UMEM Educational Pearls - Pediatrics

• The assessment of peripheral nerves in children with upper limb injuries can be challenging. 
• Neurovascular deficit was not documented in 25% of children presenting with upper extremity injury
• BOAST (British Orthopedic Association Standards for Trauma) guidelines state that each of the Median, Ulnar, Radial, Anterior Interosseous Nerve exams must be individually documented in any supracondylar fracture
• Dawson described an easy way to test and document your exam. Have the child play “Rock, Paper, Scissors, Ok”
  • Rock: tests the Median nerve
  • Paper: tests the Radial nerve
  • Scissors: tests the Ulnar nerve
  • Ok: tests the Anterior Interosseous nerve
• This method increased proper documentation and reduced missed nerve injuries in upper extremity fractures.
• Dr. Sarah Edwards and Dr. Hannah Lock created an easy infographic in the link below and found near 100% increase in NV documentation in their ED. Their poster won the prize for best infographic at the 2018 Emergency Medicine Educators' Conference (EMEC)
• https://www.peminfographics.com/infographics/rock-paper-scissors-ok

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Gunshot injuries are a leading cause of morbidity and mortality in the pediatric population.  The Pediatric Trauma Society supports the use of tourniquets in severe extremity trauma.  The Combat Application Tourniquet (CAT) that is commonly used in adults has not been prospectively tested in children.  This study used 60 children ages 6 through 16 years and applied a CAT to the upper arm and thigh while monitoring the peripheral pulse pressure by Doppler.  The CAT was successful in occluding arterial blood flow in all of the upper extremities and in 93% of the lower extremities.

Bottom line: The combat application tourniquet can stop arterial bleeding in the school aged child.

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-Benzodiazepines alone are effective in terminating status epilepticus in 40 to 60% of pediatric patients

-The guidelines for second line agents are based on observational studies and expert opinion

-Adverse effects of phenytoin include hepatotoxicity, pancytopenia, Stevens-Johnson syndrome, extravasation injuries, hypotension and arrhythmias

- Levetiracetam has a reduced risk of serious adverse events, greater compatibility with IV fluids and can be given in 5 minutes versus 20 minutes for phenytoin.

Bottom line: In a recent randomized control trial they found that levetiracetam was not superior to phenytoin as a second line agent for management of convulsive status epilepticus in children.  There was no difference between efficacy or safety outcomes between the two groups.

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Presentation:

- Prepubertal females are especially susceptible to urethral prolapse

- Can present incidentally is a painless mass found during bathing or on exam

- More commonly presents as urogenital bleeding, dysuria, or (rarely) urinary retention

Evaluation:

- Appears as a partial or circumferential "donut" of bright red, often friable prolapsed mucosa

- Typically occurs in the setting of UTI, cough, or constipation

- Need to rule out complications: UTI, urethral necrosis, and urinary retention

Treatment:

- Medical management start with sitz baths twice daily and addressing causative factors (treatment constipation, UTI, etc.)

- Can add either topical corticosteroid (hydrocortisone) or estrogen (Estrace or Premarin 0.01% twice daily)

- Urology follow-up necessary as many will require surgical resection of prolapsed mucosa

Washington state was one of the first states to legalize recreational marijuana use.  Toxicology call center data was collected on patient's 9 years old and younger with marijuana exposure between July 2010 and July 2016.  There were 161 cases during that time frame and of those 130 occurred after the legalization of recreational marijuana (over a 2.5 year period).  The median age range was 2 years old.  There were increasing cases noted after recreational marijuana was legalized and again after marijuana shops became legal.

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Measles outbreaks have been reported all over the globe, with the incidence increasing due to low immunization rates.  Italy experienced 5000 cases in 2017. This study was a retrospective multicenter observational study of children less than 18 years hospitalized for clinically and laboratory confirmed measles over a year and a half period from 2016-2017.

There were 263 cases of measles that required hospitalization during this time and 82% developed a complication with 7% having a severe clinical outcome defined by a permanent organ damage need for ICU care or death. A CRP value of greater than 2 mg/dL was associated with a 2-4 fold increased risk of developing complications. 23% developed pneumonia and 9.6% developed respiratory failure.  Hematologic involvement was seen in 48% of patients.  1.2% of hospitalized patients died.

Bottom line: Consider CRP, lipase and CBC at a minimum in your patients with suspected measles who require hospitalization.

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Over 630,000 children visit the ED every year with a diagnosis of concussion

Predictors of persistent post-concussive symptoms (PPCS):

• female sex
• age over 13 years
• previous concussive symptoms lasting over 1 week
• headache
• sensistivity to noise
• fatigue
• slow response to questions.

Appromixately 1/3 of pediatric patients will have PPCS lasting over 2 weeks

Likelihood of PPCS increases to >50% in those with risk factors identified in the ED

Every state has a youth concussion law. The basic tenants are a) immediate removal from play b) written clearance from health professional to return to play c) education for athlete, parents, coaches.

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• 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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The hyperoxia-hyperventilation test (aka 100% Oxygen Challenge test) is used to differentiate the cause of central cyanosis in the sick neonate. The majority of neonatal cyanosis is caused by either cardiac or respiratory pathology.

Classically the test is performed as follows:

1. An ABG is obtained with the neonate breathing room air

2. The patient is placed on 100% FiO2 for 10 minutes

3. A repeat ABG is performed looking for an increase in PaO2 to >150 mmHg

 -   If the hypoxia is secondary to a respiratory cause, the PaO2 should increase to >150 mmHg.

-    If the hypoxia is secondary to a congenital cardiac lesion (i.e. secondary to a right-to-left cardiac shunt) the PaO2 is not expected to rise significantly. 

In practice, many physicians instead use pulse oximetry and monitor the SpO2 pre and post administration of 10 minutes of 100% FiO2.

-          If after 10min of 100% FiO2, if SpO2 is not ? 95% (some resources use 85%) then the central cyanosis is likely secondary to intracardiac shunt.

-          When this occurs, presume the sick neonate is symptomatic from a congenital cardiac lesion and initiate prostaglandin E-1 (PGE1) at 0.05-0.01 mcg/kg/min. Use caution as PGE1 may cause apnea.

Hyponatremia is the most common electrolyte abnormality in hospitalized patients, affecting approximately 15-30% of patients.  Children have historically been given hypotonic maintenance IV fluids based off of theoretical calculations from the 1950s.  Multiple studies have shown complications related to iatrogenic hyponatremia, including increased length of hospital stay, seizures and death.

The American Academy of pediatrics completed a systematic review and developed an updated clinical practice guideline:

Patient's age 28 days to 18 years requiring maintenance IV fluids should receive isotonic solutions with the appropriate amount KCl and dextrose.

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Post tonsillectomy hemorrhage occurs and 0.1-3% of post tonsillectomy patient's.  It occurs typically greater than 24 hours after surgery and up to 4-10 days postoperatively.  A survey of otolaryngologists showed that ED management strategies for active bleeding have included direct pressure, clot suction, silver nitrate, topical epinephrine, and thrombin powder.

This article was a case study demonstrating the use of nebulized tranexamic acid (TXA) for post tonsillectomy hemorrhage in a 3-year-old patient.  The patient had a copious amount of oral bleeding and had failed treatment with nebulized racemic epinephrine and direct pressure was not an option due to the patient's cooperation and small mouth.  250 mg of IV TXA was given via nebulizer with a flow rate of 8 L.  Bleeding stopped 5-7 minutes after completion of the nebulizer.  The patient was then taken to the OR for definitive management.  No adverse effects were noticed.

TXA in the pediatric population has been shown to decrease surgical blood loss and transfusions in cardiac, spine and craniofacial surgeries.  Studies have also been done in pediatric patients with diffuse alveolar hemorrhage using doses of 250 mg for children less than 25 kg and 500 mg for those who are greater than 25 kg.

Bottom line: There are case reports of nebulized TXA use in the pediatric population with no adverse outcomes noted.  More research is needed.

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Acute Disseminated Encephalomyelitis (ADEM) is primarily a pediatric disease and can cause a wide variety of neurologic symptoms. As such, should always be in the differential for pediatric patient presenting with vague neurologic symptoms including altered mental status. It is an immune-mediated, demyelinating disease that can affect any part of the CNS; usually preceding a viral illness or rarely, immunizations.

The average age of onset is 5-8 years of age with no gender predilection. It usually has a prodromal. That includes headache, fever, malaise, back pain etc. Neurological symptoms can vary and may present with ataxia, altered mental status, seizures, focal symptoms, behavioral changes or coma.

MRI is the primary modality to diagnose this condition. Other possible indicators may be mild pleocytosis with lymphocyte predominance, and elevated inflammatory markers such as ESR, CRP. These findings, however, are neither sensitive nor specific.

First-line treatment for ADEM is systemic corticosteroids, typically 20-30 mg/kg of methylprednisolone for 2-5 days, followed by oral prednisone 1-2 mg/kg for 1-2 weeks then 3-6-week taper. For steroid refractory cases, IVIG and plasmapheresis may be considered.

ADEM usually has a favorable long-term prognosis in the majority of patients. However, some may experience residual neurological deficits including ataxia, blindness, clumsiness, etc.

Take home points:

• Always keep ADEM on the differential for any pediatric patient presenting with any neurologic symptoms
• MRI is the diagnostic modality of choice.
• If ADEM diagnosed, start treatment early in conjunction with pediatric neurology.

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Historically uncuffed endotracheal tubes were used in children under the age of 8 years due to concerns for tracheal stenosis.  Advances in medicine and monitoring capabilities have resulted in this thinking becoming obsolete.  Research is being conducted that is showing the noninferiority of cuffed tubes compared to uncuffed tubes.  Multiple other studies are looking into the advantages of cuffed tubes compared to uncuffed tubes.

The referenced study is a meta-analysis of 6 studies which compared cuffed to uncuffed endotracheal tubes in pediatrics.  The pooled analysis showed that more patients needed tube changes when they initially had uncuffed tubes placed.  There was no difference in intubation duration, reintubation occurrence, post extubation stridor, or racemic epinephrine use between cuffed and uncuffed tubes.

Bottom line: There is no difference in the complication rate between cuffed and uncuffed endotracheal tubes, but uncuffed endotracheal tubes did need to be changed more frequently.

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• 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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Coins are the most commonly ingested foreign body in the pediatric age group with a peak occurrence in children less than 5 years old.  X-rays are considered the gold standard for definitive diagnosis and location of metallic foreign bodies.  This study aimed to find a way to decrease radiation exposure by using a metal detector.

19 patients ages 10 months to 14 years with 20 esophageal coins were enrolled in the study.  All proximal esophageal coins were detected by the metal detector.  5 patient's failed initial detection of the coin with the metal detector and all of those patients had the coin in the mid or distal esophagus with a depth greater than 7 cm from the skin.

Bottom line: A metal detector may detect proximal esophageal coins.  This may have a role in decreasing repeat x-rays.

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Historically, the C-reactive protein (CRP) has been used in the assessment of the febrile child and is the only biomarker recommended by the National Institute for Health and Care Excellence (NICE).

CRP increases 4-6 hours after the onset of inflammation, doubling every 8 hours and peaking at 36-50 hours.  It rapidly decreases once the inflammation has resolved.

An elevated CRP alone is not conclusive of a serious bacterial infection (SBI).

A CRP >75 mg/L increased the relative risk of SBI by 5.4.

A CRP <20 mg/L decreased the risk of SBI, but there was still a small subset of children where SBI was present.

In infants < 3 months initial CRP measurements are poorly accurate, but when trended may be useful in deciding when to stop antibiotics (rather then when to start them).  A normalizing CRP demonstrated a 100% negative predictive value for excluding invasive bacterial infection.

Bottom line:

CRP is not a rule in/rule out test

CRP is not helpful in diagnosing SBI, but serial measurements may be useful in monitoring response to treatment

CRP has a limited role in well appearing children older than 3 months

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Originally described a Dr. West in 1841 – it is a rare (~1200 cases annually)  seizure disorder in young kids, generally less than 1 year old.  Very subtle appearance, often with only bending forward or ‘jerking’ of the extremities as opposed to Brief Resolved Unexplained Event (BRUE) or tonic-clonic in description.  The spasms can be thought of as a syndrome, where 70% of those have an undiagnosed rare metabolic/genetic disease.

A prompt evaluation, including labs, EEG, MRI, metabolic and genetic studies is vital in helping to establish a diagnosis which can have a profound impact on the patients prognosis. Examples might include Tuberous Sclerosis, Pyridoxine Dependent Seizures among over 50 others.

Bottom line: In pediatric patients less than 1 year old who present to the Emergency Department with a description of spasm-like episodes, consider Infantile Spasms on the differential, and consult your friendly neighborhood Pediatric Neurologist for help in determining a proper disposition.

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