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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: 2020
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

PEMplaybook.org

Mar 1, 2020

PEMplaybook.org

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

PEMplaybook.org

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