UMEM Educational Pearls - By Rose Chasm

• 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. 

Show References

• 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!

Show References

• 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.

Show References

• 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)

Show References

• 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

Show References

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)

Show References

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.

Show References

• 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

Show References

• 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. 

Show References

• 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.

Show References

• 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

Show References

• 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

• 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

Show References

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 1^st 24 hours with 50% of total volume in 1^st 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

Show References

• 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

Show References

• 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

Show References

• 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

Show References

• 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

Show References

• 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.

Show References