Patellar dislocations:
References:
1. http://emedicine.medscape.com/article/90068-overview
2. New England Musculoskeletal Institute. http://nemsi.uchc.edu/clinical_services/orthopaedic/knee/patellar_dislocation.html
Rashes that include palms/ soles
- Hand-Foot-Mouth Disease
- Kawasaki
- Erythema multiforme/ Stevens Johnson's Syndrome/ Toxic Epidermal Necrolysis
- Rocky Mountain Spotted Fever
- Scabies
- Syphillis
Rashes that have +Nikolsky's sign
- Scalded Skin Syndrome
- TEN
- Pemphigus Vulgaris
Rashes that desquamate
- Scalded Skin Syndrome
- Toxic Shock Syndrome
- Scarlet Fever
- Kawasaki
- TEN
Children & Appendicitis
Potential Causes of Neonatal Apnea and Bradycardia
• Central nervous system
Intraventricular hemorrhage, drugs maternal/fetal, seizures, hypoxic injury, herniation, neuromuscular disorders, brainstem infarction or anomalies (e.g., olivopontocerebellar atrophy), general anesthesia.
• Respiratory
Pneumonia, obstructive airway lesions, upper airway collapse, atelectasis, extreme prematurity (<1,000 g), phrenic nerve paralysis, severe hyaline membrane disease, pneumothorax, hypoxia, malformations of the chest.
• Infectious
Sepsis, meningitis (bacterial, fungal, viral), RSV
• Metabolic
Hypoglycemia, hyper/hyponatrmia, hyperammonemia, decreased organic acids, hypothermia.
• Cardiovascular
Hypotension/hypovolemia, heart failure, PDA, anemia, vagal tone.
There are limited direct comparisons of (intravenous (IV) vs. intramuscular (IM) ketamine for pediatric procedural sedation in the emergency department. The only RCT comparing IV and IM ketamine was by Roback et al. and compared an IV dose of 1mg/kg vs. IM 4mg/kg. The study authors reported less procedural pain with IM administration compared with IV. However, vomiting occurred more frequently in the IM group, 26.3% compared to 11.9% in the IV group and recovery time was 49 minutes shorter with IV vs IM use.
Route Onset Duration Dose
IM 3-5 min 20-30min 3-5 mg/kg
IV 1 min 5-10 min 1-2 mg/kg
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:
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.
