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Pediatric Emergency Playbook

You make tough calls when caring for acutely ill and injured children. Join us for strategy and support, through clinical cases, research and reviews, and best-practice guidance in our ever-changing acute-care landscape. This is your Pediatric Emergency Playbook.
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Now displaying: Category: general
Oct 1, 2021

PEMplaybook.org

Sep 1, 2021

Hernia

Myth: “If it’s not strangulated, it’s elective”

Reality: Unlike in adults, all hernias in children are repaired at the time of diagnosis because:

  • The risk of incarceration and strangulation is high
  • There is a 30% risk of testicular infarction due to pressure on the gonadal vessels
  • It is not worth messing around and “trying to navigate the system”

Most groin hernias in children are indirect inguinal hernias (incomplete closure of processus vaginalis).

Most indirect hernias are in boys (10-fold risk), and on the right (60%). Premature babies are at higher risk as well.  15% are bilateral.

Hernias often bulge further with crying. For infants, in supine position, gently restrain their feet on the gurney.  They hate it and will cry.  For older children, have them laugh, cough, or blow through a syringe.

The “silk glove sign” is not reliable, but if found is highly suggestive of an inguinal hernia.  Roll the cord structures across the pubic tubercle.  If you feel catching, like two sheets of silk rubbed together, this suggests edema from the patent processus vaginalis.

Most (80%) incarcerated hernias can be reduced initially and admitted for surgery 24-48 hours after edema has improved.  Use age- and patient-appropriate sedation and reduce if no peritonitis or concern for strangulation.

Hydroceles usually are: non-communicating (with the abdomen); worse with crying or during the day; improve by morning; and self-resolve by age 2 without intervention.  Communicating hydroceles are: usually present at birth; are associated with a patent processus vaginalis; and are often repaired later, if not resolved by 1 or 2 years of age.

Girls may have an ovary incarcerated in hernial sac.

Open repair or laparoscopic techniques are used.  The laparoscope offers visualization of the contralateral side without significant risk of injury to vas deferens.

A metachronous hernia develops later on the other side.  Some surgeons opt to explore both sides at the time of diagnosis, others take conservative approach (small risk of fertility issues if both are open-explored)

My take: regardless of presentation, needs admission

 

 

 

Selected References

Abdulhai S, Glenn IC, Ponsky TA. Inguinal Hernia. Clin Perinatol. 2017 Dec;44(4):865-877

Brandt ML. Pediatric hernias. Surg Clin North Am. 2008 Feb;88(1):27-43, vii-viii. doi: 10.1016/j.suc.2007.11.006.

Esposito C, Escolino M, Cortese G, Aprea G, Turrà F, Farina A, Roberti A, Cerulo M, Settimi A. Twenty-year experience with laparoscopic inguinal hernia repair in infants and children: considerations and results on 1833 hernia repairs. Surg Endosc. 2017 Mar;31(3):1461-1468.

Olesen CS, Mortensen LQ, Öberg S, Rosenberg J. Risk of incarceration in children with inguinal hernia: a systematic review. Hernia. 2019 Apr;23(2):245-254

Jun 1, 2021

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May 1, 2021

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Apr 1, 2021

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Mar 1, 2021

Constipation as a diagnosis can be dangerous, mainly because it is a powerful anchor in our medical decision-making.

Chances are, you’d be right to chalk up the pain to functional constipation — 90% of pediatric constipation is functional, multifactorial, and mostly benign — as long as it is addressed.

We’re not here for “chances are“; we’re here for “why isn’t it?

Ask yourself, could it be:

Anatomic malformations: anal stenosis, anterior displaced anus, sacral hematoma

Metabolic: hypothyroidism, hypercalcemia, hypokalemia, cystic fibrosis, diabetes mellitus, gluten enteropathy

Neuropathic: spinal cord abnormalities, trauma, tethered cord

Neuromuscular: Hirschprung disease, intestinal neuronal dysplasia, myopathies, Down syndrome, prune belly syndrome

Connective tissue disorders: scleroderma, SLE, Ehlers-Danlos syndrome

Drugs: opioids, antacids, antihypertensives, anticholinergics, antidepressants, sympathomimetics

Ingestions: heavy metals, vitamin D overload, botulism, cow’s milk protein intolerance

 

Red Flags

Failure to thrive

Abdominal distention

Lack of lumbosacral curve

Midline pigmentation abnormalities of the lower spine

Tight, empty rectum in presence of a palpable fecal mass

Gush of fluid or air from rectum on withdrawal of finger

Absent anal wink

 

 

 

You gotta push the boat out of the mud before you pray for rain.

 

— Coach

 

 

Medications for disimpaction

(do this first!)

Polyethylene Glycol (PEG) 3350 (Miralax): 1 to 1.5 g/kg PO daily for 3 to 6 consecutive days.  Maximum daily dose: 100 g/day PO.  Follow-up with maintenance dose (below) for at least 2 months (usually 6 months)

Lactulose: 1.33 g/kg/dose (2 mL/kg) PO twice daily for 7 days

Mineral Oil (school-aged children): 3 mL/kg PO twice daily for 7 days

 

Medications for Maintenance

(do this after disimpaction!)

Polyethylene Glycol (PEG) 3350 (Miralax): 0.2 to 0.8 g/kg/day PO.  Maximum daily dose: 17 g/day. Maintenance dosing for Miralax may need to be tailored; up to 1 g/day maintenance.  

Lactulose: 1 to 2 g/kg/day (1.5 to 3 mL/kg/day)PO divided once or twice daily.  Maximum daily dose: 60 mL/day in adults.

Mineral Oil: 1 to 3 mL/kg/day PO divided in 1 to 2 doses; maximum daily dose: 90 mL/day

Docusate (Colace): 5 mg/kg/day PO divided QD, BID, or TID (typical adult dose 100 mg BID)

Senna, Bisocodyl — complicated regimens; use your local reference

 

Enemas

  1. Are you sure?  Have you tried oral disimpaction over days?
  2. No phosphate enemas for children less than 2.
  3. Saline enemas are generally safe for all ages
  4. Be careful with the specific dose — please use your local reference

 

Selected References

Freedman SB et al. Pediatric Constipation in the Emergency Department: Evaluation, Treatment, and Outcomes. JPGN 2014;59: 327–333.


North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition. Clinical Practice Guideline: Evaluation and Treatment of Constipation in Infants and Children. JPGN 2006; 43:e1-e13.


Tabbers MM et al. Evaluation and Treatment of Functional Constipation in Infants and Children: Evidence-Based Recommendations From ESPGHAN and NASPGHAN. JPGN 2014;58: 258–274.

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Feb 1, 2021

Top 10

[details in audio]

  1. Set the stage – exude confidence and be prepared

  2. Choose the right cannula size – a smaller working IV is infinitely better than none

  3. Feeling is better than looking – trust yourself

  4. Mark the site – things get wonky when you take your hands off to disinfect

  5. Tourniquets can mess you up – try to use a holder’s hand to occlude the vein

  6. The holder rules – get as many hands on deck as you need.

  7. Tension is good –  a little counter traction on the skin with your non-dominant hand helps to decrease the friction as the needle goes through the fascial layers.

  8. Stay in line – your needle is an extension of your arm

  9. Gravity is your friend – the kinder, gentler tourniquet

  10. The 3 Fs – flash, flatten, and forward. Get the flash at a 30 degree angle, flatten that angle, (advance another 1mm), and advance the plastic catheter over the needle into success

Sep 1, 2020

Tuft Fracture

Yeh PC et al. Pediatric Hand Fractures. Techniques in Orthopaedics. 2009.

Seymour Fracture

Nellans et al. Pediatric Hand Injuires. Hand Clin. 2013 November ; 29(4): 569–578

Yeh PC et al. Pediatric Hand Fractures. Techniques in Orthopaedics. 2009.

Mallet Fracture

Adolescent with mallet finger and Kirschner wire fixation. Nellans et al. Pediatric Hand Injuires. Hand Clin. 2013 November ; 29(4): 569–578

Mallet finger in splint. Yeh PC et al. Pediatric Hand Fractures. Techniques in Orthopaedics. 2009.

Volar Plate Injury

Yeh PC et al. Pediatric Hand Fractures. Techniques in Orthopaedics. 2009.

Central Slip Injury

Lee SA et al. Ultrasonography of the finger. Ultrasonography 2016; 35(2): 110-123.

Yeh PC et al. Pediatric Hand Fractures. Techniques in Orthopaedics. 2009.

Rotational Deformity

A, B: Relatively normal appearance; C: in flexion, rotational abnormality evident. Liao CY et al. Pediatric Hand and Wrist Fractures. Clin Plastic Surg 46 (2019) 425–436

Yeh PC et al. Pediatric Hand Fractures. Techniques in Orthopaedics. 2009.

Extra-Octave Fracture

Mims L et al. Extra-Octave Fracture in a 14-Year-Old Basketball Player. Journal of Pediatrics. 2017; 186: P206-206

Same boy, after reduction and ulnar splint

Same boy, on follow-up at 17 days

Ulnar Collateral Ligament Injury

Yeh PC et al. Pediatric Hand Fractures. Techniques in Orthopaedics. 2009.

Bennett Fracture

radiopaedia.org

Rolando Fracture

wikipedia.org

Selected References

Kiely AL et al. The optimal management of Seymour fractures in children and adolescents: a systematic review protocol. Systematic Reviews. 2020; 9 (150).

Liao CY et al. Pediatric Hand and Wrist Fractures. Clin Plastic Surg 46 (2019) 425–436

Lin JS et al. Treatment of Acute Seymour Fractures. J Pediatr Orthop. 2009; 39(1):e23-e27.

Mims L et al. Extra-Octave Fracture in a 14-Year-Old Basketball Player. Journal of Pediatrics. 2017; 186: P206-206

Mohseni M et al. Ulnar Collateral Ligament Injury. Stat Pearls. 2020

Nellans et al. Pediatric Hand Injuires. Hand Clin. 2013 November ; 29(4): 569–578

Pattni A et al. Volar Plate Avulsion Injury. Eplasty. 2016; 16: ic22.

Stevenson J et al. The use of prophylactic flucloxacillin in treatment of open fractures of the distal phalanx within an accident and emergency department: a double-blind randomized placebo-controlled trial. The Journal of Hand Surgery: British & European. 2003; 28(5): 388-394

Yeh PC et al. Pediatric Hand Fractures. Techniques in Orthopaedics. 2009

Aug 1, 2020

A spectrum — but will you recognize the blurry signposts?

  Temperature (core) Presentation Management
Miliaria Crystallina Normal Salt-colored tiny papules, easily burst; not pruritic Modify environment; light clothing; hydration
       
Miliaria Rubra Normal Discrimiate, red papules, not assocaited with follicles; pruritic Above plus cool compresses; calamine lotion; symptomatic tx for pruritis 
       
Miliaria Profunda Normal Confluent flesh-colored, “lumpy-bumpy”; burning Same as rubra
       
Miliaria Pustulosa Normal May resemble rubra and/or crustallina, but pustular; h/o previous dermatitis Same as above, but may may need antibiotic if no improvement over time
       
Heat edema Normal Swelling of feet, ankles, and/or lower legs Modify environment; elevate legs
       
Heat syncope Normal Dizziness, orthostatic hypotension, and syncope after exertion with rapid return to normal mental status when supine Modify environment; rehydration; monitoring
       
Heat cramps May be elevated to 40°C (104°F) Exercise-induced cramping in large muscle groups, especially legs Hydration; consider labs (Cr, total CK); may counsel to stretch muscles passively, gently
       
Heat tetany May be elevated to 40°C (104°F) Hyperventilation with paresthesia, carpopedal spasm Modify environment; hydration; may place non-rebreather mask on low (or off) for rebreathing CO2
       
Heat exhaustion Elevated up to 40°C (104°F) Normal mental status, fatigue, that rapidly improves with treatment; tachycardia; GI symptoms; electrolyte abnormalities  Cool environment; hydration; consider labs with severe symptoms, or if not improved 
       
Heat Stroke >40 to 40.5°C   (104 to 105°F) Altered mental status; tachypneic; tachycardic with hypotension; electrolyte abnormalities; GI symptoms; often with renal failure, rhabdomyloysis, renal failure; possibly with cardiogenic shock or ARDS or DIC Rapid cooling with all modalities available (radiation, conduction, convection, evaporation); IV rehydration; labs; monitoring; ICU admission
Miliaria Crystallina Miliaria Crystallina — Infant Miliaria Crystallina — Older Child Miliaria Rubra — Infant Miliaria Rubra — Infant Miliaria Rubra — Toddler Miliaria Rubra — Adolescent Miliaria Profunda

Selected References

Bergeron MF, Devore C, et al. Council on Sports Medicine and Fitness and Council on School Health, Policy statement—Climatic heat stress and exercising children and adolescents. Pediatrics 2011; 128:e741.

Casa DJ et al. The Inter-Association Task Force for Preventing Sudden Death in Secondary School Athletics Programs: Best-Practices Recommendations. J Athl Train. 2013 Jul-Aug; 48(4): 546–553.

DeFranco MJ et al. Environmental issues for team physicians. Am J Sports Med. 2008 Nov;36(11):2226-37.

Ishimine P. Hyperthermia. In: Pediatric Emergency Medicine, Baren JM, Rothrock SG, Brennan JA, Brown L (Eds), Saunders Elsevier, Philadelphia 2008. p.992.

Jardine DS. Heat illness and heat stroke. Pediatr Rev 2007; 28:249.

Jul 1, 2020

Traditional Approach:

 

Secretory -- poisoned mucosal villi -- "the sieve"

Cytotoxic -- destroyed mucosal villi -- "the shred"

Osmotic -- malabsorption -- "the pull"

Inflammatory -- edema, motility -- "the push"

Lots of overlap, difficult to apply to clinical signs and symptoms.

 

Bedside Approach:

Fever/No Fever, Bloody/No Blood

 

Non-bloody, febrile -- most likely viral

Non-bloody, afebrile -- may be viral

Bloody, febrile -- likely bacterial

Non-bloody, afebrile -- full stop.  Eval for Hemolytic Uremic Syndrome

 

Workup

 

Ask yourself -- again -- why is this not... appendicitis-torsion-intussusception-etc.

Admit sick children, but most go home, so...

 

Non-bloody, febrile -- no workup necessary; precautionary advice 

Non-bloody, afebrile -- be more skeptical, but generally same as above

Bloody, febrile -- stool culture, follow up; do not treat empirically unless septic and admitted.  Culture will dictate treat/no treat/how.

Bloody, afebrile -- evaluate for hemolytic uremic syndrome, especially if under 5 years old: CBC, chemistries, UA, stool culture

 

Evaluate Hydration Status

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Selected References

Khan WA et al. Central Nervous System Manifestations of Childhood Shigellosis: Prevalence, Risk Factors, and Outcome. Pediatrics. 1999 Feb;103(2):E18


Lee JY et al. Diagnostic yield of stool culture and predictive factors for positive culture in patients with diarrheal illness. Medicine (Baltimore). 2017 Jul; 96(30): e7641.


Nelson JD et al. Treatment of Salmonella gastroenteritis with ampicillin, amoxicillin, or placebo. Pediatrics 1980; 65:1125.

 

 
 
Jun 1, 2020

PEMplaybook.org

May 1, 2020

Pediatric Readiness is not just an ideal -- it's a tangible plan, a toolkit, and even better, an attitude

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How to improve your institution, and your own personal pediatric readiness.

 

 
 
Apr 1, 2020

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Mar 1, 2020

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Feb 1, 2020
 
 

Lund and Browder Chart to Estimate Burn Size in Children

 
 
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Parkland Formula for Burns

Amount needed in addition to maintenance fluids:

4 mL/kg x BSA% = X 

Add 1/2 of X to maintenance over the 1st 8 hours

Add the other 1/2 of X to maintenance over the next 16 hours

 

 
 

Escharotomy Guide and the "Roman Breastplate"

 
 
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Selected References

Mahar PD et al. Clinical differences between major burns patients deemed survivable and non-survivable on admisssion. Injury. 2015; 46:870-873.

Mathis E et al. Pediatric Thermal Burns and Treatment: A Review of Progress and Future Prospects. Medicines. 2017; 4:91.

Osuka A et al. Glycocalyx shedding is anhanced by age and correlates with increased fluid requirement in patients with major burns. Shock. 2017; 50(1):60-65.

Sebastian R et al. Percutaneous pigtail catheter in the treatment of pneumothorax in major burns: The best alternative? Burns. 2015; e24-227

Sherren PB et al. Lethal triad in severe burns. Burns. 2014; 1492-1496.

Strobel AM et al. Emergency Care of Pediatric Burns. Emerg Med Clin N AM. 2018; 441-458.

 
Jan 1, 2020

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Dec 1, 2019

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Oct 1, 2019

The differential diagnosis is long...

You need an approach.

 

The Rule of 3s:

3 minutes -- Traumatic

3 days -- Inflammatory

3 months -- Neoplastic

3 years -- Congenital

 

3 Minutes?  Traumatic

 

3 Days?  Inflammatory

[caption id="attachment_1777" align="alignnone" width="262"] Cervical Node Chain; Lymphadenopathy[/caption] [caption id="attachment_1773" align="alignnone" width="298"] Bacterial Lymphadenitis[/caption] [caption id="attachment_1772" align="alignnone" width="300"] Bacterial lymphadenitis with small abscess[/caption] [caption id="attachment_1771" align="alignnone" width="300"] Large Abscess[/caption]

 

3 Months?  Neoplastic

 

3 Years?  Congenital

[caption id="attachment_1784" align="alignnone" width="300"] Thyroglossal Duct Cyst[/caption] [caption id="attachment_1783" align="alignnone" width="300"] Thyroglossal Duct Cyst[/caption] [caption id="attachment_1776" align="alignnone" width="278"] Branchial Cleft Cyst[/caption] [caption id="attachment_1775" align="alignnone" width="263"] Branchial Cleft Cyst[/caption] [caption id="attachment_1774" align="alignnone" width="233"] Branchial Cleft Cyst[/caption] [caption id="attachment_1779" align="alignnone" width="300"] Cystic Hygroma[/caption]

 

[caption id="attachment_1778" align="alignnone" width="235"]  Cystic Hygroma[/caption]

 
Selected References

Enepekides DJ. Management of congenital anomalies of the neck. Facial Plast Surg Clin North Am 2001; 9:131.

Lin ST, Tseng FY, Hsu CJ, et al. Thyroglossal duct cyst: a comparison between children and adults. Am J Otolaryngol 2008; 29:83.

Mandell DL. Head and neck anomalies related to the branchial apparatus. Otolaryngol Clin North Am 2000; 33:1309.

Marler JJ, Mulliken JB. Current management of hemangiomas and vascular malformations. Clin Plast Surg 2005; 32:99.

Silverman, J. F., Gurley, A. M., Holbrook, C. T., Joshi, V. V. (1991) Pediatric fine needle aspiration biopsy. American Journal of Clinical Pathology 95: 653–659

Sonnino RE, Spigland N, Laberge JM, Desjardins J, Guttman FM. Unusual patterns of congenital neck masses in children. J Pediatr Surg. 1989 Oct;24(10):966-9.

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