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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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Pediatric Emergency Playbook
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Now displaying: Page 1
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.

Sep 1, 2019

 

Selected References


Barnard, et al. Rapid sequence induction of anaesthesia via the intraosseous route: a prospective observational study. Emerg Med J. 2014; Jun 24. pii: emermed-2014-203740.

Jousi M, Saikko S, Nurmi J. Intraosseous blood samples for point-of-care analysis: agreement between intraosseous and arterial analyses. Scand J Trauma Resusc Emerg Med. 2017;25(1):92. Published 2017 Sep 11. doi:10.1186/s13049-017-0435-4

Knuth, et al. Intraosseous Injection of Iodinated Computed Tomography Contrast Agent in an Adult Blunt Trauma Patient. Annals of Emergency Medicine. 2011; 57 (4) 382-386

Miller LJ. et al A new study of intraosseous blood for laboratory analysis.Arch Pathol Lab Med. 2010 Sep;134(9):1253-60.

Miller, et al. Utility of an intraosseous vascular system to deliver contrast dye using a power injector for computerized tomography studies. Annals of Emergency Medicine. 2011; 58 (4) 240-241.

Aug 1, 2019
 

 

Your eyes may fool you...

 
Keep your differential diagnosis open.

 

 
 

Selected References

 

Aravindhan N, Chisholm DG. Sulfhemoglobinemia presenting as pulse oximetry desaturations. Anesthesiology. 2000;93:883–884.

 
Gharahbaghian L et al. Methemoglobinemia and Sulfhemoglobinemia in Two Pediatric Patients after Ingestion of Hydroxylamine Sulfate. West J Emerg Med. 2009 Aug; 10(3): 197–201

 

 Ginimuge PR et al. Methylene Blue: Revisited. J Anaesthesiol Clin Pharmacol. 2010 Oct-Dec; 26(4): 517–520.

 

 Mack E. Focus on diagnosis: co-oximetry. Pediatr Rev. 2007;28:73–4.

So T-Y et al. Topical Benzocaine-induced Methemoglobinemia in the Pediatric Population. J Pediatr Health Care. 22(6):335–339.

 
Jul 1, 2019

Failure to Thrive (FTT) is not just for the clinics. We need to be on the lookout, because if we find it, there is already a big problem.

Definitions of Failure to Thrive may quibble on the details, but for us in the ED:

  1. Consistently under 2nd percentile in weight over time
  2. "Falling off" the growth curve over 2 or more points

We can get around the longitudinal requirement by looking at weight as a "spot check" -- if grossly below weight without any other chronic condition, be alarmed.

Failure to thrive results from inadequate calories. This may be due to:

  1. Not enough offered
  2. Not enough taken
  3. Not enough absorbed

Any concern should trigger a more complete H&P (in audio).

Classic instructional video on the mother-infant dyad (scan through for various types).

After a focused H&P, you may need to admit the child for further workup, or to show that he can/cannot gain weight with routine care.

Remember, if you are the first one to bring this up, there is a real problem. By definition, an outpatient plan has failed. We will not be able to distinguish among the various possibilities of organic and non-organic causes (or mix thereof); our job is to be ready to catch it and act on it. The child's development, future intelligence, and welfare are at risk.

References

Birth to 24 months: Boys Weight-for-length percentiles and Head circumference-for-age percentiles


Birth to 24 months: Boys Length-for-age percentiles and Weight-for-age percentiles


Birth to 24 months: Girls Weight-for-length percentiles and Head circumference-for-age percentiles


Birth to 24 months: Girls Length-for-age percentiles and Weight-for-age percentiles

Jaffe AC. Failure to Thrive. Pediatrics in Review. 2011; 32(3)

Prutsky GJ et al. When Developmental Delay and Failure to Thrive Are Not Psychosocial. Hospital Pediatrics. 2016; (1):6

Jun 1, 2019

No one ever wants to find himself in this situation. A factory explodes. A building catches fire. A multi-vehicle traffic collision. Or an act of terrorism.

 
 

Very quickly, we have to scrap business as usual. We have to adapt to our new circumstances.

 
 

Definition of a mass casualty incident (MCI):

 
 

An incident which produces multiple casualties such that emergency services, medical personnel and referral systems within the normal catchment area cannot provide adequate and timely response and care without unacceptable mortality and/or morbidity.

 
 

In other words, our demand far outpaces our resources.

 
 

"If you can hear the sound of my voice, follow me". Those patients are GREEN, minor.

 
 

Otherwise, we need a system to distinguish those who can be DELAYED, IMMEDIATE, or EXPECTANT (soon to be deceased).

 
 

Use Simple Triage and Rapid Treatment (START) for 8 or older, JumpSTART for less than 8 years of age.

 
 
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An MCI drill
 
 

For Older Children, Adolescents, and Adults (8 or greater) -- START:

 
 
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For Children less than 8 years of age (Infants Use Pediatric Assessment Triangle) -- JumpSTART:

 
 
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 Selected References 

 

Briggs SM. Disaster management teams. Curr Opin Crit Care. 2005 Dec;11(6):585- 

Culley JM, Svendsen E. A review of the literature on the validity of mass casualty triage systems with a focus on chemical exposures. American journal of disaster medicine. 2014; 9(2):137-150

FEMA IS 0100.b - Introduction to the Incident Command System (ICS), Student Manual. http://training.fema.gov/emiweb/is/is100b/student%20manual/02ics100b_sm_october2013.pdf. Accessed 03 MAY 2019.

Jensen J, Youngs G. Explaining implementation behaviour of the National Incident Management System (NIMS). Disasters. 2015 Apr;39(2):362-88. doi: 10.1111/disa.12103.

Lee JS, Franc JM. Impact of a Two-step Emergency Department Triage Model with START, then CTAS, on Patient Flow During a Simulated Mass-casualty Incident. Prehosp Disaster Med. 2015 Jun 24:1-7. 

 

Lerner EB, Schwartz RB, Coule PL, et al. "Mass Casualty Triage: An Evaluation of the Data and Development of a Proposed National Guideline." Disaster Medicine and Public Health Preparedness 2(Suppl. 1) 2008, pp S25-S34.

 
Apr 1, 2019

PEMplaybook.org

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