-17 years old who had minor outpatient orthopedic surgeries.  There were 77 patients in each group.  Primary outcome was pain as rated on the Faces pain scale.  Secondary outcomes were additional analgesic requirements, adverse events, and unplanned visits to the doctor.

Bottom line: Oral morphine was not superior to ibuprofen and both drugs decreased pain with no difference in efficacy.  Morphine was associated with more adverse events.

 

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Category: Pediatrics

Title: What is the ideal observation time for a patient with croup who has received racemic epinephrine?

Keywords: Croup, epinephrine, discharge, observation (PubMed Search)

Posted: 12/15/2017 by Jenny Guyther, MD (Updated: 8/17/2022)
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The peak age for croup is 6 months to 3 years.  The cornerstone of treatment is corticosteroids, traditionally dexamethasone.  With oral administration, the peak onset is 1-2 hours. Steroids shorten the duration of symptoms, reduce the need for nebulized epinephrine and decrease the need for intubation.

Racemic epinephrine has been used for moderate to severe croup and can show an improvement in patient symptoms for up to 120 minutes.  There is little evidence to suggest how long to observe the patient for recurrence of symptoms after racemic epinephrine was given.  Previous studies have suggested both 2 and 4 hour observation.

299 patients were included in this study.  136 patients were observed for 3.1 to 4 hours.  In the 3.1 to 4 hour group, 21 (7%) failed treatment, 19 of those patients required admission and 2 returned within 24 hours.  No patients who were discharged home after 4 hours returned to the emergency department within 24 hours.

Bottom Line: Consider a 4 hour period of observation after giving racemic epinephrine in order to decrease bounce backs.

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Category: Pediatrics

Title: Pediatric marijuana ingestion

Keywords: Marijuana, symptoms, overdose (PubMed Search)

Posted: 11/17/2017 by Jenny Guyther, MD (Updated: 8/17/2022)
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In the US, there are an estimated 22.2 million users of cannabis based on the 2015 National Survey on Drug Use and Health.  The incidence of unintentional cannabis ingestion has increased in states that have legalized medical and recreational marijuana.  The cited article reviewed of 44 articles involving unintentional cannabis ingestion in children younger than 12 years.

The majority of intoxications were through cannabis resins followed by cookies and joints.

Lethargy was the most common presenting sign followed by ataxia.  Tachycardia, mydriasis and hypotonia were also noted.  Rarer but more serious presentations included respiratory depression and seizures.

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Takeaways

Within the first hour after administration, ondosterone, metoclopramide and bromopride were equally efficacious.  At the 6 hour and 24 hour period after receiving the initial dose of medication, ondansetron was statistically superior to bromopride (not available in the US) and metoclopramide.  There were no reported side effects in the ondansetron group (including diarrhea or sedation).

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Takeaways

Elective surgeries with general anesthesia are often cancelled when the child has an upper respiratory tract infection.  What are the adverse events when procedural sedation is used when the child has an upper respiratory tract infection?

Recent and current URIs were associated with an increased frequency of airway adverse events (AAE).  The frequency of AAEs increased from recent URIs, to current URIs with thin secretions to current URIs with thick secretions.   Adverse events not related to the airway were less likely to have a statistically significant difference between the URI and non-URI groups

AAEs for children with no URI was 6.3%.  Children with URI with thick/green secretions had AAEs in 22.2% of cases.  Children with URIs did NOT have a significant increase in the risk of apnea or need for emergent airway intervention.  The rates of AAEs, however, still remains low regardless of URI status.

 

 

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Category: Pediatrics

Title: Bacterial Meningitis in Pediatric Complex Febrile Seizures

Keywords: Febrile seizure, meningitis (PubMed Search)

Posted: 8/18/2017 by Jenny Guyther, MD (Updated: 8/17/2022)
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Takeaways

Febrile seizures occur in children 6 months through 5 year olds.  A complex febrile seizure occurs when the seizure is focal, prolonged (> 15 min), or occurs more than once in 24 hours.

The prevalence of bacterial meningitis in children with fever and seizure after the H flu and Strep pneumomoniae vaccine was introduced is 0.6% to 0.8%.  The prevalence of bacterial meningitis is 5x higher after a complex than simple seizure.

From the study referenced, those children with complex febrile seizures who had meningitis all had clinical exam findings suggestive of meningitis.  More studies are needed to provide definitive guidelines about when lumbar punctures are needed in these patients.

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Category: Pediatrics

Title: Reducing radiation exposure in evaluation of ventricular shunt malfunctions in children

Keywords: CT scans, radiation exposure, pediatrics (PubMed Search)

Posted: 7/21/2017 by Jenny Guyther, MD (Updated: 8/17/2022)
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Ventricular shunt (VP) malfunction can be severe and life-threatening and evaluation has typically included a dry CT brain and a shunt series which includes multiple x-rays of the skull, neck, chest and abdomen.  The goal of this study was to decrease the amount of radiation used in the evaluation of these patients since these patients will likely present many times over their lifetime.  Several institutions have more towards a rapid cranial MRI, however, this modality may not be readily available.

This multidisciplinary team decreased the CT scan radiation dose from 250mA (the reference mA in the pediatric protocol at this institution) to 150 mA which allows for a balance between reducing radiation exposure and adequate visualization of the ventricular system.  They also added single view chest and abdominal x-rays.

The authors found that after implementing this new protocol, there was a reduction in CT radiation doses and number of x-rays ordered with no change in the return rate.

 

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Category: Pediatrics

Title: Pediatric blunt trauma and the need for chest xray

Keywords: Blunt thoracic trauma, pediatric trauma, chest xray (PubMed Search)

Posted: 6/16/2017 by Jenny Guyther, MD
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Takeaways

Chest injuries represent the second most common cause of pediatric trauma related death.  ATLS guidelines recommend CXR in all blunt trauma patients.  Previous studies have suggested a low risk of occult intrathoracic trauma; however, these studies included many children who were sent home.

Predictors of thoracic injury include: abdominal signs or symptoms (OR 7.7), thoracic signs of symptoms (OR 6), abnormal chest auscultation (OR 3.5), oxygen saturation < 95% (OR 3.1), BP < 5% for age (OR 3.7), and femur fracture (OR 2.5).

4.3 % of those found to have thoracic injuries did not have any of the above predictors, but their injuries were diagnosed on CXR.  These children did not require trauma related interventions.

Bottom line: There were still a number of children without these predictors that had thoracic injuries, so the authors suggest that chest xray should remain a part of pediatric trauma resuscitation.

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