Keywords: Passive leg raise, hypotension (PubMed Search)
Passive leg raise (PLR) has been studied in adults as a bedside tool to predict volume responsiveness (see previous pearls from 5/7/13 and 6/17/2008). Can this be applied to children?
A single center prospective study looked at 40 intensive care patients ranging in age from 1 month to 12.5 years. They used a noninvasive monitoring system that could measure heart rate, stroke volume and cardiac output. These parameters were measured at a baseline, after PLR, after another baseline and after a 10 ml/kg bolus.
Overall, changes in the cardiac index varied with PLR. However, there was a statistically significant correlation in children over 5 years showing an increase in cardiac index with PLR and with a fluid bolus.
Bottom line: In children older then 5 years, PLR can be a quick bedside tool to assess for fluid responsiveness, especially if worried about fluid overload and in an under served area.
Lu et al. The Passive Leg Raise Test to Predict Fluid Responsiveness in Children - Preliminary Observations. Indian J Pediatr. Dec 2013. (epub ahead of print).
Keywords: hyponatremia, maintenance fluid (PubMed Search)
Wang et al. Isotonic Versus Hypotonic Maintenance IV Fluids in Hospitalized Children: A Meta-Analysis. Pediatrics 2014; 133;105.
Keywords: Intussusception, abdominal pain, fever (PubMed Search)
Case: A 3 year 9 month female presents with fever to 39.4 C and intermittent abdominal pain worsening over 2 days. The patient had been tolerating food and had no change in her bowel habits. Based on the imaging below, what is your diagnosis and treatment?
Answer: Intussusception. This patient failed air reduction enema and was taken the OR. No bowel ischemia was found. The ilium was inside of the colon at the ileocecal valve. There was significant mesenteric lymphadenitis noticed. The patient recovered and was discharged later that day.
The x-ray above shows a soft tissue mass under the liver projection in the RUQ that can be suggestive of intussusception in the appropriate case. The second x-ray done during attempted air reduction shows air surrounding a dense area on the right side. Ultrasound, however, has become the gold standard. The ultrasound image shows the classic target sign of hyperechoic compressed loop of bowel telescoping within a hypoechoic edematous outer loop of bowel.
A few other important facts:
The median age of presentation is 32 months, with many presenting before 12 month.
Abdominal pain and/or crying was seen in 95% of cases. 66% had vomiting, 28% had fever, and 27% had bloody stools.
Causes included 29% with enlarged mesenteric lymph nodes (followed by GJ tube obstruction and meckels diverticulium)
30% have concurrent infections (URI and gastroenteritis being most common)
91% 1st time success rates with air contrast enema
*The above percentages were taken from the article referenced, which is a retrospective review done at a tertiary pediatric center.
Lochhead et al. Intussusception in children presenting to the emergency department. Clinical Pediatrics 2013 52:1029.
Keywords: skull fracture (PubMed Search)
Pediatric patients with an isolated skull fracture and normal neurological exam have a low risk of neurosurgical intervention and outpatient follow up may be appropriate (assuming no suspicion of abuse and a reliable family). In a study published in 2011, a retrospective review over a 5 year period at a level 1 trauma center showed that 1 out of 171 admitted patients with isolated skull fractures developed vomiting. This patient had a follow up CT showing a small extra-axial hematoma that did not require intervention. 58 patients were discharged from the ED within 4 hours.
You can also check out another recent article published in Annals of Emergency Medicine on the same topic this month!
Rollins et al. Neurologically intact children with an isolated skull fracture may be safely discharged after brief observation. Journal of Pediatric Surgery. Volume 26. Issue 7. 2011.
Mannix et al. Skull Fractures: Trends in Management in US Pediatric Emergency Departments. Annals of Emergency Medicine. Volume 64. Issue 4. 2013.
Keywords: orthopedics, compartment syndrome (PubMed Search)
We have learned how to diagnose compartment syndrome in adults, but how do you determine the early warning signs in a nonverbal or even frightened child?
Rising compartment pressures are related to increasing anxiety and agitation in children. A Boston study in 2001 showed that increasing pain medication requirements were detected 7 hours earlier than a vascular exam change. 90% of the patients with compartment syndrome in this study reported pain, but only 70% had another ‘P” (pallor, parasthesia, paralysis or pulselessness).
This has led to the proposal of the 3 “A”s for early identification of compartment syndrome in children: increasing anxiety, agitation and analgesia requirement.
Noonan and McCarthy. Compartment Syndrome in Pediatric Patients. Journal of Pediatric Orthopedics. Vol 30. No 2. March 2010.
Keywords: laceration, suture, absorbable (PubMed Search)
A facial laceration on a child can present a unique challenge which is not limited to the initial visit. The traditional teaching has been to use nonabsorbable sutures and have the patient return in 5 days for removal. A recent study compared the cosmetic outcome of linear facial lacerations 1 to 5 cm that were closed with either Ethicon fast absorbing surgical gut or monocryl nonabsorbable sutures. Patients were randomized and returned to the ED in 4-7 days and 3-4 months. Scars were assessed by caregivers and blinded physicians. Results showed that caregivers preferred absorbable sutures. Visual analog scores as given by caregivers were not statistically different between the 2 groups at the 3 month mark. The blinded physicians did give better cosmetic outcome scores to the absorbable suture group which differs from previous studies that had shown equivocal results. Of note, all absorbable sutures were no longer visible after 14 days.
Bottom line: Try absorbable sutures the next time you are suturing a child and the parents may be happier and you will not have to try and take out your sutures from a squirming, screaming child.
Luck et al. Comparison of Cosmetic Outcomes of Absorbable Versus Nonabsorbable Sutures in Pediatric Facial Lacerations. Pediatric Emergency Care. Vol 29. No 6. 2013.
Keywords: lactate, sepsis, pediatric (PubMed Search)
Lactate is commonly used in the adult ED when evaluating septic patients, but there is a lack of literature validating its use in the pediatric ED. Pediatric studies have suggested that in the ICU population, elevated lactate is a predictor of mortality and may be the earliest marker of death.
A retrospective chart review over a 1 year period showed that one elevated serum lactate correlated with increased pulse, respiratory rate, white blood cell count and platelets. Serum lactate had a negative correlation with BUN, serum bicarbinate and age. Elevated lactate levels were higher for admitted patients. However, the mean serum lacate level was not statistically different between those diagnosed with sepsis and those that were not.
The study included 289 patients less then 18 years who had both blood cultures and lactate drawn. This community hospital had a sepsis protocol in place that automatically ordered a lactate with blood cultures. Only previously healthy children were included.
The study is limited by its small sample size and overall low lactate levels. Despite having a protocol in place, only 39% of patients who had blood cultures drawn had lactate levels available for analysis. The mean serum lacate in this study was 2.04 mM indicating that the study population may not have been sick enough to determine mortality implications. There were no serial measurements.
Bottom line: Consider measuring serum lacate in your pediatric patient with suspected sepsis. Pediatric ICU literature does suggest that an serum lactate as low as 3mM is associated with an increased mortality in the ICU.
Reed et al. Serum Lactate as a Screening Tool and Predictor of Outcome in Pediatric Patients Presenting to the Emergency Department With Suspected Infection. Pediatric Emergency Care. 2013; Vol 29: 787-791.
Infant lumbar puncture is often difficut and may require repeated attempts. The traditional body positioning is lateral decubitus. Previous studies have examined the saftey of having the patient in a sitting position, and neonatal studies have suggested that the subarachnoid space increases in size as the patient is moved to the seated position. A study by Lo et al published last month looked to see if the same held true in infants.
50 healthy infants less then 4 months old had the subarachnoid space measured by ultrasound between L3-L4 in 3 positions: lateral decubitus, 45 degree tilt and sitting upright.
This study found that the size of the subarachnoid space did not differ significantly between the 3 positions. Authors postulated that a reason for increase sitting LP success rate that had been reported in anestesia literature with tilt position could be due to other factors such as increased CSF pressure, intraspinous space widening or improved landmark identification.
Sitting or Tilt Position for Infant Lumbar Puncture Does Not Increase Ultrasound Measurements of Lumbar Subarachnoid Space Width. Pediatr Emer Care 2013;29: 588-591.
Keywords: stroke, children, infection (PubMed Search)
Acute ischemic stroke occurs in 3.3/100,000 children per year. Up to 30% of these are caused by varicella. This can be diagnosed if the patient has had varicella infection within the past 12 months, has a unilateral stenosis of a great vessel, and has a positive PCR or IgG from the CSF.
Treatment includes anticoagulation, acyclovir for at least 7 days and steroids for 3-5 days.
Outcome is normally good and spontaneous improvement can be seen.
Inflammation of other arteries, including other areas of the brain, can also be seen. Treatment options for this can include high dose glucocorticoids and possibly immunosuppresive agents.
Simma et al. Therapy in pediatric stroke. Eur J Pediatr. Published online 06 November 2012.
Keywords: Conjunctivitis (PubMed Search)
Children frequently present with "pink eye" to the ED. When they do, parents often expect antibiotics. How many of these kids actually need them? Previous studies have shown approximately 54% of acute conjunctivitis was bacterial, but antibiotics were prescribed in 80-95% of cases.
A prospective study in a suburban children's hospital published in 2007, showed that 87% of the cases during the study period were bacterial. The most common type of bacteria was nontypeable H. influenza followed by S. pneumoniae.
Topical antibiotic treatment has been shown to improve remission rates by 6-10 days.
Patel et al. Clinical Features of Bacterial Conjunctivitis in Children. Academic Emergency Medicine 2007; 14:1-5.
Trampoline injuries doubled between 1991 and 1996, increasing from 39,000 injuries per year to more then 83,000 injuries per year. Injury rates and trampoline sales peaked in 2004 and have been decreasing since; however, hospitalization rates are still between 3% and 14%.
¾ of injuries occur when multiple people are on the trampoline at once
Smaller participants were 14x more likely to be injured then their heavier playmates
Falls account for 27-39% of all injuries
Springs and frames account for 20% of injuries
Up to ½ of injuries occur despite adult supervision
Lower extremity injuries are more common than upper extremity
Head and neck injuries accounted for 10-17% of trampoline injuries
Proximal tibial fractures
Manubriosternal dislocations and sternal injuries
Vertebral artery dissection
Trampoline Saftey in Childhood and Adolescence. Pediatrics 2012; 130; 774-779.
Conventional pediatric nasal cannula can safely deliver up to 4 lpm but are limited by cooling and drying of the airway. This leads to decreased airway patency, nasal mucosal injury, bleeding and possibly increase in coagulase negative staph infections.
HFNC delivers flow up to 40 lpm with 95-100% relative humidity at a controlled temperature. In infants, the initial flow rate is set between 2-4 lpm and can be increased to 8 lpm. Older children and can be started at 10 lpm and increased as high as 40 lpm. Oxygen is also adjustable.
Studies have shown improved comfort, respiratory rate and oxygenation compared to nasal CPAP.
Noninvasive Ventilation Techniques in the Emergency Department: Applications in Pediatric Patients. Pediatric Emergency Medicine Practice. Vol 6 No 6. June 2009.
Spentzas et al. Children with Respiratory Distress Treated with High-Flow Nasal Cannula. Journal of Intensive Care Medicine. Vol 24 No 5. September/October 2009.
Keywords: Vaccines (PubMed Search)
We often ask our pediatric patients if there vaccines are up to date, but what does this mean?
Hepatitis B: birth, 2 and 6 months
Diphtheria/Tetanus and Acellular Pertussis: 2, 4 and 6 months
Pneumococcal vaccine: 2, 4 and 6 months
Haemophilus influenzae B : 2, 4 and 6 months
Polio: 2, 4 and 6 months
Rotavirus: 2 and 4 months or 2, 4 and 6 months depending on the brand.
Influenza: 6 months and older
Children less than 8 years old should receive 2 doses of flu vaccine at least 4 weeks apart during the first flu season that they are immunized. Children older than 2 years are eligible for the nasal vaccine if they do not have asthma, wheezing in the past 12 months or other medical conditions that predispose them to flu complications.
To see the full vaccine schedule including exact time frames between doses and catch up schedules, see: http://www.cdc.gov/vaccines/
Keywords: hospitalization, RSV, bronchiolitis (PubMed Search)
Willwerth B, Harper M and Greenes D. Identifying Hospitalized Infants Who Have Bronchiolitis and Are at High Risk for Apnea. Annals of Emergency Medicine 48 (4) 2006.