UMEM Educational Pearls - By Rose Chasm

Category: Pediatrics

Title: PECARN Head Injury Rule

Posted: 8/10/2013 by Rose Chasm, MD (Updated: 2/27/2020)
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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: 2/27/2020)
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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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Category: Pediatrics

Title: Coxsackie Virus Infections

Posted: 6/14/2013 by Rose Chasm, MD (Updated: 2/27/2020)
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  • enterovirus which lives in digestive tract, and is highly contagious
  • outbreaks worse in summer and fall, but is a self-limited illness
  • causes mild flu-like symptoms such as fever, headache, muscle aches, sore throat. with fever usually lasting less than 3 days
  • hand, foot, and mouth disease: syndrome of painful blisters in oropharynx and plams of hands and soles of feet
  • herpangina: painful blisters in oropharynx, usually posterior in location
  • hemorrhagic conjunctivitis: eye pain with injected conjunctivia
  • serious complications include: viral meningitis and encephalitis, myocarditis, and secondary bacterial infections

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  • diarrhea lasting less than 14 days
  • in children, almost all diarrhea is due to an infectious agent
  • most etiologies are self-limited and do not need further evaluation except in the following conditions:
  1. infants < 2 months of age
  2. gross blood in stool
  3. WBC's on microscopic exam of stool
  4. toxic-appearance
  5. immunocompromised child
  6. diarrhea developing while an inpatient
  • therapy is aimed at oral rehydration and providing nutrional needs
  • ORT is best with commerical formulations specific for this as most other clear liquids (juice, sodas) are hypertonic and have excess glucose resulting in ongoing diarrhea-like stools
  • after rehydration, resume the child's normal diet. 

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  • CDC recommends pediatric influenza antiviral treatment for those at higher risk for influenza complications, and include the following:
  1. less than 2 years of age;
  2. chronic diseases including: pulmonary (ie asthma), cardiovascular (except hypertension alone), renal, hepatic, hematologic (ie sickle cell disease), metabolic (ie diabetes), neurologic/neurodevelopmental (ie cerebral palsy, epilepsy), and intellectual disability (ie mental retardation)
  3. immunosuppression (ie HIV)
  4. less than 19 years of age and on chronic aspirin treatment;
  5. morbid obesity (BMI>40)
  • adamantanes (amantadine and rimantadine) should not be used due to high levels of resistance to influenza A
  • neuraminadase inhibitors (oseltamivir and zanamivir) should be started within 48 hours of illness onset to reduce the duration and severity of disease
  • oseltamivir can be used in children as young as 2 weeks of age at a dose of 3mg/kg twice daily for 5 days.

 

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Category: Pediatrics

Title: Pediatric Cerebral Edema in DKA

Posted: 10/12/2012 by Rose Chasm, MD (Updated: 2/27/2020)
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  • approximately 1% of children in DKA have some degree of cerebral edema, and up to 25% of them may die
  • known risk factors include the following:
  1. younger children (especially <5 years)
  2. new onset or newly diagnosed
  3. increased BUN at presentation
  4. severity of acidosis at presentation
  5. bicarbonate therapy use
  6. failure of sodium to improve following therapy

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Category: Pediatrics

Title: Night Terrors

Posted: 9/15/2012 by Rose Chasm, MD (Updated: 2/27/2020)
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  • sleep disruption silimar to a nightmare, but much more dramatic most often between 4-12 years
  • sudden fear reaction which occurs during the transition to and from deep non-REM sleep while nightmares occur during REM sleep
  • occurs 2-3 hours after falling asleep when the child suddenly awakens in distress and may thrash about, scream, cry
  • child returns to sleep with no memory of the event the following morning
  • often occurs when a child is stressed, overtired, on new medication, or sleeping in a new environment
  • do not awaken the child during the event but rather allow them to calm on their own

  • small growth of grainy pink/redish tissue that forms on an area of the umbilical stump which is inflamed and produces a sticky mucous dishcarge not allowing normal tissue to grow on top of it
  • caused by abnormal tissue healing after the remaining umbilical cord dries up and falls off
  • treatment is painless as the granuloma lacks innervation, and requires applying chemical silver nitrate directly to the granumloma to burn the tissue off
  • although rare, careful examination of the tissue is needed to enssure the tissue is not intestinal or bladder in origin

Category: Pediatrics

Title: Laryngomalacia

Posted: 7/13/2012 by Rose Chasm, MD (Updated: 2/27/2020)
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  • congenital disorder which is the most common cause of stridor in infancy
  • larynx appears disproportionately small, and supporting structures are abnormally soft
  • stridor begins within the first 4 weeks of life, and accentuates with increased ventilation (crying, excitement, URI, etc.)
  • stridor usually resolves by 12 months but may recur with URI until about 3 years of age
  • diagnosis is by fiberoptic bronchoscopy or direct laryngoscopy
  • therapy is usually not needed, but rarely laser therapy of redundant tissue or traceostomy when stridor occurs with failure to thrive or apnea

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Category: Pediatrics

Title: Pediatric Burns

Posted: 6/29/2012 by Rose Chasm, MD (Updated: 2/27/2020)
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Submitted by Dr. Lauren Rice

The summertime can be full of lots of fun activities (beach, fireworks, cookouts, and campfires) that can put children at risk of burns. 

Burn depth classification:

1. Superficial (first-degree): red and blanching with minor pain, resolves in 5-7 days 

2. Partial thickness (second-degree): red and wet with blisters, very painful, resolves in 2-5 weeks

Treatment: clean with soap and water twice daily, and apply silvadene wrap with gauze, kerlex

3. Full thickness (third-degree): dry and leathery without pain, no resolution after 5-6 weeks, may require graft

Treatment:  wound debridement and dressings as above

Parkland formula: 4ml/kg/%TBSA in 1st 24 hours with 50% of total volume in 1st 8 hours

 Calculate burn surface area:

-SAGE: free computerized burn diagram available at www.sagediagram.com

-Rule of Nines > 14 years old

-Rule of Palm <10 years old

Burn Center Referral

-Extent: partial thickness of >30% TBSA or full thickness of >10-20%

-Site: hands, feet, face, perineum, major joints

-Type: electrical, chemical, inhalation

 

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  • usually in preschool or early school-age children presenting with tea-colored urine
  • most commonly is postinfectious (following URI)
  • may also have periorbital edema and high blood pressure
  • UA shows blood, and microscopy shows RBC's and RBC casts
  • no definitive emergent treatment, but prognosis is usually good with resolution of symptoms over 8-10 weeks

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Category: Pediatrics

Title: Paroxysmal Torticollis of Infancy

Posted: 3/31/2012 by Rose Chasm, MD (Updated: 2/27/2020)
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  • both head tilting to one side and rotation of the chin toward the other side
  • develops during infancy with episodes that last for hours to days
  • idiopathic neurologic condition which wanes after 2 years and stops by 3 years
  • mild delays in fine and gross motor skills are common along with family history of migraines
  • no accepted medical treatment or therapy
  • must have a normal physical and neurological examination that does not include abnormal/assymetric muscle tone, abnormal eye movements, or cranial nerve palsy

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  • acute gastroenteritis is a self-limited illness
  • however, damage to the brush border of the small intestine mucosa where lactase is present may lead to a secondary lactase deficiency and subsequent inability to digest lactose properly
  • partially or minimally digested lactose moves into the colon where it is fermented by enteric bacteria resulting in hydrogen, carbon dioxide, and acids
  • these byproducts result in symptoms reported for those with lactase deficiency: cramps, abominal pain and distension, and flatulence
  • the increased solute load in the large intestine leads to increased osmotic pressure, causing watery diarrhea
  • early refeeding following gastroenteritis is recommended, but many clinicians recommend dairy restricted diets acutely

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Category: Pediatrics

Title: Growing Pains

Posted: 2/10/2012 by Rose Chasm, MD (Updated: 2/27/2020)
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  • diagnosis of exclusion
  • bilateral leg pain only in the evening/night
  • should NOT have a limp, pain, or symptoms during the day
  • completely normal physical exam
  • no systemic symptoms, localizing signs, joint involvement, or limitation of activity
  • look for something else if there is anything wrong on review of systems, examination, or imaging studies

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Category: Pediatrics

Title: Bechet Disease

Posted: 12/30/2011 by Rose Chasm, MD (Updated: 2/27/2020)
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  • vasculitis of small vessels with neutrophilic infiltration of venules and arterioles
  • classic triad:  painful recurrent oral and genital ulcers with inflammatory eye disease
  • key finding of recurrent buccal apthous ulcers (nearly 100% of patients)
  • diagnosis is made when recurrence of oral ulceration occurs at least 3 times in 1 year plus 2 of the following: recurrent genital ulceration , eye lesions, skin lesions, or positive pathergy test.
  • initial ED treatment is corticosteroids (oral or topical).  Reserve colchicine and pentoxifylline for ulcerative maifestations.

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  • causes gastric outlet obstruction and vomiting
  • 1 in every 500 infants; with a 4:1 male-to-female ratio and a family history in another sibling
  • symptoms begin 2-4 weeks after birth, with projectile NON-bilious vomiting
  • firm, mobile, nontender, olive-shaped mass in right hypochondrium or epigastric area
  • diagnosis confirmed with US or upper GI series
  • treatment is a pyloromyotomy, but fluid and electrolyte replacement is vital in ED

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Category: Pediatrics

Title: Newborn Erb Paralysis

Posted: 11/11/2011 by Rose Chasm, MD (Updated: 2/27/2020)
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  • ocurs with significant lateral traction during vaginal delivery of an infant
  • results in damage to the upper part of the brachial plexus, especially the 5th and 6th cervical roots
  • results in paralysis of hte shoulder and arm
  • the affected arm is held in adduction and internal rotation
  • most resolve spontaneoulsy, but some may require physical therapy after 2 weeks
  • surgery is rarely required, and has poor results
  • always palpate for ipsilateral clavicel fractures!

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Category: Pediatrics

Title: Cerebral Edema in Pediatric DKA

Posted: 10/14/2011 by Rose Chasm, MD (Updated: 2/27/2020)
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  • 0.3-1.5% of all pediatric DKA cases
  • 21-24% mortality rate
  • usually at 4-12 hours after therapy starts
  • risk factors:  <5years old, new onset diagnosis, increased BUN at presentation, severity of acidosis at presentation, bicarbonate use
  • have low threshold to diagnose and treat:  don't wait to treat for the CT!

Category: Pediatrics

Title: Pediatric ECG

Posted: 9/9/2011 by Rose Chasm, MD (Updated: 2/27/2020)
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  • newborns have a thick right ventricle resulting in a mean QRS axis which points anteriorly and to the right demonstrating a right axis deviation (70-180degress) and large R waves in the precordium
  • by 3 months of age, the QRS axis in the frontal plane shifts to the left with a mean of 65degress (0-125degress)
  • by older childhood, the normal mean QRS axis is -30-100degress)
  • thus, with age the R wave decreases in V1 and increases in V6
  • take home:  right-axis deviation is often a normal finding in children and young adults when you see left-axis deviation in children consider tricuspid atresia, atrioventricular septal defects, and LVH as the most associated conditions

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  • occurs when the small opening in the abdominal muscles which allows passage of umbilical cord does not completley close after birth
  • allowing intestinal loops to pass through the opening
  • 10% of all children are affected
  • more common in blacks, girls, and premature infants
  • most resolve by age 1year, but consider outpatient referral if becoming larger or still present after 2-3 years of age
  • emergent consultation if not reducible, but rarely as most are harmless