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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: 2021
Jun 1, 2021

PEMplaybook.org

May 1, 2021

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Apr 1, 2021

PEMplaybook.org

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

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