Pediatric forearm fractures:
You just finished assessing a 6 month old in the Pediatric ED who can’t move his right leg. You suspect child abuse. You’re ready to order labs, a head CT, ophtho consult, skeletal survey and call Child Protective Services. While your doing all of this, your medical student asks you, “What exactly are you looking for on the skeletal survey?”
A skeletal survey is mandatory for cases of suspected child abuse in children under the age of 2 years. Approximately 60% of the fractures seen in abused children are younger than 18 months old.
When you are looking at a skeletal survey, carefully look for the following:
1. Multiple, healing fractures of various ages
2. Rib fractures, especially in the posterior ribs
3. Metaphyseal chip and buckle fractures
4. Spiral fractures in long bones (especially in children that can’t walk)
5. Skull fractures which are not simple and linear
6. Scapula fractures
More to come about child abuse….
Classic Kawasaki is diagnosed by fever for greater than 5 days plus 4 out of 5 classic signs.
But what about an 8 month-old with 6 days of fever plus nonexudative conjunctivitis, unilateral cervical adenopathy and a diffuse maculopapular rash? Send some labs!
Incomplete Kawasaki is defined as fever for >5 days with 2 or more of the classic findings plus elevated ESR (>40mm/hr) and CRP (>3.0mg/dL). It is most common in infants under 12 months of age.
Disposition for the 8 month-old?
If the echo is normal, follow up in 24-48 hours and will need a repeat echo if fever persists.
TREAT kids with IVIG and aspirin (which generally means admission) if echo is positive, or with normal echo and the presence of 3 or more supplemental criteria:
1111251332_2009_Red_Book.doc (384 Kb)
Child Passenger Safety.
Perhaps one of the greatest contributions emergency physicians can provide to society comes in the form of anticipatory guidance. It is important to take the opportunity during the ED encounter to provide information to parents to prevent future injuries. Child passenger safety is one clear example. With over 330,000 pediatric visits to EDs across the US annually attributed to motor vehicle collisions, the need to provide clear recommendations to parents on how to restrain their children in their vehicle is paramount. Despite a recent survey of over 1000 EPs in which 85% of respondents indicated child passenger safety should routinely be a part of pediatric MVC discharge instructions, only 36% of EPs knew the latest guidelines on child passenger safety. The American Academy of Pediatrics provides such guidelines. These recommendations were recently adjusted in 2011.
(1) Infants up to 2 years must be in REAR-facing car seats
(2) Children through 4 years in forward-facing car safety seats
(3) Belt-positioning booster seat for children through at least 8 years old
(4) Lap-and-shoulder seat belts for those who have outgrown booster seats. How does one know when the child has outgrown the booster seat?
a. Can the child sit with his/her knees bent at the edge of the seat?
b. Does the shoulder belt lie across the middle of the chest/shoulder?
c. Does the lap belt lie across the upper thighs and not the abdomen?
(5) Children younger than 13 should sit in the rear seats
Special Thanks to JV Nable, MD, EMT-P for writing this pearl.
Peritoneal dialysis (PD) is a commonly used form of dialysis for pediatric patients with end-stage renal disease, particularly in children less than five years of age.
One well known complication to this mode of dialysis is PD-associated peritonitis.
Children may present with fever, abdominal pain and a cloudy dialysate.
If peritonitis is suspected, obtain sample of dialysate fluid and send for cell count, Gram’s stain and culture.
Cell count in PD-associated peritonitis is usually WBC >100 with >50% neutrophils.
Both gram-positive and gram-negative organisms are involved with PD-associated peritonitis . Keep both MRSA and Pseudomonas in mind.
In the ED, empiric therapy should cover both gram-positive and gram-negative organisms. Initiate antibiotic therapy with vancomycin and either a third-generation cephalosporin (ceftazidime) or aminoglycoside, respectively.
For PD-associated peritonitis, intraperitoneal (IP) administration of antibiotics is preferred over IV.
You are seeing a high school football player following a head injury. After your exam or head CT, you determine the child to have had a mild traumatic brain injury (aka concussion). You are ready to discharge him home when the parents or coach ask you when he can return to playing football.
A concussion is a form of functional, rather than structural, brain injury that displays no evidence of injury on structural neuroimaging. Symptoms include transient loss of consciousness, amnesia, vomiting, headache, poor school work, sleep changes, and emotional lability. Remember that children’s brains (even adolescents) are still developing, and are more prone to prolonged recovery following injury.
Recovery of symptoms usually follows a sequential course. Current guidelines recommend a stepwise return to play (aka concussion rehabilitation) involving both physical and cognitive rest (e.g. no texting, video games, limited school work). Once asymptomatic, the patient goes through each stage with at least 24 hours between stages. If symptoms return during a stage, then the patient is expected to return to the previous stage for 24 hours before attempting the higher stage again.
Return to Play Guidelines:
| Rehabilitation stage | Functional Exercise |
| Complete physical and cognitive rest |
| Walking, swimming, stationary cycling at 70% maximal heart rate, no resistance exercise |
| Specific sport related drills but no head impact |
| More complex drills, may start light resistance training |
| After medical clearance, participate in normal training |
| Normal game play |
References:
Infantile botulism
1) C-A-B for CPR. Now recommended to start compressions immediately instead of the conventional rescue breaths.
2) Capnography during CPR. Continuous capnography recommended during CPR to guide the resuscitation, especially the effectiveness of chest compressions.
a. If ETCo2 is less than 10 to 15 mm Hg consistently, focus your efforts on improving chest compressions.
3) Etomidate for RSI induction. Okay to use in infants and children, BUT not recommended for pediatric patients in septic shock. Etomidate was not addressed in 2005 guidelines.
4) Cuffed ET tubes. Acceptable to use in infants and children.
5) Limit FiO2 after resuscitation. Keep O2 sats ≥94%. Avoid hyperoxia.
6) Therapeutic hypothermia after cardiac arrest. Recommendation based off of adult data, no pediatric prospective RCT done on this. This is beneficial in adolescents with out-of-hospital VF arrest.
a. Consider therapeutic hypothermia for infants and children.
b. Cool to 32oC-34oC
Acute Poststreptococcal Glomerulonephritis (APSGN) is a sequela of group A beta-hemolytic streptococci (GAS) infection of the skin or pharynx with nephrogenic strains of GAS. Damage to the kidneys is due to deposition of antigen-antibody complexes in the glomeruli.
Presentation:
Testing:
Treatment:
Prognosis (favorable):
Reference:
Kit, Brian. Assess the volume status and electrolytes in children with poststreptococcal glomerulonephritis. Avoiding Common Pediatric Errors. 2008. p356-57.
You're called to bedside to evaluate a "lethargic" infant. You wisely ask for a POCT glucose which returns at 35. How much dextrose do you give (since you know it's not just "an amp" of D50?
Here's a simple mnemonic:
Rule of 50-100 = multiply type of dextrose solution by ____ factor (ml/kg) to total 50-100
D10 (neonate) x 5-10 ml/kg = 50-100
D25 (infant) x 2-4 ml/kg = 50-100
D50 (child/adolescent) x 1-2 ml/kg = 50-100
Now that summer is in full swing, the question is: Should the evaluation of the febrile young infant change during the summer and fall months? And can that affect length of hospitalization and antibiotic use?
Two retrospective cohort studies from the Children’s Hospital of Philadelphia (CHOP) suggest yes! The addition of enterovirus polymerase chain reaction (PCR) testing to cerebrospinal fluid (CSF) may improve the care of infants with fever during enterovirus season (early June through late October).
Of note, at CHOP: 1) infants 56 days or younger routinely undergo lumbar puncture during evaluation for fever. 2) Most CSF enterovirus PCR test results (90%) were available within 36 hours; 95% of results were available within 48 hours.
In the King study, having positive enterovirus PCR CSF results decreased the length of hospitalization and the duration of antibiotic use for young infants less than 90 days, supporting the routine use of this test during periods of peak enterovirus season. In multivariate
analysis, a positive CSF enterovirus PCR result was associated with a 1.54-day decrease in the length of stay and a 33.7% shorter duration of antibiotic use.
Bottom line: Consider adding enterovirus PCR testing to CSF obtained during the evaluation of febrile young infants during enterovirus season, as this may reduce length of hospitalization and duration of antibiotic use. The effects, however, may be limited at institutions with slower lab turnaround times.
References:
1) King RL, Lorch SA, Cohen DM, Hodinka RL, Cohn KA, Shah SS. Routine cerebrospinal fluid enterovirus polymerase chain reaction testing reduces hospitalization and antibiotic use for infants 90 days or younger. Pediatrics. 2007 Sep;120(3):489-96. http://pediatrics.aappublications.org/content/120/3/489.full.pdf
2) Dewan M, Zorc JJ, Hodinka RL, Shah SS. Cerebrospinal fluid enterovirus testing in infants 56 days or younger. Arch Pediatr Adolesc Med. 2010 Sep;164(9):824-30.
