UMEM Educational Pearls - By Jenny Guyther

Smith S, Giordano K, Thompson A and DePiero A.  Failure of Outpatient Management With Different Observation Times After Racemic Epinephrine for Croup.  Clinical Pediatrics.  Epub ahead of print.  Accessed October 2017.

Richards JR, Smith NE, Moulin AK.  Unintentional Cannabis Ingestion in Children: A Systemic Review.  The Journal of Pediatrics.  2017.  Epub ahead of print.

This was a randomized control trial of children 1 year to 12 years seen in the pediatric emergency department in Brazil for vomiting and given intramuscular bromopride (0.15mg/kg to a maximum of 10 mg), metoclopramide (0.15mg/kg to a maximum of 10 mg), or ondansetron (0.15mg/kg to a maximum of 8 mg).  175 children were included.

Epifanio et al.  Bromopride, metoclopramide, or ondansetron for the treatment of vomiting in the emergency in the pediatric emergency department: a randomized control trial.  J Pediatr 2017.  Article in Press.

 

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.

Data was collected on over 83,000 patients retrospectively from a voluntary database, The Pediatric Sedation Research Consortium.  Children with URIs (no fever) who underwent procedural sedation for things such as imaging or hematology/oncology procedures were included.  Propofol, dexmedetomidine, ketamine and opiates were the most commonly used agents.

AAEs included wheezing, secretions requiring treatment, cough, stridor, desaturations, obstruction, snoring, laryngospasm, and apnea.

Mallory et al.  Upper Respiratory Infections and Airway Adverse Events in Pediatric Procedural Sedation.  Pediatrics. 2017; 140 (1): 1-10.

 

Guedji R et al.  Do All Children Who Present With a Complex Febrile Seizure Need a Lumbar Puncture?  Annals of Emergency Medicine. 2017; 70 (1):52-62.

Marchese et al.  Reduced Radiation in children presenting to the ED with Suspected Ventricular Shunt Complication.  Pediatrics. 2017; 139 (5).

This was a retrospective review of children aged 0-17 with blunt trauma requiring trauma team activation who had a chest xray preformed.  483 eligible children were included, all of whom were admitted to the hospital.  108 children had their thoracic injury detected on chest xray, 110 on chest CT and 76 on abdominal CT.  Pneumothorax, pulmonary contusion and multiple rib fractures were the most commonly found thoracic injuries.  All children also had other injuries.

Weerdenburg et al.  Predicting Thoracic Injury in Children with Multi-trauma.  Pediatric Emergency Care.  Epub ahead of print.  2017.

This is the first study looking at ziprasidone in the pediatric emergency department population.  This was a retrospective observational study of children 5-18 years old who were treated with IM ziprasidone.  40 patients received IM ziprasidone in a tertiary care pediatric emergency department between 2007-2015.  2/3 of the patients had ADHD and 1/3 had autism spectrum disorder.  Other diagnosis included post-traumatic stress disorder, bipolar disorder and intellectual disabilities.

68% of patients responded to the initial dose.  The initial dose was 0.19 +/- 0.1 mg/kg in the responder group and 0.13 +/- 0.06 mg/kg in the non-responder group.  Single doses ranged from 2.5 mg to 20 mg total.

No patients had respiratory depression.  Two patients had potential extra-pyramidal symptoms, but one was prior to ziprasidone administration and the other patient had baseline facial twitching with no documentation if there was a change after ziprasidone administration.

Nguyen T, Stanton J and Foster R.  Intramuscular Ziprasidone Dosing for Acute Agitation in the Pediatric Emergency Department: An observational Study.  Journal of Pharmacy Practice 1-4.  2017.

This was a retrospective study of 1991 children younger than 2 years that presented between 2000-2010 who were diagnosed with bronchiolitis.  Primary care records were reviewed 1 year after their visit to the ED to see if the patient had a primary care diagnosis of asthma. 

Of the initial study population, 817 patients had received a diagnosis of asthma at 1 year.

Since these patients were only followed up at 1 year, the amount of children who were later diagnosed with asthma may be underestimated.

Waseem et al.  Factors Predicting Asthma in children with Acute Bronchiolitis.  Pediatric Emergency Care.  March 2017.  Epub ahead of print.

This was a retrospective study of 2700 infants < 3 months old who were evaluated for urinary tract infections (UTI).  The UTI prevalence in this group was 7.8%.  A UTI was defined as at least 50,000 colony forming units/mL from a catheterized specimen.  Test characteristics looked at white blood cell and leukocyte esterase cut-offs, dichotomized into specific gravities: dilute (<1.015) and concentrated (>/=1.015).

Diagnosis: Pathologic fracture with a unicameral bone cyst

Unicameral bone cysts are benign lesions that mainly affect children and adolescents.  On xray the cyst is noted to be a mildly expansile, lytic, thin walled lesion without periosteal reaction.  The most common sites are the proximal humerus and femur.  These lesions can resolve spontaneously, but there is a risk of pathologic fracture.  If fracture is detected, then the fracture site should be treated as any other fracture in the area.  These lesions can also be found incidentally in which case they should be referred to orthopedics for outpatient follow up.

Kadhim, M, Thacker M, Kadhim A and Holmes L.  Treatment of unicameral bone cyst: systemic review and meta analysis.  J Child Orthop.  2014 Mar; 8(2): 171-191.

Mascard E, Gomez-Brouchet A, Lambot K.  Bone cysts: Unicameral and aneurysmal bone cyst.  Orthop Traumatol Surg Res. 2015 Feb; 101.

 

Nail bed injuries occur in 15-24% of children with fingertip injuries.

In 1997, medical adhesive was first used to secure the avulsed nail plate back to the nail bed instead of suturing back into place.  By 2008, there were small studies looking at the utility of using medical adhesive to close the laceration of the nail bed.  The studies were small, but there was a tendency towards shorter repair times and no difference between pain, cosmetic outcome or function.

A total of 6 articles were included in this review – 2 using histoacryl and 4 using demabond.

Edwards, S, Parkinson L.  Is Fixing Pediatric Nail Bed Injuries with Medical Adhesives as Effective as Suturing?  A Review of the Literature.  Pediatric Emergency Care.  2016.

80 children between 4 months and 6 years of age with fever > 101 degress F and watery stools (> 3 episodes) were evaluated for hydration status using urine samples.  The urine was collected either by catheterization or clean catch, depending on age.  All urine cultures were negative.

Nibhanipudi KV.  A Study to determine the Incidence of Urinary Tract Infections in Infants and Children Ages 4 months to 6 Years with Febrile Diarrhea.  Glob Pediatr Health. 2016. Published online Sept 12, 2016.

 

Kannikeswaran et al.  Optimal dosing of intravenous ketamine for procedural sedation in children in the ED – a randomized control trial.  American Journal of Emergency Medicine 24 (2016) 1347-1353.

This was a prospective randomized double blinded study in 8 pediatric emergency departments. Patients were at least 6 months old and younger than 11 years. To be included they had to have at least 3 episodes of vomiting or diarrhea in the previous 12 hours and a Gorelick score of at least 4. 100 children were included. Serum bicarbonate was measured at 0 and 4 hours and dehydration scores were reassessed. There was a change of bicarbonate of 1.6 mEq/L for plasma-lyte A (PLA) and no change for sodium chloride. There as an improvement in the dehydration score at 2 hours for the PLA group, but the dehydration scores were not statistically significant between the 2 groups at the 4 hours mark.

Allen et al. A randomized trial of Plasma-Lyte A and 0.9% sodium chloride in acute pediatric gastroenteritis. BMC Pediatrics 2016 16:117.

Jacob R, Bentur L, Brik R, Shavit I and Hakim F. Is capnometry helpful in children with bronchiolitis? Respir Med 2016; 113:37-41.

Kasmire K, Rogers S and Sturm J. Trampoline Park and Home Trampoline Injuries. Pediatrics 2016: 138 (3).

Bernstein HH and Kimberlin DW. Intranasal FluMISSED its target. AAP News. July 2016.

Chung J et al. Seasonal Effectiveness of Live Attenuated and Inactivated Influenza Virus. Pediatrics 2016: 137 (2).

Hypertension is defined as a systolic or diastolic blood pressure > 95% for age, sex and height based on repeated measurements. There is no numeric blood pressure cut of for defining hypertensive emergency in pediatrics. Use a reference book such as Harriet Lane Handbook to determine percentiles. The proper size BP cuff should be used: bladder width that is at least 40% of the arm circumference at the midpoint of the upper arm and a length that is 80-100% of the arm circumference.

Hypertensive crisis in children younger than 6 years may present with: irritability, feeding disturbance, vomiting, failure to thrive, seizure, altered mental status, or congestive heart failure.

Treatment in the Emergency Setting

-Lower the BP to < 95 percentile in children with HTN and no signs of end organ dysfunction

-Lower the BP to < 90 percentile in children with end organ dysfunction or co-morbid conditions

-Start with IV if able

-Few anti hypertensive medications have been studied adequately in children.

-The cited article has a table of antihypertensive medications with doses to be used in children, but only 4 have FDA approved labeling for pediatrics (hydralazine, fenoldopam, sodium nitroprusside and minoxidil)

Stein DR, Ferguson MA. Evaluation and treatment of hypertensive crisis in children. Integr Blood Press Control 2016; 9:49-58.

Tieder JS, Bonkowsky JL, Etzel RA, et al. Brief Resolved Unexplained Events (Formerly Apparent Life-Threatening Events) and Evaluation of Lower-Risk Infants. Clinical Practice Guideline. Pediatrics. 2016; 137 (5):e20160590.