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
Failure to thrive
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.
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
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
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.
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
|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|
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.
[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]
[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]
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.
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.
Aravindhan N, Chisholm DG. Sulfhemoglobinemia presenting as pulse oximetry desaturations. Anesthesiology. 2000;93:883–884.
So T-Y et al. Topical Benzocaine-induced Methemoglobinemia in the Pediatric Population. J Pediatr Health Care. 22(6):335–339.
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:
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:
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.
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
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.
For Older Children, Adolescents, and Adults (8 or greater) -- START:
For Children less than 8 years of age (Infants Use Pediatric Assessment Triangle) -- JumpSTART:
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
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.