UMEM Educational Pearls - By Rose Chasm

  • Pediatric visits for behavioral and mental health issues is on the rise.
  • From 2008 to 2015, rates of PED visits for suicidal thoughts/attempts doubled.
  • Shortage of pediatric psychiatrists:  8,300 nationwide with a need for 30,000.
  • Deinstitionalized Movement of 1980's, has worsened this ED crisis-based culture.
  • 50% of all mental illness begins by age 14.
  • 1 in 5 children experience a mental disorder in a given year.
  • Aggressive or agitated behavior in pediatric patients is different from adults.
  • Children are more amenable to environmental and behavioral techniques, especially verbal de-escalation, once a trigger is identified.
  • If not successful, avoid physical restraints and consider medications instead.
  • Review current or previously prescribed medications, and consider extra/early/higher dosing. If naive to medications:
  • First line is Diphenhydramine.
  • Followed by Chlorpromazine, Risperidone, and Olanzapine
  • Thorazine should be avoided in children under 12 years due to extra-pyramidal effects.
  • Lorazapam not recommneded in children under 12 years, as it can cause disinhibition and worsen behavior.
  • Avoid sedating children with neurodevelopmental disorders as they can have paradoxical reactions to diphenhydramine and benzodiazepines, and antipsychotics sometimes are not as effective.
  • Boarding is common due to lack of resources, so starting treatment in the ED is imperative. 

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Category: Pediatrics

Title: Pediatric Fever

Posted: 12/1/2018 by Rose Chasm, MD (Updated: 6/16/2019)
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As we enter cold and flu season, expect to see rising visits for pediatric patients with fever.  There is much evidence based literature regarding pediatric fever, but wives tales and misinformation persist.
  • No matter what the school nurse says, only a temperature >/= 100.4 F or 38 C is a fever.
  • Routine use of rectal and oral routes to measure temperature are not required to document a fever in children.
  • Use of electronic thermometers in the axilla is acceptable even in children under 5 years
  • Forehead chemical thermometers are unreliable.
  • Reported parental perception of fever should be considered valid and taken seriously.
  • Measure heart rate, respiratory rate, and capillary refill as part of the assessment of a child with fever.
  • Heart rate typically increases by 10, and respiratory rate increases by 7 for each 1 C temperature increase.
  • If the heart rate or capillary refill is abnormal in a child with fever, measure blood pressure.
  • Do not use height of temperature to identify serious illness.
  • Do not use duration of fever to predict serious illness.
  • Tepid sponging/bathing, underessing, and over-wrapping are not recommended in fever.
  • Do not give acetaminophen and ibuprofen simultaneously.

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  • Migraine diagnosis should only be made after other serious intracranial diagnoses have been ruled out.
  • Pediatric migraine is a difficult diagnosis to make before the age of 7 years, due to communication difficulties
  • Avoid opiates and barbiturates. They have not proven to be effective, and have been shown to decrease the effectiveness of future triptan treatments. 
  • First line treatment for mild to moderate migraines is acetaminophen and/or NSAID's.  The addition of caffeine, has been shown to potentiate the analgesic effects of both.
  • First line treatment for moderate to severe migraines is triptans.
  • Most pediatric migraines presenting to the ED, are severe migraines that have failed the above abortive home treatments and have persisted for 24+ hours.  These patients often require intravenous therapy.
  • Dopamine receptor antagonist, specifically Prochlorperazine, 0.15mg/kg, 10mg max, has demonstrated the greatest effectiveness. Consider administration with diphenhydramine, 1mg/kg, 50mg max to prevent dystonic reactions.
  • Concomitant dexamethasone, 0.6mg/kg, 20mg max administration has been shown to decrease acute recurrence.
  • If prochlorperazine fails, other alternatives include Sumatriptan, 5-20mg IN, 50-100mg PO and lidocaine, 0.5mL of 4% solution IN.
  • IVF hydration, and reduction of light and sound stimuli may be helpful.

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  • The rainy East coast spring has increased tick populations in endemic areas such as Maryland resulting in more tick bites.
  • ED visits for known tick bites present acutely, often with parents bringing in the tick to be identified/tested.
  • Routine serologic testing and antibiotic prophylaxis is not recommended after every tick bite.
  • If an attached tick is engorged, identified as I. scapularis, and has been attached for >36 hours, then antibiotic prophylaxis for Lyme can be prescribed if started within 72 hours of tick removal in those patients > 8 years of age
  • Prophylaxis: Single dose of doxycycline 4 mg/kg or 200mg max 
  • If early Lyme Disese is present in the form of the classic rash of Erythema migrans, then treatment is doxycycline, 4 mg/kg or 100mg max BID for patients > 8 years of age or amoxicillin 50 mg/kg per day divided TID with 500 mg max TID in those < 8 years of age for 14 days 
  • Serologic testing is false negative in the first month of testing, and unnecessary in the ED  for acute presentations. 

  • Stevens-Johnsons like rash and mucositis
  • Most common in children and adolescents, with a mean age of 12 years old
  • More common in males than females, 2:1
  • Prodromal symptoms of cough, fever, and malaise precede
  • Mucositis far out of proportion to body rash, 90% vs 10%
  • Mucositis is primarily oral > ocular > genital in distribution, and can be severe
  • Body rash may involve palms and soles
  • Complications: dehydration, GIB, epiglottitis, blindness, pericardial effusion
  • Testing: PCR nasal wash/BAL; agglutination assays IgM/IgG
  • Treatment: azithromycin and supportive care; occasionally steroids; rarely IVIG
  • Unlike Stevens-Johnsons, prognosis is good.

Category: Pediatrics

Title: Pediatric Cervical Spine Injuries

Posted: 12/29/2017 by Rose Chasm, MD (Updated: 6/16/2019)
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Children less than 8 years, and especially infants, are more susceptible to upper cervical spine injury.  Moreover, validated decision rules for suspected cervical spine injury imaging have not been proven to be as sensitive or specific for children less than 8 years of age.

The pediatric cervical spine has greater elasticity of the ligamentous structures, while the cartilaginous structures are less calcified. An infant's neck musculature is underdeveloped, with a disproportionally large head.  These factors increase the risk of cervical spine injury, and can make it difficult to properly place protective cervical collars in infants while assessing them for injury. 

In very young children, consider placing padding under the shoulders to prevent abnormal flexion that can occur with placement of a cervical collar, and consider having a lower threshold to image if mechanism history or exam is concerning.

Children are not little adults!  Clinicians must acknowledge the anatomic differences, varying age-related ability to cooperate with examination, pediatric specific injury mechanisms, and decreased reliability of validated decision rules for imaging in children, especially when younger than 8 years old.

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  • Evidence-based guidelines recommend therapeutic hypothermia in adults following resuscitation from cardiac arrest.
  • Very few trials exist for children.
  • The most recently published study on the subject (New England Journal of Medicine, May 2015) was of 295 children aged 2 days to 18 years old, at 38 different childrens hospitals who underwent targeted temperature management. 
  • There was no significant difference in primary outcome between the hypothermia and normothermia groups.  One year survival and 28-day survival were similar, as were incidences of infection, serious arrhythmias, and use of blood products.
  • "In comotose children who survived out-of-hospital cardiac arrest, therapeutic hypothermia, as compared with therapeutic normothermia , did not confer a significant benefit in survival with a good functional outcome at 1 year."

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  • Pediatric forearm fractures are common, and on the rise due to increasing sporting activity and increasing BMI.
  • The most common mechanism is falling on an outstretched hand, which often leads to rotational displacement. 
  • If not properly reduced, it leads to reduced range of motion.
  • The majority do well with closed reduction, if properly reduced.
  • A recent study (Debrovsky, et al. Ann of Emerg Med), found  the accuracy of bedside ultrasonography to determine when pediatric forearm fractures have been adequately realigned was comparable to fluoroscopy. 
  • Consider using US for post-reduction evaluation of pediatric forearm fractures to reduce radiation exposure, cost, and time.

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Category: Pediatrics

Title: Intranasal Ketamine

Posted: 1/10/2015 by Rose Chasm, MD (Updated: 6/16/2019)
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  • Ketamine popularity for procedural sedation is on the rise, again.  It provides pain relief, sedation, and memory loss while maintaining airway reflexes and has little effect on the heart. 
  • Traditional administration has been the intravenous or intramuscular route, but consider intransal now. 
  • Recent articles have touted the intranasal administration of ketamine for pediatric procedural sedation with good success.
  • Admittedly, the number of patients enrolled in the studies to date have been small and the dosages have varied from 1 to 9 mg/kg/dose.  However, none of the studies have reported any bad outcomes or complications.
  • So, consider IN ketamine for your next pediatric procedural sedation. 

 

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Category: Pediatrics

Title: Hirschsprung's disease

Posted: 12/13/2014 by Rose Chasm, MD (Updated: 6/16/2019)
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  • Irregular bowel movements and constipation are a common complaint pediatric complaint.
  • The majority of cases are functional, but providers should take extra care to rule out organic causes like Hirschsprung's disease particularly during the neonatal period. 
  • 1 in 5000 incidence, with abnormal innervation of the distal colon resulting in tonic contraction, and obstruction of feces.
  • In most cases, the agangionic segment is limited to the rectosigmoid area.
  • Symptoms usually begin in the first month of life and consist of obstuctive complications such as abdominal distension, bilious vomiting, and poor feeding.
  • Rectal examination should be done in all patients with constipation, and often reveals a narrowed high-pressure region adjacent to the anal sphincter.
  • Barium enema, anal manometry, and rectal biopsy all aid in the diagnosis.

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Category: Pediatrics

Title: Pediatric Pneumonia

Posted: 10/10/2014 by Rose Chasm, MD (Updated: 6/16/2019)
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  • For uncomplicted community acquired pneumonia which is treated as an outpatient, high dose amoxicillin (80-90mg/kg/day) is the first-line antibiotic of choice.
  • Macrolides and third-generation cephalosporins are acceptable alternatives, but are not as effective due to pneumococcal resistance and lower systemic absorption, respectivley.
  • Hospitalization should be strongly considered for children younger than 2 months or premature due to an increased risk for apnea.
  • Patients hospitalized only for pneumonia, should be treated with ampicillin while those who are septic should be treated with a combination of vancomycin along with a second- or third- generation cephalosporin.

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Category: Pediatrics

Title: Enterovirus D68

Posted: 9/12/2014 by Rose Chasm, MD (Updated: 6/16/2019)
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  • The human enterovirus D68 is a rare virus closely related to the rhinovirus which causes the common cold.  However, there have been recent outbreaks throughout the midwest and the areas are rapidly expanding.
  • Mild symptom onset of rhinorrhea and cough rapidly progress to hypoxia and respiratory distress.
  • Key features are the rapid progression, presence of wheezing even without a history of reactive airway disease, and typically an absence of consolidation on chest XR.
  • Children under 5 years and those with asthma are at the greatest risk for respiratory failure.
  • There are a limited number of labs in the US which test specifically for EV-D68. At UMMC, the Luminex respiratory virus panel can be ordered using the kit form which includes a flocked swab and viral transport media.  Unfortunately, the panel does not differentiate between the closely related enterovirus and rhinovirus. 
  • There is no definitive cure, rather only supportive care and low-threshold for admission/observation for high risk patients.

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Some Pearls concerning Strep Throat in Kids:
  • Only treat strep pharyngitis after confirmed via rapid antigen test or culture
  • Remember the rapid antigen test has high specificity, but low sensitivity.  All negative rapid antigen tests should be followed up with a confirmatory culture
  • Traditionally, strep pharyngitis was treated with penicillin V, 250mg PO tid for children and 500 mg tid for adolescents. This was then changed to bid dosing.
  • Now, consider treating with amoxicillin, 50mg/kg once daily (max 1000mg). Once daily dosing and better taste improve compliance 
 

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  • Over the last decade, multiple studies have shown that pain and sedation in children can be easily and quickly treated via intransal administration of traditional drugs.
  • Inexpensive atomizers are used to quickly administer medications which are absorbed through the mucosal surface and rapidly delivered to the bloodstream and CNS with equivalent effects to intravenous administration.
  • Considerations include using concentrated forms as volumes greater than 1mL per nostril may over-saturate the mucosa and drip out rather than be fully absorbed.
  • The few side effects included cough, vocal cord irritation, and laryngospasm; but pre-treating with a single puff of lidocaine spray minimizes them and has been found to enhance sedative effects.
  • Fentanyl, 2mcg/kg for pain
  • Midazolam, 0.2 - 0.5mg/kg for sedation and antiepileptic.
  • Ketamine and Dexmedetomidine have also been used with success, but standardized doses are still being studied. 

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Category: Pediatrics

Title: Sweets Before Sticks

Posted: 4/11/2014 by Rose Chasm, MD (Updated: 6/16/2019)
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  • Male infants are routinely given a sweet solution prior to circumcision for analgesia.
  • Michelis and Hoyle recently published a great review of the possible use of sweet solutions in the ED for pediatric patients.
  • Pediatric patients often undergo painful, but rather routine procedures in the ED such as IV and urinary catheter placement, venipuncture, and lumbar punctures.
  • More often than not, however, they are not provided analgesia prior to these procedures.
  • It is believed that repetitive early pain events lead to anxiety and other behavioral disorders while also decreasing pain tolerance.
  • In children less than 12 months, consider giving a sweet solution (2mL of 24% sucrose) 2 minutes before any painful procedure.
  • Multiple studies indicate decreased pain as measured by significantly reduced crying times.
  • It's cheap, safe, and works!

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  • Much attention has been paid towards early goal-directed therapy for sepsis in adult ED patients, but there has not been as much consideration for the pediatric ED patient. 
  • R-C analyses and M&M reviews have consistently identified system difficulties  recognizing sepsis in children, especially cases of compensated shock, and subsequent management.
  • Protocols beginning in triage to recognize abnormal vital signs, followed by timely execution of interventions especially antibiotic and fluid administration are worthwhile to reduce overall morbidity and mortality.
  • Protocols should include 3 major goals:
  1. Triage vital signs adjusted for age, and corrected heart rate for pyrexia to recognize sepsis.
  2. Obtain vascular access within 5 minutes followed by a 20mL/kg bolus of IV fluids administered within 15 minutes in cases of volume depletion.
  3. Antibiotic administration within 30 minutes.

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  • Significant morbidity and mortality has been consistently documented in pediatric sickle cell patients due to overwhelming sepsis from encapsulated organisms, especially S. pneumoniae
  • All pediatric sickle cell patients presenting with fevers greater than 101.5F (38.6C) should receive antibiotics within 60 minutes of triage.
  • Historically, and still in many pediatric sickle cell centers, ceftriaxone (75mg/kg/dose) is administered
  • However, reported cases of deadly intravascular hemolysis in pediatric sickle cell patients whom had recieved multiple doses of ceftriaxone has led to new recommendations for antibiotic coverage to include cefuroxime (200mg/kg/day) or ampicillin/sulbactam (200mg/kg/day)

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  • occurs during neonatal period
  • sterile pustules which then change to hyperpigmented macules, often with a rim of scale
  • may persist up to 3 months
  • histology is characterized by leukocytes
  • benign condition with no sequelae
  • requires no treatment

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Category: Pediatrics

Title: PECARN Head Injury Rule

Posted: 8/10/2013 by Rose Chasm, MD (Updated: 6/16/2019)
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Clinically important traumatic brain injuries are rare in children.  The PECARN study provides decision rules for when to avoid unnecessarily obtaining a CT for children who have suffered head trauma.

For children < 2 years old: <0.02% risk of clinically important TBI

  • Normal mental status
  • No scalp hematoma, except frontal
  • Loss of consciousness < 5 seconds
  • No palpalble skull fracture
  • Normal behavior
  • Nonsevere mechanism (fall < 3ft, pedestrian struck, rollover MVC)

For children > 2 years old: <0.05% risk of clinically important TBI

  • Normal mental status
  • No signs of basilar skull fracture
  • No loss of consciousness
  • No vomiting
  • No severe headache
  • Nonsever mechanism (fall < 5ft, pedestrian struck, rollover MVC)

 

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Category: Pediatrics

Title: Pediatric Appendicitis Score

Posted: 7/12/2013 by Rose Chasm, MD (Updated: 6/16/2019)
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Risk stratisfication score introducted by Maden Samuel in 2002.

The Pediatric Appendicitis Score had a sensitivity of 1, speciificity of 0.92, positive predictive value of 0.96, and negative predictive value of 0.99

Signs:

  • Right lower quadrant tenderness = 2 points
  • Cough/Percussion/Hop RLQ tenderness = 1 point
  • Pyrexia = 1 point

Symptoms:

  • RLQ migration of pain = 1 point
  • Anorexia = 1 point
  • Nausea/Vomiting = 1 point

Laboratory Values:

  • Leukocytosis = 2 points
  • Polymorphonuclear neutrophiia = 1 point

Scores of 4 or less are least likely to have acute appendicitis, while scores of 8 or more are most likely.

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